AFI CHANGEMAKERS !
UNITED NATIONS, GENEVA, FEBRUARY 2014 REPORT ON THE SUSTAINABILITY OF HEALTHCARE AND ACCESS TO MEDICINES
Report Written By: Henry Gilliver (Chair) Daisy-May Super (Rapporteur) Emma Robinson Maria-Alexandra Radu Rinisha Yagarajah
2 © Ariel Foundation International 2015 ISBN: 978-0-9964523-0-4
Authors (from left to right): Maria-Alexandra Radu, Rinisha Yagarajah, Henry Gilliver (chair), Daisy-May Super (Rapporteur), and Emma Robinson. Report edited by Henry Gilliver.
Acknowledgements We would like to thank Dr Ariel King, president of Ariel Foundation International, for enabling young people to gain access to the United Nations and work on issues such as those contained within this report. Her continued dedication to the global youth, and unrelenting belief that we deserve a place within the world’s international organisations, is what has made this report possible. The working group on the sustainability of healthcare and access to medicines also wish to thank the co-chairs of our summit at the UN: Catherine White, Megan Smith and Michael Fox. Their organisation and enthusiasm ensured that we were able to gain from our involvement with the international community, as well as contribute through the work we were able to undertake as a youth organisation. Special thanks go to Ambassador Ireno Namboka and Roy Morris, whose knowledge, experience and advice were invaluable to our working group whilst at the United Nations. We also give thanks to Ambassador Collette Samoya for chairing the Changemakers’ Side Panel event at the Social Forum in Geneva. We also wish to thank the keynote speaker of the Social Forum, Dr Deqo Mohamed, who generously donated her time and to our organisation. Her unique perspective based on first hand experience was an enormous help to the working group, for which we are all grateful.
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Table of Contents
2! INTRODUCTION*.................................................................................................*4! 2.1* DEFINING SUSTAINABLE DEVELOPMENT!..................................................................!4* 2.2* DEFINING SUSTAINABILITY IN RELATION TO HEALTHCARE AND ACCESS TO MEDICINES!.................................................................................................................................!5* 3! EDUCATION*AND*AWARENESS*OF*HEALTH*..............................................*7! 3.1* IMPLEMENTATION!...........................................................................................................!7* 3.2* POLICY RECOMMENDATIONS:!.....................................................................................!9* 4! INFRASTRUCTURE*..........................................................................................*10! 4.1* KEY ISSUES!....................................................................................................................!10* 4.2* IMPLEMENTATION!........................................................................................................!12* 4.3* POLICY RECOMMENDATIONS:!..................................................................................!13* 5! DIGITAL*INFRASTRUCTURE*.........................................................................*14! 5.1* KEY ISSUES!....................................................................................................................!14* 5.2* SUCCESSFUL EXAMPLES!.............................................................................................!15* 5.3* MENTAL HEALTH!.........................................................................................................!16* 5.4* POLICY RECOMMENDATIONS!....................................................................................!17* 6! A*BOTTOM*UP;*COMMUNITY@LED*APPROACH.*.....................................*18! 6.1* KEY ISSUES!....................................................................................................................!18* 6.2* IMPLEMENTATION!........................................................................................................!19* 6.3* POLICY RECOMMENDATIONS!...................................................................................!22* 7! CONCLUSION*.....................................................................................................*23! 8! MEET*THE*WORKING*GROUP*......................................................................*24!
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Introduction
Ensuring the provision of sustainable access to healthcare and medicines is a challenge faced by all states, from the least to the most developed. There are many factors that can inhibit the sustainability of these provisions, including poverty, environmental challenges, corruption, a lack of educational opportunities, a lack of economic stability, and a lack of direct access to competitive markets, amongst others. In order to tackle these issues at a global level we must first ensure that we have an understanding of them as they exist within local communities. That is, the international community must orient their approach to work from the local level upwards; i.e. a ‘bottom up approach’. In the following report we will present four key areas that must be considered in order to ensure the long-term sustainability of healthcare coverage and access to medicines. These are: ●
The inclusion of health issues in universal education
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The evaluation and improvement of relevant infrastructure necessary for the sustainable delivery of healthcare services
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The creation and promotion of a health based digital infrastructure
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The consideration of the bottom up approach in all areas of healthcare
The report will introduce and explain: ●
The concept of sustainable healthcare provisions and access to medicines, and why this is necessary for long-term development
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The necessary elements to ensure such sustainability, which we believe are often overlooked
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The necessity for a community-centred approach towards delivering health services
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Infrastructural, educational and social requirements which are necessary for the sustainable provision of, and access to, healthcare and medicines
2.1
Defining Sustainable Development
Sustainable access to healthcare and medicines can best be understood as a subset of sustainable development. As such, an understanding of this broader concept will help
5 inform sustainability in relation to healthcare. Sustainable development may be surmised as follows:
"Development that meets the needs of the present without compromising the ability of future generations to meet their own needs”.1
Meeting the needs of the future depends on how well we balance current social, economic, and environmental objectives through the decisions taken today. That is, there are numerous factors that must be considered to ensure that today’s development projects do not threaten the development of tomorrow, such that the benefits of development can successfully persist through time. Sustainable projects are required to be economically viable, socially positive and environmentally sound.2 The concept of sustainability is therefore a broad one, and as such is applicable to all areas of development. Youth actors are therefore major stakeholders in sustainable development projects, as it is they, along with subsequent generations, whose wellbeing depends on their longevity. The relative success of the Millennium Development Goals (MDGs) and the imminent finalisation of the Sustainable Development Goals (SDGs) highlight the importance of longlasting, sustainable solutions to global development issues. As the ultimate beneficiaries of these policies, it is important to actively engage with the youth perspective when formulating and enacting such long-term goals.
2.2
Defining Sustainability in Relation to Healthcare and Access to Medicines
In relation to healthcare, sustainability must be ensured in order to guarantee that the supply of provisions and services can continue indefinitely. In order for this to be achieved, health policies must be formulated with the long-term aim of self-sufficiency in mind, such that they do not rely on contingent external aid for their continuation. There are a myriad of different areas that must be addressed in order for this goal to be realised, and this
1
“Our Common Future” The World Commission on Environment and Development; Oxford University Press (1987). United Nations Environment Program (2008)
6 report will emphasize the need for a holistic approach in order to achieve this. Whist we believe our considerations have the potential to improve the overall sustainability of healthcare, this will only be possible through close collaboration between the public and private sectors, and the international community. It cannot be overstated that such collaboration is a difficult task. The large number of stakeholders involved in global healthcare present a wide array of different, and sometimes conflicting, interests. Sustainability may represent different challenges and goals for these various actors. Universal access to medical innovation and quality healthcare remains a global challenge however, and only through such collaboration can this fact be remedied. It should also be noted that the issue of sustainable healthcare and access to medicines is not simply an issue for the developing world. The concern is present the world over, with the European Commission recently declaring that modern health systems need to remain accessible and effective while pursuing long-term sustainability; a goal that requires them to be fiscally sustainable.3 The pertinence of these considerations has only recently become apparent, following the financial crisis of 2008. There are however, many non-fiscal factors that must be considered in order to achieve sustainability in healthcare services. Such services must be able to adapt to changing environments and use innovative approaches to tackle difficult challenges, often with limited resources. In order to maximize the effectiveness of such approaches, sustainable and comprehensive solutions that are tailored to the needs of local healthcare should be pursued.4 It is for this reason that the need for a bottom-up approach features so prominently in this report. Such an approach to the provision of healthcare and services will require a more holistic vision regarding development projects, as well as close collaboration between the public and private sectors. Only by adopting this vision will we ensure access to vital primary care to all of the world’s most impoverished people. Key elements of this holistic approach are also central to the content of our report. The Following points summarize some of our key discussions relating to the sustainability of healthcare and access to medicines:
3
#“Identifying#fiscal#sustainability#challenges#in#the#areas#of#pension,#health#care#and#long9term#care# policies”:#The#European#Commission#(2014). 4
“Improving access: overcoming barriers”; Roche (2013)
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Physical barriers to healthcare services in rural and isolated communities impede the benefits of initiatives planned by governments, NGOs and aid agencies.
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A lack of education and awareness of health issues prevents health initiatives from being successful and properly understood. This serves to reduce the sustainability of such initiatives.
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Initiatives put in place often neglect to include and integrate with local communities, resulting in disenchantment and demotivation regarding their long-term involvement in these projects.
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While necessary, short-term crisis relief does not tackle the root cases of health problems. As such, more preventative, long-term measures must be implemented to reduce the need for such crisis relief, and to prevent an escalation of dependency on short-term solutions.
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Education and awareness of health
In many cultures and demographics, in both the developed and the developing world, there may be a lack of understanding and awareness about good health practices. In the developing world, access to comprehensive medical services may be extremely limited, particularly to people living in poverty, and in remote areas. However knowledge of good health and sanitation practices can dramatically reduce the risk of infection and disease. As UNICEF states, “hand washing with soap is among the most effective and inexpensive ways to prevent diarrheal diseases and pneumonia, which together are responsible for the majority of child deaths5”. Education and awareness campaigns can be an effective tool in spreading simple messages that can combat these serious problems. The spreading of this knowledge through West and Central Africa could save about half a million children a year, and yet across the world hand washing with soap at critical moments ranges in frequency from zero to 34%6.
3.1
Implementation
Education and awareness is the key to delivering individual-led preventative healthcare. While many healthcare initiatives focus on the provision of treatment, education offers the opportunity to prevent health crises occurring in the first place, dramatically reducing the
5 6
http://www.unicef.org/wcaro/english/overview_4553.html Ibid.
8 human and financial cost of disease. In countries where there are less than one doctor for every 2000 people7 (and these are not spread evenly throughout the population) the benefit of preventative measures cannot be overstated. However given the small number of doctors per capita in many countries, healthcare messages must be conveyed through alternative methods in order to successfully reach the population. These messages must also be conveyed in an appropriate fashion that respects cultural norms and beliefs. Schooling is one method through which health messages can be conveyed. Achieving primary education for every child is a key aspect of the MDGs, and even in the Least Developed Countries (LDCs), 73% of children attend primary school8. While we accept that this still excludes many pupils from the benefits of education, it does allow medical education to be included within curricula while this number continues to rise. It is important that all curricula worldwide are culturally sensitive and age appropriate but that they are used to create awareness of the body, and how to protect it from disease, both through healthy lifestyle and correct sanitation and hygiene. Children may also pass information they have learned at school on to their parents, spreading these positive messages further into the community. Educational initiatives around healthcare can be hard to communicate if a person cannot read or understand key aspects of the information. Information must always be provided in an accessible manner, particularly in local dialects, to ensure it is as far-reaching and effective as possible. In places with low literacy rates, radio broadcasts can be another costeffective method of disseminating crucial medical advice. Further initiatives of this kind will be discussed in the digital infrastructure section of this report. Graphic representations rather than words are another method of transmitting information quickly and easily, especially for those who may be illiterate. An example of this could be a simple diagram placed above taps portraying best practice of washing hands effectively.
7 8
http://data.worldbank.org/indicator/SH.MED.PHYS.ZS http://data.unicef.org/education/overview
9 3.2
Policy Recommendations: •
The inclusion of sanitation and healthcare within school curricula, to reinforce best practices as social norms and prevent avoidable deaths. A standardized curriculum in basic health and sanitation, drafted and approved by the World Health Organization and distributed at a local level to educational institutions would ensure these messages were conveyed correctly and effectively to children of all ages. This standardized message could also be visualized in the form of a poster to be displayed prominently in the classroom. Vocalized education is not enough however; making toilets and hand washing stations available at schools to instill routine behavior is crucial. In the Democratic Republic of Congo, for example, less than 25% of schools have adequate sanitation9, a significant barrier to the education of children in preventative hygiene methods. Instilling healthcare initiatives like hand washing as a social norm is a highly sustainable development program, as once these values have become normalized they no longer need to be promoted.
9
http://www.unicef.org/wcaro/english/overview_4553.html
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4
Infrastructure
As in all sustainable development, the prevention of a crisis in the first instance is preferable to emergency crisis relief. Health education is an important first step in any long-term preventative health policy, but will only be maximally successful when implemented as part of a holistic approach to public health. Of equal importance is a readily accessible infrastructure network of health services and provisions, as well as basic sanitation services, such that any provided health education can be put into practice. A top down approach to health and access issues is insufficient, as physical barriers resulting from poor local infrastructure often go unobserved or ignored. The negative consequences of such failure are twofold: 1) A lack of infrastructure, or the low quality of available infrastructure, may reduce the efficacy and efficiency of health care initiatives; increasing their financial cost and furthering dependency on external aid programs. Such failure inherently reduces the long-term sustainability of these programs. 2) Many individuals may not benefit from healthcare initiatives because a lack of quality infrastructure may act to physically prevent them from reaching life saving medical services.
4.1
Key Issues
An example of such infrastructural inadequacy is the fact that basic sanitation services are still lacking in many developing countries; 780 million people do not have access to clean drinking water, and 2.5 billion don’t have access to improved sanitation.10 As a prerequisite to health, investment in this infrastructure must be considered necessary to the realization of every human's right to health. According to the WHO, around 760,000 children under five die each year as a result of Diarrhoeal disease; leading causes of which are poor sanitation and hygiene, and lack of access to safe drinking water.11 Until these infrastructural failings are addressed, any health services and international aid directed at a health problem will not be sustainable, as basic preventative measures have not been put in place.
10 11
World Health Organisation: Diarrhoeal Disease; Factsheet No.330 (2010) ibid
11 Such preventative measures are also far more cost effective than retrospective action. Research indicates that investing $3.35 in hand washing brings the equivalent health benefits as investing $11.00 in latrine construction and thousands of dollars in immunization programmes.12 Furthermore, heavily promoting hand washing will internalize the practice within communities, which will be passed on to future generations. Investments of this kind are therefore efficient, effective, and sustainable. This is just one example of how addressing infrastructural inadequacies can have far-reaching benefits with regard to preventing health crises in a sustainable way. Whilst global targets for clean water and sanitation set out in the MDGs have been met in urban areas, they will not be reached in rural areas. Many water and sanitation development projects in these areas are never completed, leaving communities highly vulnerable to health crises that are costly both financially and in terms of human life. We are pleased that the SDGs will attempt to “ensure [the] availability and sustainable management of water and sanitation for all�,13 however greater care must be taken in the planning of such initiatives to ensure their successful completion. These projects should also be denoted as imperative to the right to health, in addition to constituting general development goals. In many of the least developed areas of the world, road networks and transport links are severely lacking. For example, the UN report on Infrastructure states that only 2757km of Somalia's 22,000km road network is paved.14 Of these, only 2900km are passable year round due to seasonal environmental conditions. Whilst such poor transport linkage is indicative of wider developmental problems, there are specific implications for people's ability to access health services. A community cannot benefit from health services, regardless of how comprehensive they are, if the local environment constitutes a physical barrier to these services. These barriers will not be adequately accounted for without the involvement of local people and governments who can best advise on how to integrate health services within the existing infrastructure. All health oriented policies should include an assessment of the available infrastructure in the area, based on local knowledge, and should use this information to better tailor the provision of health services. This may include the decentralization of health services, such that health practitioners are based in these inaccessible areas. Such practitioners will have knowledge of the issues of greatest
12
Unicef: West and Central Africa; Handwashing. Accessible at http://www.unicef.org/wcaro/english/overview_4553.html 13 Open Working Group Proposal for Sustainable Development Goals; Sustainable Development Knowledge Platform. Accessible at: https://sustainabledevelopment.un.org/focussdgs.html 14 Somalia Joint Needs Assessment; United Nations Infrastructure Cluster Report (2006) p.11
12 importance to these areas, as well as general medical knowledge such as ante/neo natal care. This will ensure that isolated communities are still able to access health services, as is their human right. 4.2
Implementation
It is important to emphasize the fact that the infrastructural challenges mentioned above will be different on a case-by-case basis. The levels of existing infrastructure will vary between regions, as may regional political stability, which can impact people’s ability to safely seek medical services. There will also be significant variance in the most pressing health concerns. The implication of this is that there is no “one size fits all” solution to the problem of making healthcare sustainable. In order to implement sustainable policies, each region must be assessed independently to ensure the most appropriate solutions are adopted. These infrastructural challenges may be considered as the “binding constraints” on sustainable healthcare within the target policy area. Recognising that each policy and region will encounter different binding constraints is a fundamental step in the realisation of sustainability in healthcare and access to medicines. The logic of ascertaining the individual binding constraints within a region before implementing policy has been considered in the literature on sustained economic growth. Adapting this reasoning to healthcare may provide an initial platform from which to gain a thorough understanding of these individual challenges. The following three-step process has been adapted from Rodrik and The World Bank (2006), to suit the challenges posed to sustainable healthcare. 1. A diagnostic analysis must be undertaken in order to ascertain where the most significant infrastructural constraints on sustainable healthcare are in a given setting. 2. Creative policy must be tailored to specifically target the identified constraints appropriately. 3. The process of diagnosis and individually tailored policy response must be institutionalized, such that every health challenge is subject to rigorous infrastructural assessment before it is implemented.15
15
D.Rodrik; A Review of the World Bank’s Economic Growth in the 1990s: Learning from a Decade of Reform; Journal of Economic Literature; 44: 4.(2006)
13 By following a structure of this kind, health policies will reach more people more efficiently, due to the fact that they have been specifically formulated to suit the local environment, based on local knowledge. This process therefore inherently increases the sustainability and social value of the resultant health services.
4.3
Policy Recommendations: 1. Greater planning and sustainability studies must be implemented to ascertain the long-term viability of clean water and sanitation developments. As a necessary precursor to the right to health, such developments must be prioritized and seen through to the most efficient completion possible. Additionally, such infrastructural challenges must be included in the planning and formulation of health policy, such that sustainable development goals become embedded within the discourse of health policy. 2. Both nationally and internationally formulated health policy must include infrastructural assessments to ensure everyone in the policy target areas will have safe, sustainable access to the services to be provided. The cost of any required infrastructural improvements must be included and implemented as part of a holistic health policy. These infrastructural assessments must be based on knowledge provided by local governments and communities to ensure a complete understanding of the practicalities of delivering health services in an area. 3. Should it be determined that identified infrastructural inadequacies cannot feasibly be completed; health policy must be adjusted appropriately to ensure the widest possible access to the proposed health services. Where necessary this will include the replacement of proposed health service access points with decentralised general practitioners who will be able to provide care to isolated communities, until such a time that the local infrastructure can be sufficiently improved.
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5
Digital Infrastructure
Despite the aforementioned policy recommendations, we must face the fact that global infrastructural improvements will not happen immediately. In a modern, globalized world, digitalized infrastructure can be harnessed to reach places where physical infrastructure cannot be, or has yet to be implemented. Such digital infrastructure can also serve to strengthen and complement any existing hard infrastructure that is already in place. Digital infrastructure can be used as a platform to spread ideas, messages and information; vital to the provision of sustainably accessible healthcare.
5.1
Key Issues
There are many pioneering initiatives delivering health services in different parts of the world, but there is no network for the integration and sharing of these initiatives. In order to create accessible and sustainable healthcare systems on a global level, it is vital that there is a place to share and combine ideas, skills, resources, funding and expertise. We recognise the need for a global initiative platform; a forum for ideas sharing and training. We must build a platform for people to share their ideas through a digital medium; knowledge sharing is vital in the journey towards globally accessible health care. Pooling skills and sharing ideas and enterprises which can be replicated and applied in different situations and locations (with some tailoring to make them effective in each applicable situation) would promote wider and more diverse and innovative access to health. Mobile and internet technology is the easiest, most far-reaching and cheapest platform for sharing best practices, innovative solutions and advice quickly and efficiently; helping to remove some of the barriers to healthcare in rural areas and (where possible) conflict zones. This ‘global initiative platform’ would provide the digital infrastructure to enable the: 1. Sharing of expert advice on good medical and healthcare practice 2. Sharing of creative ideas and solutions for social enterprise and health businesses
15 3. Sharing of positive experiences in how medical care has been transported to rural areas 4. Implementation of targeted training programs to train healthcare professionals and local staff in new skills
A fundamental barrier to accessing healthcare programs is that many of the world’s population live in areas where it can be remarkably difficult, expensive and time consuming to reach for a multitude of different reasons. For example, those living within conflict zones may not be too far away from railways and roads but there would be grave implications for healthcare workers trying to access them in a capacity they would see fit and in many cases access is not granted. Technology can be harnessed to deliver many services usually performed face-to-face by health professionals and also many that cannot. Therefore, we recognise the need for a strengthened network of remote healthcare programs. One billion people will never see a healthcare professional in their lifetime, although 95% have access to a mobile signal.16 The nature of the technology is that it can be adapted for global use by different demographics, age groups, and locations. For example, the launch of personal fitness and wellbeing apps used to track heart rate, calorie intake and calories burnt are popular in more economically developed countries and can be harnessed as a tool to promote healthier lifestyles and relieve pressure on national health services. In turn, this promotes sustainability by awareness of the over-consumption of food and promotes exercise and walking as opposed to taking public transport or driving vehicles. Broadly speaking, the most popular uses for health apps are: for personal fitness and wellbeing, for clinical and care-enhancing tools, and for health research. 5.2
Successful Examples
Samsung plans to incorporate a free app entitled “Smart Health” into all devices distributed to the African continent. “Smart Health” is said to be the ‘first ever Pan-African Mobile Health Delivery Network’ and was launched in 7 countries. The app provides real-time
16
GSM Association, Universal Access Report, 2012.
16 information on three pandemics; HIV/AIDS, tuberculosis, and malaria, along with approved symptom checkers for each disease.17 The benefits of this app are that is provides access to essential information that individuals may not easily obtain from their governments or public health authorities. By being purpose built into the technology of the smart phone, it becomes standard through which users are questioning their health; hopefully removing taboos and stigmas that might be attacked with asking questions about the type of subject matter covered. Medic Mobile is another example of mobile technology facilitating access to healthcare. Examples of how this technology has been used include18: 1. Antenatal care – health workers use the app to register pregnancies, schedule reminders about care visits, report danger signs to clinical teams, and coordinate with clinics to ensure delivery in facilities with skilled birth attendants. 2. Childhood immunization – health workers use Medic Mobile to register every infant and send texts to remind mothers about appointments 3. Disease surveillance – Health workers can report symptoms to the nearest clinic, send and receive advice about treatment and emergency referrals and provide information about the disease burden in their community. 4. Drug stock monitoring – Medic Mobile platform is used to report stock levels every week, monitor dashboards, and guide and oversee distribution to ensure access. 5.3
Mental Health
Remote access to healthcare must also be provided to treat mental health conditions. For example, in conflict zones and refugee camps, where it is not possible to reach a trained mental health professional, advice and therapy could be provided remotely via digital platforms such as Skype. It is essential to ensure that a safe, private location is provided to facilitate the sessions. It is important that people can access psychiatric care in places where a trained professional may not be able to physically access, so remote access would be the next possible method of provided treatment.
17
Mobilium. Press release in Cape Town- South Africa, 1st October 2013. http://mobilium.com/wp-content/uploads/2013/10/1st-October-2013_Mobilium-Smart-Health-Hub-PressRelease.pdf 18 http://medicmobile.org/usecases, 2015
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5.4
Policy recommendations
In order to harness digital infrastructure in the most effective way possible, the following policy recommendations should be implemented: 1. In the modern world, access to a mobile signal is becoming increasingly wider and necessary. In order to implement the best practices of sustainable, advanced healthcare to every global citizen, access to a mobile signal must be recognised as being a necessity for humans; therefore, it should be included in the sustainable development goals. In turn, this would mean that governments must build better digital infrastructure to ensure that their citizens are not denied access to these healthcare initiatives. 2. It should be a legally binding condition that remote access to healthcare cannot be compromised or interfered with within conflict zones. 3. Mobile technology companies/app companies should be encouraged to work with local communities to build free, culturally sensitive apps which use human-centred design to address the particular needs of that community and pre-install them on devices or make them free to download and use. It must be a collaborative effort with community health workers, nurses, patients, and community members who are seeking ways to make health care delivery more efficient, effective, and wide reaching. It is essential to remember that no one-size-fits-all policy can be made when creating remote health care programs, the policy focus should instead be on keeping the communities at the heart of the design, cost, implementation and promotion. 4. The 'global initiative platform for access to healthcare' should be set up as an international organisation that is absolutely free at the point of access and cannot be politicised by governments.
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A Bottom Up; Community-led Approach.
International Organizations and NGOs carry out invaluable work regarding healthcare services in the developing world. Such actors help drive development projects, and have excellent expertise in the areas in which they work. It is important, however, that wherever possible local people and communities are integrated into development projects. There are many benefits to involving local actors in every possible stage of healthcare programmes. Awareness and enthusiasm for initiatives being implemented will increase if a community feels that it is an integral part of its operation. Furthermore, the more local actors who are involved in healthcare programmes, the further that awareness of them is likely to spread. Knowledge and behaviour relating to such health initiatives will become internalized more effectively within communities with the involvement of local actors. In addition, this involvement will increase the long-term sustainability of healthcare initiatives, as they will no longer be completely reliant on external actors for their implementation. With locals trained and experienced at each stage of the process, a transition may eventually be made such that programmes can be fully sustained without the need for external actors to be present. 6.1
Key Issues
We acknowledge that in times of health crises, international intervention and emergency humanitarian aid delivered by external actors are both necessary and successful. With a view to the long-term development however, the international community must consider how best to enable these regions to take control of their own health initiatives effectively and affordably. Only through policies of this kind will health programmes be sustainable, and dependency on external actors broken. This community centred approach, involving extensive contributions from local people, will provide an opportunity for economic growth, employment, and social empowerment, as well as improvements to public health. Whenever crisis relief is not the focal issue in a region, a long-term strategy to domestic health care in states should be a priority. A continued reliance on international intervention and aid in response to health issues is not sustainable and does not remove the sense of dependency throughout the developing world. Internalizing the production and delivery of healthcare services will contribute to economic growth, employment opportunities and improved public health across the world. We acknowledge that production and manufacturing outside of the target state can often be cost effective. Despite this, the overall benefits of regional and domestic production, distribution, and delivery of health related materials and services must also be considered.
19 Job creation for local actors, who may otherwise be unemployed, brings both economic and social benefits to a region, as well as increasing the likelihood that the healthcare services provided will be positively perceived. The benefits of a domestic response to health issues we have identified are: •
Sustainability. International interventions to health issues require large amounts of funding and ongoing support. The involvement and inclusion of local actors has the potential to enable healthcare developments to become self-sufficient within the communities in which they operate.
•
Cultural integration. By fully internalizing health care in a given region, good health practices will become normalized and health stigmatization will be reduced.
•
Economic Value. By increasing production and distribution of healthcare materials within a state, opportunities for employment and social enterprise will arise.
6.2
Implementation
As emphasized throughout this report, there can be no “one size fits all” response to improving sustainability within healthcare. The differences between regions, cultures, the health issues they face and the services that must be provided means that every situation must be considered independently. This report does not, therefore, suggest a blueprint for the inclusion of local actors in all cases. In some policy areas it may be relatively straightforward to implement this at every stage of the process. In others, technical challenges, or the necessity for specific expertise may make this unfeasible. Instead, we suggest a general framework of considerations that can be applied to a health programmes; in order to assess the viability of the inclusion of community based actors. For every policy, each stage of the process of production of health and medical materials to distribution and implementation should be reviewed. The AFI Changemakers suggest that primary, secondary and tertiary policies should be considered and would maximize sustainability and national production and distribution of health care. Below is a flowchart containing the type of questions that should be considered when implementing sustainable health programmes, as working example. These questions are accompanied by the current approach to each area of programme implementation.
20
The higher the number of these questions which can be answered in the affirmative, the greater is the potential for the inclusion of local actors at each stage of the implementation
21 of the programme. By bringing these questions to bear on future health initiatives, they can be more effectively tailored with long-term sustainability in mind. An example of such an enterprise is A to Z Textile Mills Ltd, who manufactures insecticidal mosquito nets. It has a strong focus on local production and, as such, has provided employment opportunities to over 7000 Tanzanians.19 By setting up their operation in East Africa, local people are able to become involved at every stage of the process, from production to distribution and use. This model brings more wide ranging benefits to the region than simply providing malaria nets from the outside, increasing employment opportunities and the potential for economic growth, as well as imparting knowledge and skills to the people involved. This approach is not only limited to the production of malaria nets, but can be used in all areas of healthcare provision. From drug manufacture and administration to health education resources and workshop mentoring, health management and organisation should come from within the effected state wherever possible. Other health initiatives which are being driven through social enterprise and local application include Living Goods who, through ‘networks of franchised microentrepreneurs’ distribute vital drugs throughout Uganda using local door to door salespeople and set their prices at 20%-40% below other retailers.20 This model is being adopted in other states, such as in Kenya, where Marie Stopes are extending a network of agents and mobile outreach teams to inform rural villages and urban slums about quality contraception services.21 Social enterprise in health with a focus on community involvement is not only beneficial in the developing world, but developed countries have also considered local involvement in providing medical expertise and support. In the UK, social enterprises have become a pioneering service offering great support and helping to relieve the pressure on the NHS. Programs such as Wellbeing Enterprises offer community support groups with ‘holistic interventions’ with the aim to work ‘collaboratively with residents and local organisations to mobilise the skills and talents of people and to empower them to gain a greater sense of control over their health and wellbeing’.22
19
http://www.azpfl.com/index.php/en/profile/company-profile http://livinggoods.org/what-we-do/mission2/ 21 http://mariestopes.org/what-we-do/family-planning 22 http://www.wellbeingenterprises.org.uk/what-we-do/ 20
22 Our aim to involve local actors and encourage communities to internalise their own wellbeing through grass roots programs is applicable worldwide. While a range of issues face different parts of the world – such as TB and malaria in sub-Saharan Africa and wide range of mental illnesses throughout Europe – the same bottom up approach can be applied across the globe to combat health problems and improve access to medicines.
6.3
Policy Recommendations •
Any proposed health policy should be disaggregated into its component parts during formulation. Each of these constituent parts should then be considered in turn, with a view to involving as many local people from within the policy target area as possible. This may be achieved by analyzing the proposal in terms of its primary, secondary and tertiary stages, and each should aim to provide additional benefits to the community in question. By following this process, as illustrated graphically in the flowchart above, each element of healthcare provision can be considered as a separate opportunity to improve the long-term sustainability of the proposal.
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Where manufacture within a state is not feasible, local networks, drawing on the success of initiatives already in place across the world, must implement outreach programs. Such programs must seek to actively engage the community through education about, and involvement in, projects being implemented locally.
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Conclusion
This report has emphasized the necessity of a holistic approach if healthcare initiatives are to be sustainable. Education, infrastructure, new technologies, and the comprehensive involvement of local actors must all be considered together, in order for the implementation of health policies to be maximally effective and sustainable. It is important that rather than separate issue areas, the topics covered in this report are all perceived as fundamental to healthcare. When designing health policy, actors must consider all of these areas equally to ensure that the benefits they are trying to achieve reach as many people as possible, are efficient and effective, and will be actively engaged with by those they are trying to reach. The report has also acknowledged that there is no “one size fits all� approach when attempting to solve health crises. For this reason, the majority of the recommendations detailed within have been widely applicable frameworks, with a view to helping guide policy makers when tackling specific health issues. By applying these suggestions, issue and region specific solutions can be made more sustainable and effective, and thus go further towards achieving the targets set out in the SDGs. Whilst some initiatives are short-term by their very nature, we hope that this report will help to reinforce the importance of taking a wide, holistic view of healthcare. By understanding that health care encompasses everything discussed here, small changes can be made which will dramatically improve the long-term impact of our actions today. Ensuring that the benefits of healthcare persist far into the future, with the ultimate aim of creating a world where short-term solutions are no longer required, should be the primary focus of all healthcare programmes.
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Meet the Working Group
Henry Gilliver (Chair and editor): Henry is currently studying for a master’s degree in International Public Policy at University College London. He is especially interested in the power of international norms, and the individuals and organisations that create and promote them. He is involved with AFI Changemakers because he passionately believes that young people have a vital role to play in this process, and can be instrumental in bringing about positive global change. Henry is currently on the AFI Changemakers organisational team.
Daisy-May Super (rapporteur): Daisy is in her fourth year studying English Law with Australian Law at King’s College London. She is currently undertaking an internship with an NGO specialising in social enterprise and community empowerment with Tanzanian youth and women and has previously volunteered with an NGO in Kenya implementing sustainable development initiatives in secondary education. She believes that the way out of poverty and national inequality is through business and economic stimulation achieved through global co-operation and discipline.
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Emma Robinson: Emma is a student of Theoretical Physics at King’s College London. She is passionate about addressing educational inequality and childhood disadvantage. She has worked for a variety of organisations and NGOs that aim to promote social justice and hopes to continue pursuing a career that allows her to help to create more equal opportunities for all. Emma is currently on the AFI Changemakers Organisational Team.
Maria-Alexandra Radu Alexandra is currently reading Business Management and Media Publishing in the UK, where she is currently based. Her passion for international development and social entrepreneurship has led her to work in various countries and for multiple projects, including India, Zambia, the UK, Romania and Belgium. She is dedicated to connecting and sharing ideas with people from all parts of the world, and wants to continue to work in empowering women – particularly in her area of interest: STEM fields.
Rinisha Yagarajah: Rinisha is currently a final year medical student in Moscow, Russia. She is passionate about instigating positive global change, and is involved with Changemakers so that she can use this passion to have a real world impact.
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