Health for All! Wemos Strategy : a bird's eye view

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1 Health for All! November 2009

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3 A10f November 2009 Health for All! Wemos International Health Advocate Wemos is an International Health Advocate that influences, in close collaboration with Southern and Northern partners, national and international policies through advocacy work towards key Dutch, European, and International actors in order to assure that sustainable national health systems in developing countries effectively serve the population, with a specific focus on: Financial Resources for Health, Human Resources for Health, Medicines, and Nutrition as Wemos has a solid track record and extensive expertise, experience and international networks on these key areas of concern.

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5 Contents Prologue 7 Executive summary 8 1. The health issues at stake Everyone has the right to health Health is a major concern to millions of poor people Dysfunctional health systems National actors in health are taking the lead International actors increase coordination efforts Wemos International Health Advocates Wemos core business Wemos vision, mission and overall objective Wemos Way of Working Wemos approach to advocacy Wemos Southern partners Wemos strategic alliances & networks Focus areas in improving people s health Focus area criteria Financial Resources for Health Human Resources for Health Medicines Nutrition Exploration of new themes 30 Abbreviations and acronyms 35

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7 Prologue Before you lies a bird s eye view of the Wemos strategy for the period : Health for All. The strategy builds on the Wemos strategy : Breaking the Vicious Circle, and it includes inputs from the Mid Term Review in 2008, an analysis of trends in the health sector, consultations with Southern partners (February 2009), expert advice and our own reflections and lessons learned. The main difference in the new strategy is that Wemos from 2011 onwards will not focus exclusively on working with four institutional partners in four countries. The Mid Term Review revealed that this was a too narrow and risky base for the leverage that Wemos seeks to create in advocacy for the right to health for all. A larger and more varied network of relations will be built for joint advocacy. In addition, the nature of these relations will change. Wemos will no longer be involved in organisational strengthening processes and administration of institutional funding that took much of our attention away from the strength and core business as International Health Advocate. We will, however, respect, and fulfil all commitments made under the Breaking the vicious cycle strategy and gradually grow into our new strategy. In our continued quest for Health for All, Wemos will deepen and expand its collaboration with partners in development that share a strong drive and commitment to realise changes on specific thematic areas. We will therefore look for strong partnerships at the national and international level with organisations that advocate for changes in the thematic areas that we have jointly identified. We strongly believe that it is only through joint efforts that we will create the necessary clout to address the structural causes of inadequate health policies, to improve the coordination of health efforts, to shape and implement adequate regulations and codes of conduct and to contribute to the further strengthening of health systems in developing countries that effectively serve the population. Moreover, our global context is changing rapidly, the global food and energy crisis have taken a dramatic toll on the poor and some predictions show that the financial crisis will have an even deeper and more damaging effect on the situation of millions of poor people. In this context, Wemos structural approach to giving the poor a voice and therewith strive for more effective use of resources, and the elaboration of coherent and inclusive policies that aim at strong health systems are more urgent than ever. It is my aspiration that health will finally be seen not as a blessing to be wished for, but as a human right to be fought for. (Kofi Annan, Former United Nations Secretary General) 7

8 Executive summary The right to health is one of the basic human rights: all people have the right to the enjoyment of the highest attainable standard of health", and all people are entitled to have access to health services and to the other determinants of health, including safe water, nutrition, and housing. The improvement of people s health is a crucial prerequisite for sustainable development. For millions of people in this world, living a healthy life however remains a distant goal. In this context, Wemos core business as an International Health Advocate is to influence, in close collaboration with Southern and Northern partners, national and international health policies through advocacy work on key Dutch, European, and International actors, with a specific focus on four interlinked themes: Financial Resources for Health, with an aim to strengthen national health systems through securing and increasing quantity and quality of international development assistance for health; Human Resources for Health, with an aim to promote policy changes and interventions that have a positive impact on developing countries abilities to expand and retain their health workforce through e.g. increase technical and financial support of donors and refraining from recruitment of health staff from developing countries at all times; Medicines, with the aim to promote clinical trials contribution to public health priorities through improved transparency, enforcement of ethical standards, and the establishment of a public fund for paediatric clinical trials, improving the protection of the rights of clinical trial subjects and poor people s access to child size medicines in developing countries; Nutrition, with an aim to promote policy changes that effectively address undernutrition in pregnant women and children between 0-2 years of age through strengthened national health systems and the implementation of sustainable solutions, like monitoring the International Code of Marketing of Breast-milk Substitutes and the promotion of policies that support exclusive breastfeeding and global guidance and policies on the marketing and use of Ready to Use Therapeutic Foods (RUTFs). As an International Health Advocate, Wemos holds international actors (donors, international and multilateral agencies, and businesses) accountable for fulfilling their health responsibilities and for strengthening national health systems in developing countries that equitably and effectively serve the population. Wemos comes in action when the policies, budgets and actions of (inter)national actors are incoherent and fail to respect, protect and fulfil the Right to Health in developing countries, and weaken national health systems. With her Southern partners and international strategic allies, Wemos designs theme-specific strategies addressing the health and health system issues at stake and implements a chain 8

9 approach to advocacy; an approach that connects the local, national and international dynamics to improve policies for better health. The connection involves feeding each other with information, addressing a specific issue with different actors simultaneously and being able to refer to each other if action at a higher level is needed. Within the advocacy strategies agreed upon, Wemos generally focuses on advocacy activities towards international organisations (Dutch, European, and global) (Wemos acts here), whereas the Southern organisations direct their attention to national governments and institutions and the national bureaux of international organisations (Southern Partners act there). Wemos has a long history of working in different strategic alliances and networks. It is inherent to the organisation s way of working; Wemos can achieve better results in advocacy in strong alliances putting pressure on policymakers and implementers to really change and improve specific health issues. Wemos maintains an extensive network of national and international organisations with which it shares information and pursues joint action on a broad range of health related issues. 9

10 1. The health issues at stake Further reduction in poverty is probably not possible without significant improvements in the health condition of people (Deepa Narayan, Senior Advisor at the World Bank, 2007) 1.1. Everyone has the right to health The right to health 1 2 is one of the basic human rights: all people have the right to the enjoyment of the highest attainable standard of health", and all people are entitled to have access to health services and to the other determinants of health, including access to sufficient, safe and nutritious food for an active and healthy life, safe water, and housing. All people, furthermore, are entitled to healthy working conditions, health-related information and education, and gender equal access to health and decision making; all crucial to realise the right to health. These services, goods and conditions should be in place and available, of good quality, and accessible to every person without any discrimination. Governments are responsible for the realisation of the right to health of their citizens. They are invited to respect health in all their policies and actions, to protect health by preventing third parties from interfering with the right to health and to fulfil health by taking steps to ensure access to health services and other health determinants through an integrated and comprehensive national health system. Governments also need to be accountable to their citizens and to be transparent about their efforts to realise the right to health. The right to health also drives governments to international assistance and cooperation to realise the universal right to health; rich countries support poor countries which have inadequate means to realise the right to health of their citizens, and respect the right to health in other policies (e.g. by ensuring that migration policies do not jeopardize health programmes in developing countries) and protect the right to health by regulating other actors (such as pharmaceutical companies involved in clinical trials in developing countries) Health is a major concern to millions of poor people Let hunger be ranked first, because if you are hungry, you cannot work! No, health is number one, because when you are ill, you cannot work. Discussion group of women and men, Musanya Village, Zambia 3 The improvement of people s health is a crucial prerequisite for sustainable development. Three of the United Nations Millennium Development Goals (MDGs) are health-related, six out of the MDGs are related to malnutrition. Good health is fundamental to a life in dignity. 10

11 Health is of daily concern to people, and our most basic and essential asset. Ill-health prevents people from working, learning, caring for others; from active participation in society. People are willing to make many sacrifices when confronted with ill-health. It is for this reason that poor people worldwide list their living conditions and the exclusion from health services in their top-5 of sufferings 4. For millions of people in this world, living a healthy life however remains a distant goal. Every hour 1000 children under five die, whereby malnutrition is responsible for about 35% of child deaths and 11% of the total global disease burden. Although average health indicators show improvement at global level, progress is not evenly spread and health inequalities between and within countries is increasing. The most recent MDG progress report 5 shows negligible progress in reduction of maternal mortality in sub-saharan Africa and South Asia. 1 million people still die each year due to malaria, again mostly children and in sub Sahara Africa. 1.4 billion people still have no access to proper sanitation. In Africa, malnutrition contributes to more than half of all deaths from malaria and childhood illness and interactions with HIV hasten the onset of disease and death. Furthermore, the food and economic crises further exacerbated the amount of people suffering from chronic and acute malnutrition; hunger is on the rise again, from 800 million to 1 billion people. Children are most affected: more than 25% of the children in developing countries are underweight. Joyce Wafula lives in a small village in western Kenya. She is 50 years old and lives with her husband and four grandchildren. Three of her six children have died: two when they were very young, and one last year at the age of 30. Of her 20 grandchildren three have also died, of malaria. Joyce had hoped that time would bring change for herself and her family, but she is still a poor woman struggling to survive. She notices that the doctor in the nearest village is rarely present. On the radio she heard that the government plans to spend more money on health care, but she has not seen any effects of increased spending in her village yet: many people around her are sick and very little is done to improve the situation. Joyce is just one of the millions of people in this world trapped in a vicious circle of poverty and ill health. She is a fictitious person, but her story represents that of many women in Africa Dysfunctional health systems Yesterday Joyce went to the district hospital where she waited for hours to see a doctor. When she was finally called to his room he excused himself for being late but he had to meet two foreign officials who came to see him to discuss one of the health programmes. The district hospital is now running five different programmes funded by foreign donors, each focusing on a different disease. The doctor said that he is now spending most of his time receiving the different delegations and has hardly any time left to treat patients. According to the guidelines of the programmes, however, he is not supposed to use the programme budgets for investments in health personnel. At the same time, some of his best staff members have left the hospital to work in a private clinic in town where they can earn much more money. Joyce and many others complained about the long waiting times but he said that there is nothing he can do about it. The conditions in which people live, work and age have a powerful influence on their health. 11

12 Inequalities in these conditions lead to inequalities in health. According to the World Health Organisation (WHO), strong health systems are properly financed, have a well-trained and motivated workforce, reliable procurement of drugs and medical technologies, have an effective referral system and service delivery, adequate information systems to support policy and management and have the capacity to formulate and implement policies to guide stakeholders in the system. However, health systems in many developing countries are weak, suffering from structural underfunding and severe understaffing. Common problems in health service delivery as identified WHO are: inverse care (those who need most, receive least care), impoverishing care (catastrophic health expenditure causes 100 million people to fall in poverty each year, the economic losses due to malnutrition are as high as 6 to 10% of GDP in Africa.), fragmented care (with a narrow focus on disease control), unsafe care (lack of hygiene and safety measures) and misdirected care (disproportionate focus on a narrow set of curative care at the cost of prevention and promotion) 6. In addition, WHO points at the risks of a growing unregulated commercialised health care provision and financing. A stumble block for developing countries is that their regulatory capacity is generally very weak to oversee and coordinate the functioning of all health providers in the system. Where regulatory frameworks exist, weak or non-existent capacity to monitor compliance is another stumbling block. These issues that can only be addressed through coordinated structural support that targets functional national health systems. As the Mexican flu (H1N1) pandemic is currently showing us, health systems in the world are inextricably linked. The global health security of all nations is compromised by any health system that is not functioning properly. The same virus that causes manageable disruption in affluent countries will almost certainly have a devastating impact in countries with too few health facilities and staff, no regular supplies of essential medicines, little diagnostic and laboratory capacity, and vast populations with low resistance due to malnutrition and no access to safe water and sanitation National actors in health are taking the lead Governments in developing countries are increasingly taking leadership of their own health policies and take steps to improve engagement of parliaments and civil society organisations in shaping health policies and their implementation. National ownership of policymaking and implementation was one of the key elements of the 2008 Accra Agenda for Action. In the Africa Health Strategy , African health ministers agreed to enhance governance, community participation and ownership. Most countries have a multiannual national health strategy and regularly review progress. Many efforts have been undertaken to strengthen the health sector, especially with regards to service delivery, advocacy capacity within the sector remains, on average, very weak. Traditionally, national and international civil society organisations (especially the faith-based ones) have been providing health services and community-based programmes, more or less complementary to public sector providers. More and more civil society organisations 12

13 (CSOs) now also claim space in health policy formulation; they monitor implementation and increasingly hold local and national governments to account. Health budget advocacy initiatives empowering local communities and strengthening their demand in health service delivery are becoming more prominent. Also health professionals, working in the forefront of the health sector, are working to organise themselves and demand better working conditions. Increasingly, they also work in coalition on common goals with population groups International actors increase coordination efforts Global funding for health in developing countries has quadrupled from $5.6 billion in 1990 to $21.8 billion in A growing share (30% in 2007) of total funding for health comes from private sources (private foundations, non-governmental organisations (NGOs), citizens) 7. The enormous increase in funding for health has resulted in improvements in average (often MDG-related) health indicators at global level. The number of people that are infected with HIV is decreasing since Child mortality has also been decreasing slowly each year since 2007, to 9 million deaths annually 8. Distribution of Development Assistance to Health (DAH), however, is unequal. There are large differences between countries in the amount of DAH they receive, with some countries receiving much less than can be expected from their income level and disease burden 9. Distribution of DAH according to health needs is also uneven. In 2007, of $14.5 billion DAH, $5.1 billion was allocated to HIV/AIDS, $0.8 billion to malaria, $0.9 billion to health sector support 10 and $ 0.3 billion to basic nutrition. The number of donors, agencies and NGOs that are active in health, also increased considerably over the past decade, whilst global governance in health remains weak; regulatory frameworks and codes of conduct if existent are often not sufficiently acted upon and/or enforced. The WHO has the mandate to coordinate but not the leverage and financial independence to set international standards that go beyond mere disease control. Private foundations like the Bill and Melinda Gates Foundation have the resources, but lack accountability and public control, often resulting in investments not directly within the national health systems. The numbers of Global Health Initiatives have mushroomed enormously at the international level to about 100, creating huge coordination problems and transaction costs 11. Private commercial actors in health often provide or finance services for the better off, leaving the public sector to cater for the poor but without the political and financial support that is required. Services for the poor then often lead to poor services 12. The lack of coordination and divergence of views and strategies is impacting negatively at country level. Many developing countries struggle to obtain an overview of the plethora of donor programmes active in their country. Sector Wide Approach (SWAP) coordination structures have sometimes been undermined by new and big disease specific programmes that often operate outside country health systems. It has been widely recognised now that health system strengthening is also crucial for achieving the goals of disease intervention programmes. 13

14 The donor community recognises the limited quality of much health aid, including volatility, unpredictability, tying of aid, and lack of coordination, that leads to increasing transaction costs, distortion of country priorities, unreliable funding for health systems, lack of accountability to recipients. Efforts are underway to improve the situation (e.g. Paris Declaration, Accra Agenda for Action). The 8 biggest international agencies in health (including World Bank, Global Alliance for Vaccines and Immunisation (GAVI), the Global Fund, WHO) announced their intention to better coordinate and streamline their support. A recently formed taskforce on Innovative International Financing for Health Systems strives to increase investments in the health sector. 2. Wemos International Health Advocates We need to invest now in our ability to bring actual performance in line with our aspirations, expectations and the rapidly changing realities of our interdependent health world. United by the common challenge of primary health care, the time is ripe, now more than ever, to foster joint learning and sharing across nations to chart the most direct course towards health for all. (Dr Margaret Chan, Director-General World Health Organisation, 2008) 2.1. Wemos core business In this highly complex context, Wemos core business as an International Health Advocate is to influence, in close collaboration with Southern and Northern partners, national and international policies through advocacy work on key Dutch, European, and International actors. The advocacy work involves direct lobbying, public campaigning and awareness raising as well as creating alliances in order to achieve the desired changes in people s lives. Wemos advocacy work focuses on four interlinked themes: Financial Resources for Health, with an aim to strengthen national health systems through securing and increasing quantity and quality of international development assistance for health; Human Resources for Health, with an aim to promote policy changes and interventions that have a positive impact on developing countries abilities to expand and retain their health workforce through e.g. increase technical and financial support of donors and refraining from recruitment of health staff from developing countries at all times; Medicines, with the aim to promote clinical trials contribution to public health priorities through improved transparency, enforcement of ethical standards, and the establishment of a public fund for paediatric clinical trials, improving the protection of the rights of clinical trial subjects and poor people s access to child size medicines in developing countries; 14

15 Nutrition, with an aim to promote policy changes that effectively address undernutrition in pregnant women and children between 0-2 years of age through strengthened national health systems and the implementation of sustainable solutions, like monitoring the International Code of Marketing of Breast-milk Substitutes and the promotion of policies that support exclusive breastfeeding and global guidance and policies on the marketing and use of Ready to Use Therapeutic Foods (RUTFs). All Wemos advocacy efforts on these four themes are geared towards the further emergence and strengthening of sustainable national health systems in developing countries that are equitable, accessible and effectively serving the population in general and people like Joyce and her family more in particular. All advocacy efforts are furthermore informed by Wemos strong stance on the introduction of and respect for and obedience to standards of ethical conduct in health. Wemos has a solid track record and extensive expertise, experience and links with international networks on these key areas of concern. Wemos envisages to further research a number of new areas of concern and interest that might develop into future key focus areas for Wemos international advocacy activities (see par 5.6) Wemos vision, mission and overall objective Vision: Wemos envisages a world in which every person can realise his or her right to the highest attainable standard of health. Mission: Wemos advocates for the right to health of people in developing countries. Wemos advocates for the right to health with an overall objective: to further strengthen national health systems that effectively serve the population in developing countries. Wemos focuses its advocacy activities on a limited number of themes that are all of key importance to strengthened national health systems and people s improved health. Health systems need to pay attention to health care delivery and to the conditions for leading a healthy life and are therefore crucial in the Wemos vision and mission. Health systems should fulfil certain criteria so they can contribute to the structural improvement of people s health. First of all, health systems should make health services available to all, not only in urban areas but throughout each country. This implies that health systems should comprehensively guarantee the availability of a wide range of services (preventive and curative delivered by both public, private, including donor-run services) covering local health priorities taking into account a broad variety of health services as there are: reproductive health services and vaccination programmes, and IEC (Information, Education and Communication). All health determinants should be taken into account as there are: 15

16 housing, healthy food, water & sanitation, stress related to conflict and other conditions for leading a healthy life. Secondly, health systems should facilitate the accessibility of services to all. Men and women, old and young, poor and rich, disabled people and people from minority groups should all have access to health services. This implies geographical and financial accessibility as well the acceptability of the services that respects cultural preference of health users and have a non-discriminatory approach. Thirdly, health systems have to be sustainable. This implies that they have to be in line with local priorities, norms and values regarding health. The gender equal participation of the population in making decisions regarding health systems is vital in ensuring sustainability. This participation implies the involvement of CSO or other representatives of the population in policy formulation, implementation and monitoring and evaluation. Another aspect of sustainability is the importance of long-term investments in health systems. Short-term programmes that end within a year or two should be part of a broader strategy to strengthen the health system or a national health policy. As an International Health Advocate, Wemos holds international actors (donors, international and multilateral agencies, and businesses) accountable for fulfilling their health responsibilities and for strengthening national health systems. Wemos comes in action when the policies, budgets and actions of (inter)national actors are incoherent and fail to respect, protect and fulfil the Right to Health in developing countries, and weaken national health systems, e.g.: 1. respect health in other policies, e.g. trade agreements that protect intellectual property rights at the expense of the availability and affordability of life-saving drugs; migration policies that do not jeopardize, nor undermine health policies and programmes. 2. protect health through regulation of other actors, e.g. effectively monitoring the compliance to international ethical standards by pharmaceutical companies in clinical trials conducted in developing countries; 3. fulfil health by providing sufficient and effective support to governments in developing countries, e.g. donor programmes that finance recurrent costs including wages, to support national systems and priorities. 3. Wemos Way of Working 3.1. Wemos approach to advocacy With her Southern partners and other strategic allies, Wemos designs theme-specific strategies addressing the health and health system issues at stake and implements a chain approach to advocacy; an approach that connects the local, national and international dynamics that improves conditions and policies for better health. The connection involves feeding each other with information, addressing a specific issue with different actors 16

17 simultaneously and being able to strengthen and support each other if action at a higher level is needed. Within the advocacy strategies agreed upon, Wemos generally focuses on advocacy activities towards international organisations (Dutch, European, and global) (Wemos acts here), whereas the Southern organisations direct their attention to national governments and institutions and the national bureaux of international organisations (Southern Partners act there). If so requested, Wemos supports Southern organisations in strategising and in addressing their target actors. Depending on the theme-specific advocacy strategies that have been defined, Wemos and her partners in the South can play a variety of roles. Wemos being an International Health Advocate, the three main roles that Wemos fulfils are; being a watchdog, an expertinformant, and a lobbyist. As a watchdog policy implementation is monitored and governments and international organisations confronted with the gap between the realities on the ground and the ideal and/or agreed upon conditions and circumstances; As an expert-informant technical advice and information is provided to policy-makers and decision-makers when the analysis points out that their knowledge-gap is part of the problem; As a lobbyist the policy process is entered as a full participant and direct approaches are made to influence policy. This involves formulating and representing positions in public situations or meetings with policy makers Wemos Southern partners To be effective in influencing and changing policies for better health and stronger health systems, Wemos works closely with able Southern organisations. The themes on which Wemos focuses its advocacy activities are all identified in close collaboration with these Southern organisations and allies and based upon shared analyses of the health issues at stake. In pursuing the shared advocacy agenda s, Wemos collaborates with Southern organisations: with which it shares a common vision on health and health systems; that have a shared interest in one of the four thematic focus areas; are equally interested in pursuing jointly identified outcomes; are well established and able actors; and that are operational in developing countries. In partnering and collaborating with Southern organisations, a win-win situation is created: Wemos depends on Southern partners to anchor its activities at the level where it counts for people like Joyce striving for better health the field and national level. And Wemos needs field inputs and real life stories to make its case on the international stages of policy making, whereas Southern organisations rely on Wemos for access to sound information and research as well as access to international fora for decision making. 17

18 Wemos disseminates information, analyses and opinions, on the issues relevant for the advocacy efforts within the thematic focus areas, to partner organisations and networks in the South. This involves both technical information about the thematic focus areas of interest, as well as the status of international policies and decision-making processes and their relevance for the country level. Wemos also facilitates the participation of various actors in international lobbying, e.g. by preparing joint statements for the World Health Assembly (WHA), inviting organisations to sign-on to lobbying letters, inviting organisations to participate together with Wemos in international lobbying events. Networking and exchange between organisations working on the same themes within one country or between countries is promoted, to explore possible synergies and discuss advocacy agendas and strategies. Where needed, Wemos links partner organisations with international actors at country level: opening doors to international actors and (co-)organising in-country meetings including donor representatives along with civil society representatives. Upon request, Wemos also brokers for financial and capacity development support to Southern organisations in shaping, managing and executing their advocacy activities Wemos strategic alliances & networks Wemos has a long history (over 25 year) of working in different strategic alliances and networks. It is inherent to the organisation s way of working; Wemos can achieve better results in advocacy when it forms strong alliances putting pressure on policymakers and implementers to really change and improve specific health issues. In its rich experience with alliances, Wemos has learned that for these alliances to be 18

19 successful: their members trust each other and share enthusiasm and drive for the goals of the alliance and agree to the joint mission, vision, and jointly defined objectives, outcomes and outputs; they are focused on specific thematic areas; they are focused on key actors that can influence the political agenda and that have the leverage to achieve the intended results through the implementation of specific and jointly developed action programmes; they build upon members complementing roles and mutually reinforcing activities; ranging from implementing organisations with a large partner network, health workers organisations HERE and THERE, trade unions, research institutes with international recognition, or experts that promote ethical standards in health; and they are well-managed (clearly defined roles, responsibilities, and decision-making processes and procedures). The key trait of a strategic alliance is the pooling of resources (human and financial) to achieve jointly identified goals through the implementation of a shared programme of activities. Strategic allies can be organisations or networks in the North and in the South. Apart from these, Wemos collaborates and maintains an extensive network of national and international organisations with which it shares information and pursues joint actions on a broad range of health related issues. 19

20 4. Focus areas in improving people s health 4.1. Focus area criteria Within the vast area of health and health related issues, Wemos focuses its advocacy activities on specific areas of attention that are all considered to be of key importance in strengthening national health systems that contribute to the structural improvement of people s health in developing countries. More specifically, the areas on which Wemos focuses its attention are: relevant for helping poor people in executing their right to health; considered to be of great interest by able Southern organisations that have expressed active engagement on the issue at stake; within Wemos areas of recognised expertise and experience; appealing and revealing to a wider public; specific in the sense that one can identify both actors to be targeted with advocacy activities, as well as outcomes achievable by Wemos and her Southern partners; interesting for a wider group of international organisations and; inspirational to Wemos staff Financial Resources for Health The issues at stake Joyce is member of the district budget club. Every month, the local CSO monitors the quality of public health service delivery, such as presence of medical staff, availability of drugs, and cleanliness in the health facilities. Problems that arise are discussed with local authorities or, if issues cannot be solved locally, with provincial or national level authorities. Achievements so far include filling up a vacant post for a doctor and an increase in the budget for patient meals. One issue that the budget club cannot solve is the overall limited availability of funds. Even if the government allocates a fair share of national resources to health, and the money is managed better, it remains insufficient. Health services are also provided outside the public facility, through NGOs and, increasingly, specific programmes aimed at HIV/AIDS or other diseases. The budget club doesn t know how these programmes are managed, or whether the resources could be used to address the permanent shortage of staff in the health centre. Not enough money is being allocated to health. To attend the health needs of people in lowincome countries, total health expenditure needs to be raised from an estimated USD 31 billion in 2009, to USD 76 billion a year by Typically, developing countries do not have the domestic financial resources to fully assure their citizens right to health and they remain dependent on international development assistance to (partially) fund their health systems. Providing support to poor countries is a core obligation for rich countries under the right to health. Despite the recent rise of Development Assistance to Health (DAH), the 20

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