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

21 total amount is still far from sufficient. In order to help fill the finance gap for health in developing countries, donor countries should increase their official development assistance (ODA) for health to 0.1% of Gross Domestic Product (GDP) 1415 and realise additional ways to increase finance for development, such as a tax on international currency transactions 16. Innovative financing mechanisms may become more important as the global economic crisis is putting the levels for development assistance for health further at risk. Secondly, despite many efforts to improve aid effectiveness in general and the quality of health aid in particular, imbalances and lack of integration are still very problematic. The existence of the International Health Partnership and related initiatives (IHP+) reflects the acceptance by the donor community of the need to invest in health systems. Within some of the Global Health Initiatives (GHIs), which mostly focus on disease specific results, Health System Strengthening (HSS) funding opportunities are (modestly) increasing and mainstreaming of HSS components is encouraged. But there is still a long way to go. 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 17 This resulted in clear progress on the three diseases but also a neglect of other health outcomes, fragmentation of aid and service provision, high transaction costs, expensive parallel bureaucracies to manage GHIs, overburdening of fragile health workforces, misalignment of GHIs and country health needs, distraction of government officials from their overall responsibilities for health and weak accountability of the rapidly expanding number of GHI funded NGOs 18. Furthermore, development assistance to health is increasingly channelled through private and commercial actors like hospitals and insurance companies. High expectations exist of what the private for profit sector could bring to the health sector. Public Private Partnerships (PPP) aiming to engage private actors for health outcomes have been booming. Private for profit investments in the health sector have been modest though, especially in sub-saharan Africa. Experiences thus far indicate that PPPs can create winwin situations, but can also have adverse effects for the health sector. These include fragmentation of the health system, increasing costs, pulling health workers out of the public sector, lack of access for the poor and decreasing political support for the public system. These effects occur especially in poorly regulated and governed environments. As hazardous effects of PPP on health systems should be absolutely avoided, proper monitoring mechanisms on the effects of PPP are required. 19, 20 The Netherlands meets (and exceeds) the general 0.7% ODA target, but does not allocate 15% of it s ODA to the health sector. Dutch development assistance for health will be around 10% of the total ODA budget in Political will to maintain the total ODA budget at 0.8% of GDP is weakening. A large share of Dutch DAH is spent through GHIs. The Netherlands is per capita the biggest donor in AIDS. Meanwhile, budget cuts are announced for bilateral sector-wide programs, while sector support is becoming accepted as the most effective way to support national health systems. The Dutch government provides financial support to the private actors in health (e.g. insurance, nutrition and medical equipment companies), but it lacks a clear policy framework to guide these financial investments. The Netherlands Government promotes f.i. private health insurance as an innovative way of the private sector contributing to health systems. Independent assessments of this contribution could shed light on its effects regarding access for all, equity policies and it s contribution to the functioning of the broader health system. This could provide input in formulating policy 21

22 guidance that ensures that poor people also benefit from private interventions and that health systems are strengthened in a sustainable manner. The European Commission, based on recommendations from an audit of its development assistance to health services in Sub-Saharan Africa, has declared that sector budget support will become the preferred aid modality, and will be increased from 9% under the 9th EDF to 16% under the 10th EDF (European Development Fund). The EU has collectively committed to increase the EU support to health to 8 billion by 2010, of which 6 billion for Sub-Saharan Africa. An Inter Service Group has been established within the EC to define EC actions for more efficient use of Global Fund resources The advocacy agenda Wemos calls for strong public and political support to protect the overall aid budget against budget cuts and increase the share allocated to health to 15%. In addition, Wemos calls for increased efforts by the Dutch Ministry of Foreign Affairs, to increase availability of global DAH for health systems strengthening and health outcomes beyond those captured in the MDGs. The Netherlands can play a powerful role, through its contribution to and Board membership of the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM) and other GHIs and certainly through its bilateral sector programmes. Wemos calls as well for the elaboration of a policy framework of the Dutch Ministry of Foreign Affairs to guide private (commercial) sector support in the health sector, to ensure its contribution to equity and increased access of the poor and to stronger overall health systems. Throughout the world, national and international NGOs are advocating for an increased aid budget for health. Many of them ask for funding for priority diseases (especially AIDS). There is also a growing movement that advocates for increased funding for health systems that respond to local needs and priorities. In Europe, Action for Global Health is a key advocate addressing both European Commission (EC) and member states contributions. Oxfam-members are also active on this issue. In the Netherlands, Wemos will seek to broaden the existing alliance with Dutch organisations for the overarching objective of increasing financial resources for the public health sector in developing countries, aiming to overcome competition among disease-specific targets. Collaboration with Southern partner organisations is important for joint lobbying. In addition, the design and implementation of local action-oriented research for evidence-based advocacy requires close collaboration. Based on the agendas and findings of partners in the South, Wemos will put pressure on Dutch and European policy- and decision makers to raise levels of financial resources and advocate for their effective use to enforce the right to the highest attainable quality health care for all. 22

23 4.3. Human Resources for Health We have to work together to ensure access to a motivated, skilled, and supported health worker by every person in every village everywhere. (Dr. Lee Jong-Wook, former Director General of the WHO, WHR 2006) The issues at stake The shortage of health personnel seriously impacts the life of Joyce. In Kenya, in the area where Joyce and her family live, there is absolutely no guarantee that, when she goes to the health facility, there is a doctor or nurse to attend to her. Should she be in need of medical care there might not be a health worker available to treat her. A workforce of dedicated, committed, professional and skilled health workers form the heart of every health system, these health workers are key to guarantee the right to the highest attainable and quality healthcare for all. Today, hospitals, health centres, ministries and other institutions are faced with huge challenges due to lack of personnel. The WHO 21 estimates that there is a worldwide shortage of 4.3 million doctors, midwives, nurses and support workers. About 59 million people make up the global health workforce but they are distributed unevenly. The crisis is extremely severe in 57 countries, especially in sub-saharan Africa. Four of every hundred health workers can be found in sub-saharan Africa, which makes up for only 3% of the world s health workers. It is the same region that has to deal with a quarter of the global burden of disease with less than one percent of the world s financial resources for health available. By contrast, around 23% of the doctors trained in sub-sahara Africa are currently working in OECD countries. Health workers in developing countries face low salaries and limited training options, poor working conditions with little equipment and a lack of career opportunities, this, combined with attractive green pastures abroad, forms a range of both push and pull factors that provoke the movement of health workers and contribute to the unequal distribution of the health workforce across the globe. The OECD countries are also faced with a shortage of personnel which is solved by actively recruiting staff from developing countries. The education of these health workers was paid for by the government of the source country. These recruitment practices are often incoherent with the ODA investments in the health sector in developing countries or other policies (e.g. on migration) of these OECD countries. In 2006 the World Health Report laid out an action plan to address these issues and in March 2008 the Global Health Workforce Alliance (GHWA) held its first forum which resulted in the Kampala Declaration and Agenda for Action. The Agenda for Action consists of six interconnected strategies for joint action; building coherent national and global leadership; ensuring capacity; scaling up health worker education and strategy; retaining an effective, responsive and equitable distributed health workforce; managing pressures of the international health workforce market and its impact on migration; and securing additional and more productive (donor) investment in the health workforce. Wemos, as GHWA 23

24 member, has adopted this Agenda for Action and uses it as its base for defining the focus for its advocacy which links primarily to the first strategy and the final three strategies The advocacy agenda Addressing the global health personnel shortage effectively requires, according to the GHWA, coordination and commitment from both national and international actors to invest in the health workforce. In 2006, the EU has adopted a European Programme for Action to tackle the shortage of health workers in developing countries ( ) 22 with interventions at global, regional and national level. Implementation of this programme by the European Member States is lagging behind. Wemos focus will be to advocate, with a wide range of collaborating partners, for action, policy changes, and interventions in a number of European Member States which are geared towards implementation of the EU Programme for Action to tackle the shortage of health workers in developing countries. Wemos advocacy will address both the push and pull factors in the source and destination countries and clearly entail the interaction between lobby activities at national, regional and international level. At international level: in close cooperation with international, European and Dutch organisations, Wemos is actively contributing to the development of a Global Code of Practice on international recruitment. The Global Code is being developed by the WHO in consultation with its Member States and expected to be finalised in Wemos advocates for explicit inclusion in the Code of the obligation of countries to assist each other in the implementation of the Right to Health. This obligation means that donor countries ought to provide technical and financial support to tackle the shortage of health workers in a country. In addition, Wemos advocates for the formulation and implementation of policies and practices in a country that does not undermine the functioning of a health system in another country. This means for example that recruitment practices in the Netherlands should not have a negative impact on the availability of health staff in another country. At the Dutch level, Wemos will target part of its lobby activities towards the Dutch government (Ministry of Health and Ministry of Foreign Affairs) as it can play a guiding role at international level on this issue. In 2009, the Minister of Health has acknowledged that a Dutch code of practice for international recruitment of health workers might be developed to ensure avoidance of negative consequences of brain drain for developing countries. Wemos works in close collaboration with Cordaid, Oxfam Novib, trade unions, health professional organisations and the European Forum for Primary Care (via a multi-sectoral approach) to urge the Dutch government to give more priority to the issue of human resources for health in order to contribute to strengthening health systems in developing countries. In the South, Wemos works in collaboration with its partner organisations in a number of countries (Kenya, Zambia) and with the partner organisations of Cordaid. There is also a close working relationship with the Regional Network for Equity in Health in East and Southern Africa (EQUINET). In the international arena Wemos will continue its cooperation 24

25 with a.o. GHWA, Medicus Mundi International (MMI) and Physicians for Human Rights. At European level, Wemos is collaborating with European civil society organisations and networks such as MMI to assure implementation of the commitments of EU Member States made in the European Programme for Action to tackle the shortage of health workers in developing countries ( ). Wemos continues her advocacy for the formulation and implementation of a European code of practice on the recruitment of health workers. Wemos is encouraging the Dutch government to take a more pro-active role in policy discussions related to HRH at European level. In sum, Wemos advocates for actions, interventions, measures, and policy changes in the Netherlands and Europe (HERE) which prevent further negative impact on Health System Strengthening and Human Resources for Health in developing countries (THERE). This way Wemos, as international health advocate, contributes to tackling the global Human Resources for Health crisis Medicines The issues at stake Joyce has a need for safe, essential and affordable medicines. A small minority of the medicines that have been developed in the past years were primarily for diseases that predominantly occur in developing countries. 23 New drugs for wealthy markets are however increasingly tested on people in developing countries. For Joyce participating in a clinical trial might be the only way to get access to medicines. Joyces children particularly lack access to safe and affordable medicines as few pharmaceutical companies are involved in the development of paediatric drugs. As a result Joyces 1 year old daughter uses medication that has been developed for adults, which means she has to take pills that are hard to swallow and of which the effects on children are not known. Clinical trials. Clinical trials are an important part of the process of drug development as this is the phase where new drugs are tested on human beings to gather data on safety and efficacy. It is also the most costly part of the drug development process. Pharmaceutical companies increasingly outsource clinical trials to developing countries, mainly as lower costs are incurred. In these countries, trials can also be carried out more quickly because regulatory constraints are less stringent, while the low level of income in developing countries entails that people are often more willing to participate. However, trial subjects in developing countries are more vulnerable than those in wealthy nations. Health systems in developing countries often function inadequately, leaving the poor without access to treatment. As a result poorer citizens in need of medical attention may see themselves forced to participate in a trial to get at least some access to treatment. In addition, the end of a drug trial often means the end to all treatment. A study by Wemos partner in India, the Centre for Studies in Ethics and Rights, 24 described how a breast cancer drug that was tested in India was unaffordable for the majority for Indian patients. International ethical guidelines, such as the Declaration of Helsinki, have been formulated to protect the rights of trial participants; this includes the right on continued treatment and informed consent. However the bodies charged with overseeing and implementing these guidelines in developing countries such as 25

26 regulatory agencies and ethics committees, do not function properly. The weakness of the regulatory framework is caused by insufficient financial resources, lack of training and corruption. Since 2006 Wemos partners in Europe, Latin America and India have gathered evidence of serious ethical violations of clinical trials carried out in developing countries. Drugs tested in these countries enter the European market. Wemos believes it to be unacceptable that trial subjects in the South are exploited for the benefit of European consumers. Since 2006 Wemos has lobbied successfully for strict ethical checks before granting drugs market authorisation to the European Union. The rationale behind that approach was that pharmaceutical companies would refrain from unethical testing if their pharmaceuticals would be denied market access. Wemos has supported partners in the South in their work towards strengthening regulatory bodies. Paediatric medicines. The pharmaceutical industry sets the global research & development agenda for medicines. As a result, mainly drugs are being developed for which a large return on investment is expected. As mentioned before, these are often not the drugs that address public health priorities in developing countries. Several international organisations such as Knowledge Ecology International, Oxfam and Health Action International are addressing the causes of this problem and are developing alternative models to stimulate R&D for public health priorities. Within this broad R&D discussion, Wemos will focus on clinical trials for public health priorities in relation to access to safe and affordable paediatric medicines. First of all, Wemos has built up expertise and a strong partner network on clinical trials. And secondly as the lack of paediatric clinical trials has a major negative impact on the safety and availability of paediatric drugs world wide. Pharmaceutical companies hardly invest in paediatric clinical trials as they consider them to be complicated and not profitable. A substantial part of the essential drugs that should be available for children are no longer protected by patent and therefore there is no commercial incentive for companies to invest in clinical trials. As a result, percent of the daily prescriptions for sick children are off label, meaning that scientific evidence is lacking for use in this population 25. This leads to inefficacy and possibly toxicity. As few companies are involved in developing drugs for children, the prices tend to be very high. According to the World Health Organisation a thousand children under five die every hour. For most of the diseases prevalent in children a treatment exists 26. However not in dosages or forms that are suitable for children. The World Health Assembly expressed its concern by passing resolution WHA60.20 "Better Medicines for Children" setting goals and calling for action by Member States, WHO and its partners to address the global need for safe, effective and accessible children's medicines. One of the proposed solutions is increased funding for paediatric clinical trials The advocacy agenda Wemos advocacy efforts will focus on strengthening of regulatory frameworks in North and South to control and enforce ethical standards of clinical trials. Wemos will do so together with its partners in India (CSER) and Latin America (Red Latino Americana de Etica y Medicamentos). Wemos will continue its lobby vis à vis the European Medicines Agency and national medicines agencies in the European Union to improve the oversight on ethics 26

27 in clinical trials carried out on trial subjects in developing countries. Wemos partners will strengthen the regulatory framework by providing advice to national governments and regulatory agencies and by creating monitoring mechanisms such as a clinical trial watch. Wemos will support its partners by facilitating information exchange and joint lobby events. Secondly Wemos will advocate for clinical trials that address public health priorities of developing countries. Parts of the clinical trial process should be brought back into the public realm. As this requires a fundamental system change, Wemos is realistic as to what can be achieved in 5 years. Wemos will play a role in stimulating the public debate and play a broker role in bringing together knowledge and best practices. Wemos expects that it will be possible to achieve concrete results on paediatric clinical trials, as public opinion and decision-makers are easily mobilised on this topic. The focus of Wemos lobby will, therefore, be towards increased public EU funding for paediatric clinical trials. Wemos will furthermore support the activities of Southern partners such as the Indian Centre for Studies in Ethics and Rights that wants to advocate for safe and affordable drugs for children Nutrition The issues at stake Ann, Joyce s daughter of 19, has a baby of 2 months old. Her baby has had diarrhoea for 3 days, and shows signs of serious dehydration. She does not know why her baby is so sick, since she has given her baby high quality milk-powder, which is considered to be the best ways to feed her child within her village. During her stay at the local hospital, she was given a package for free, which only needed additional water and heating. Although the quality of the water in her village might not be optimal, she ensured that her baby received the high-quality milk powder, occasionally substituting the powder for cow-milk and water if she did not have enough money to cover the costs to provide her baby with sufficient milk-powder. The facts are clear- undernutrition remains the world s most serious health problem and the single biggest contributor to child mortality. Undernutrition is estimated to be responsible for 3.5 million child deaths per year. Undernutrition, especially for unborn babies and children 0-2 years can have irreversible long-term consequences for their future health, cognitive development, and productivity. Hunger and undernutrition is the first stated Millennium Development Goal. In the Abuja declaration 2006, African leaders have committed to end child hunger and undernutrition 27 in collaboration with development partners. However attention and resources for addressing undernutrition have consistently fallen in the past decade, including by the Dutch government. Direct funding has been replaced by indirect funding which did not tackle maternal and child undernutrition. Some recent developments have led to a resurgence of interest and international focus of development partners on reducing undernutrition and address MDG 1: A publication by the World Bank Repositioning Nutrition as Central to Development - A Strategy for Large-Scale Action (2006) 27

28 A series in the Lancet on Maternal and Child Undernutrition, which provides a list of nutrition actions that are effective, evidence-based and can work in reducing Undernutrition (2008) A draft EC strategy paper: Enhancing EC s contribution to address Maternal and Child Undernutrition (2008) The current global food and financial crises In September 2009, the international nutrition experts of different development partners28 drafted a statement for the Global Action Plan (GAP) on nutrition. The aim is to mobilize substantially greater support for addressing undernutrition. The High level meeting on Food Security for All (Madrid, January 2009) reaffirmed the Right to Food, especially of children under-five years old, women and other vulnerable groups. There is increasing commitment from governments in the South as well as some donor countries to directly address the global problem of hunger and undernutrition in particular. Focussed attention will be on the most vulnerable target groups- pregnant women, lactating women and children under 2 years of age, who are at highest risk and vulnerable to issues of hunger and undernutrition, The Lancet series indicated that coherent action from the international community was needed on proven and cost-effective interventions, and conclude that Of the reviewed interventions, breastfeeding promotion, appropriate complementary feeding, supplementation with vitamin A and zinc, and appropriate management of severe acute malnutrition showed the most promise for reducing child deaths and future disease burden related to undernutrition. -Wemos advocacy efforts on nutrition are aimed at ensuring that the above mentioned policy intentions are fulfilled through adequate resources, strengthened national health systems and the introduction of sustainable solutions The advocacy agenda Ensuring good nutrition is a matter of international law conveyed by several international declarations and human rights instruments: Food security (World Food Summit, 2002) is a situation that exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life. Furthermore, the Convention on the Rights of the Child (CRC) ensures the right of the child to the enjoyment of the highest attainable standard of health. Article 24 of the CRC obligates governments to diminish infant and young child mortality and combat disease and undernutrition by taking measures to ensure that all sectors of society, particularly parents, "have access to education and are supported in the use of basic knowledge of child health and nutrition, and the advantages of breastfeeding. Wemos focuses on proven and effective early childhood feeding practices, like breastfeeding. Wemos advocates for the use of practices and interventions that work and calls for regulation of Public Private Partnerships that intend to improve maternal and child undernutrition. Wemos opposes practices such as the dumping of breast milk substitutes and baby food and strives for the implementation, establishing and enforcing of guidelines 28

29 on infant and child food supplements in Dutch, European and global policies. Public-private partnerships (PPP) There seems to be growing international acceptance that in order to make nutrition available and affordable partnerships between businesses, governments and civil societies are required. Although Wemos acknowledges the engagement of a range of stakeholders, including the for-profit food companies in promoting solutions for undernutrition, we are concerned by the growing influence of the private sector in the formulation of public health policies and priority setting. The private sector primarily represents its own interests, which are not necessarily consistent with public health priorities. As a result there is a risk that PPPs overemphasize nutrition interventions for which the private sector has a solution and that they do not sufficiently tackle the underlying causes of undernutrition (which is often beyond the span of control of this sector). Therefore it is important that Wemos plays a watchdog role in PPPs and insists on solutions that do address the underlying causes and the problems of the most vulnerable target groups. Wemos believes that PPPs need to stay vigilant and embedded in comprehensive strategies to structurally address nutrition focussed on national solutions that are linked to national plans in health. PPPs need to implement solutions that are affordable to those that are most vulnerable, sustainable over the long term, and evidence-based. In 2009 the Global Alliance for Improved Nutrition (GAIN) launched the Amsterdam Initiative on Malnutrition (AIM) 29. The goal of this public-private partnership is to improve the quality of food and attack hidden hunger (i.e. the lack of vitamins and micronutrients) by providing more low cost - high quality fortified foods through innovative marketing and effective distribution channels. The effort will target 100 million people in Africa by The Dutch government is an official partner within AIM and co-finances this initiative. Wemos is keen to provide its expertise and experience and, together with its partners, to critically monitor AIM and call upon public actors (Dutch, EU, UN) to formulate policies and guidance for PPPs in nutrition that contribute to structural solutions. Protecting and promoting exclusive breastfeeding The promotion of breastfeeding is identified as one of the most effective strategies in reducing infant mortality and in reducing child under nutrition. Estimates suggest that proper implementation of exclusive breastfeeding has the potential of preventing 12 to 15% of all under 5 deaths in the developing world. The promotion of breastfeeding is therefore an essential element of a comprehensive policy to fight undernutrition. Marketing practices that undermine breastfeeding are potentially hazardous. Evidence shows for example that there are still cases of unsolicited donations of breast-milk substitutes to emergencies sites. Wemos opposes unethical practices such as the dumping of breast milk substitutes and baby food and strives for the implementation, establishment and enforcement of guidelines on infant and young child feeding practices in Dutch and European policies and directives following the International Code of Marketing of Breastmilk Substitutes 30. Ready to Use Therapeutic Foods (RUTFs) 29

30 Over the past 6 to 8 years, the use of ready to use therapeutic foods has proven to be successful in the rehabilitation of severely malnourished children. This is when provided as a well-defined therapy under supervision of qualified health personnel. Currently a trend is emerging whereby this product is also promoted as useful to treat moderate malnutrition and in the prevention of undernutrition. Wemos is concerned that this approach provides for short term expensive solutions only and that it is not in line with searching for long term and locally available solutions, nor that it is a truly evidence based solution. We therefore call for the need for proper implementation and monitoring of regulations around the use and marketing of RUTF. To ensure a strong position and to be a constructive and well-informed partner within the nutrition debates and agenda, Wemos will seek to strengthen links with the established working groups on nutrition at the European and the Dutch level. Wemos relation with strong Southern and Northern organisations will be essential to advocate for the policy change indicated above. Wemos will have to invest resources in the collection of data and building evidence based cases. The current Wemos partners in Bolivia, Kenya, Zambia and Bangladesh are good starting points to identify and link up with Southern national and regional networks to advocate for sound practices that address undernutrition Exploration of new themes In order to continuously adapt to the ever changing health situation and related global dynamics, Wemos envisages researching a number of areas of concern and interest that might develop into future key focus areas for Wemos international advocacy activities Organ Trade The growing organ shortage and unequal global distribution of organ supply leads to crossborder movement of patients in need of organ transplantation. Developing countries have become a major source of organs for rich patients, including from European countries, who are prepared to travel and can afford to purchase organs. Unfortunately, legal frameworks in developing countries are either not present, less stringent or less actively enforced. This puts organ donors/vendors in a vulnerable position and makes them prone to the exploitation inherent in organ sales. The WHO has estimated that about ten percent of organ transplants around the world involve unacceptable activities and in some countries the rate is much higher. Wemos intends to advocate for the improved protection of organ donors/vendors in developing countries Health and Global Climate Change Global Climate Change has become reality and its impact is casting a dark shadow on the already vulnerable health conditions of millions of poor people. Expected effects are increased number of droughts, floods, storms, food shortages/ less nutritious foods and water supply being threatened, that will all exacerbate existing vulnerabilities of poor people. In close collaboration with its Southern partners, Wemos intends to research the effects of climate change on the health of the poor. In the Netherlands and Europe Wemos will strengthen its ties with organisations to further research whether or not a joint effort to 30

31 ensure policy coherence at Dutch and European level to advocate for measures that negatively effect health conditions of people in the South Health Advocacy Support In our role as international health advocate, Wemos will be a sparring partner for and provide support to its strategic allies, those organisations with whom Wemos is engaged in joint lobbying. This will constitute of a limited group though, while the need for support for advocacy in health is wide spread. As is mentioned above, there are few civil society organisations in low income countries that are engaged in advocating for health at the national level, and even less who advocate towards international actors in health. In order to contribute to stronger health advocacy in the South, Wemos wants to establish a unit that will provide coaching and training in health advocacy. Wemos experience in capacity building over the past years has shown that there is a need particularly for long-term support in the area of developing and implementing lobbying strategies. There already are institutes that develop tools and offer training opportunities, including for advocacy, but very few provide the required long term guidance to organisations in the application of these new tools and capacities. In 2010, Wemos will further explore this niche in terms of type of coaching needed and how this tailor made support to strengthen advocacy capacity in health can be done and develop a strategy accordingly. We want a better functioning health care, especially for poor people. Better health care gives them back their dignity and helps them escape the poverty trap. So let s put health care centre stage. (Minister Koenders, 2007) 1 International Covenant on Social, Economic and Cultural Rights, United Nations, adopted in 1966 and in force since 1976, 2 The right to the highest attainable standard of health, General Comment No. 14, Committee on Social, Economic and Cultural Rights, Geneva, May Dying for Change: Poor people s experience of health and ill-health, World Health Organisation and World Bank, Ibid. 5 The Millennium Development Goals Report 2009, United Nations, New York, The World Health Report Primary Health Care: Now More Than Ever, World Health Organisation, Geneva, `Financing of global health: tracking development assistance for health form 1990 to 2007, N. Ravishankar et.al., The Lancet, June The Millennium Development Goals Report 2009, United Nations, New York,

32 9 Ibid Global Health Funding: how much, where it comes from and where it goes, David McCoy et.al., Health Policy and Planning, July Ibid Health systems and commercialisation: In search of good sense, Koivusalo M and Mackintosh M,, Paper produced for the UNRISD International Conference on Commercialisation of Health Care, UNRISD, New York, More money for health, and more health for the money, Taskforce on Innovative International Financing for Health Systems, Investing in Development: A Practical Plan to Aachieve the Millennium Goals, The Millennium Project, % GDP equals 15% of the 0.7% target, the internationally agreed target for ODA that currently is being met by only a handful of countries. 16 More money for health. 17 More money for health and more health for money, taskforce innovative international financing for Health Systems, March Different sources ao. Lancet, WHO study synergies 19 Blind Optimism, Challenging the myths about private health care in poor countries, Oxfam Briefing Paper 125, February Commercialisation of health and capital flows in east and southern Africa: Issues and implications, Equinet Discussion Paper 77, August WHO (2006) The World Health Report 2006: Working together for Health 22 European Commission (dec.2005). A European Program for Action, to tackle the critical shortage of health workers in developing countries ( ) Com (2005) endorsed in May Pierre Chirac, Els Torreele. Global framework on essential health R&D. Lancet 2006;367: Sandhya Srinivasan, Centre for Studies in Ethics and Rights (CSER). Ethical concerns in clinical trials in India: an investigation. February WHO news release: WHO receives fund for children s medicines research with UNICEF

33 The African 10-year strategy (ATYS) was formulated by the Africa core working group (NEPAD, GAIN, DBSA, AED, HKI, MI, UNICEF, USAID, and WFP). African Regional Nutrition Strategy, the NEPAD African Nutrition Initiative within the Comprehensive African Agriculture Development Policy (CAADP), and the NEPAD 10-year strategy for combating Vitamin and Mineral Deficiency by draft statement developed by international Nutrition experts of Global Action Plan (GAP) developments partners group which includes nutrition leaders of BMGF, Bread for the World, CIDA, CDG, CORE, Cornell University,DFID, EC/ EuropeAID, GAIN, HKI, MI, PATH, REACH, SC-UK, SC-USA, Tuft University, UNICEF, USAID, WFP, WHO, WB. 29 AIM brings together members of the GAIN business forum including Unilever, DSM, AkzoNobel,as well as Wageningen University and the Dutch Ministry of Foreign Affairs. 30 World Health Assembly,

34

35 Abbreviations and acronyms abbreviation in English in original language AIS Health Action International, Bolivia Acción Internacional por la Salud, Bolivia BMS breast milk substitutes CSER Centre for Studies in Ethics and Rights CSO Civil Society Organization DAC Development Assistance Committee/Development Co-operation Directorate of the Organisation for Economic Co-operation and Development DAH Development Assistance for Health DGIS Directorate-General for International Cooperation Directoraat-Generaal Internationale Samenwerking DORP Development Organisation of the Rural Poor, Bangladesh EC European Commission ECHO European Commission's Humanitarian Aid Office EMEA European Medicines Agency ESAFF Eastern and Southern Association for Small Scale Farmers Forum EU European Union GAVI Global Alliance for Vaccines and Immunisation GDP Gross Domestic Product GFATM Global Fund to fight AIDS, Tuberculosis, and Malaria GHI Global Health Initiative GHWA Global Health W orkforce Alliance HENNET Health NGOs Network, Kenya HIF Health Insurance Fund HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HSS Health System Strengthening IFE Infant and young child Feeding in Emergencies IHP+ International Health Partnership and related initiatives MDG Millennium Development Goal NGO Non-Governmental Organization Niet-Gouvernementele Organisatie ODA Official Development Assistance OECD Organisation for Economic Co-operation and Development PPP Public Private Partnerships RELEM Latin American Network of Ethics and Medicines Red Latina Americana de Ética y Medicamentos SWAp Sector Wide Approach UN United Nations UNICEF United Nations Children's Fund USD United States Dollar WHA World Health Assembly (General Assembly of the World Health Organization) WHO World Health Organization 35

36 36

37 Colophon Title: Document: Author(s): Health for All!, A10f Wemos staff Date: November 2009 Wemos Foundation P.O.Box BR Amsterdam The Netherlands T F E [email protected] 37