Community Centered Health Systems for improved governance and accountability in Health: An Analysis of the COPASAH Symposium
Denis Bukenya (People’s Health Movement Uganda/HURIC)
The title to the COPASAH Symposium alone set the pace to this Analysis, “Leaving no one behind: Strengthening Community Centred Health Systems for Achieving Sustainable Development Goals”. This title in my mind alludes to a commitment to serve people and humanity through a more democratic approach that allows them to be involved in their own health challenge solving and development. It is important to note that many marginalized people’s lives in the community are in jeopardy the world over hence the need for community ethos and creation of a conversation between grassroots practitioners, policy advocates, research and academia, policy makers and the implementer. The symposium encased a motley of approaches from the grassroots, practitioners, researchers and academia, policy makers and implementers from all over world, uniquely modeled to gainfully engage members of community and their leaders to improve governance and encourage community accountability.
While COPASAH has been run since 2011, this was my first time to attend the event. The practitioners use social accountability approaches to strengthen the linkage between communities and the health systems to provide quality and accountable care. The symposium revolved around five themes emanating from a specific theme anchor of Leaving No One Behind: Strengthening Community Centered Health Systems for Achieving Sustainable Development Goals. This year, the symposium was organized at the India Habitat Center, New Delhi-India. Approximately 500 people were in attendance from diverse political, social and cultural contexts including COPASAH members from Latin America, Southern Central Europe, Sub Saharan Africa, Eastern and Southern Asia along with researchers, donors and policy makers in the field of public health governance.
The five major areas considered included: Community Action; Indigenous and Marginalized Peoples; Sexual & Reproductive Health and Rights; the Private Sector in Health and Health Workers. Alongside plenaries and parallel sessions, the Symposium comprised workshops, dramas, cultural events and film screenings, and a poster exhibition. Dedicated sessions for regional consultations allowed time for in-depth consideration of the draft COPASAH Charter and Call to Action, as well as other geographic-based discussions. Most importantly, the vast majority of participants hailed from the Global South. I should say that the Arab region, North Africa, and the Pakistan perspectives were greatly missed.
Although in this case the outcomes were fairly benign, the structure and content of the Symposium and the discussions were fascinating. Owing from my point of view, combined with my experiences at such Global Health fora, below I outline what I have learned about citizenship, governance and accountability in health considering strengthened community centered health systems.
The need to continuously empower Civil Society as a feat for citizens’ voices
The narrative showed that Development cooperation has been highly characterized and the Civil Society Oorganizations (CSO) are being steered towards certain actions over others depending on the funding curve of the donor. Multinational corporations have tuned development corporation into a weapon to disguise profit in the health sector. So many examples were sited, notably was the issue of medical tourism in India where the doctors will treat all cost regardless of the survival rate of the patients.
Evidence interrogated at the symposium showed that due to these deliberate efforts through aid and other Civil Society Organization partnerships, the focus has turned to treatment rather than prevention. Simply because the multinational corporations will then line their pockets for trade and profits. Truly so, development corporation focusing on prevention is steadily dwindling. The broader challenges that I hailed the symposium for exposing in the SDG era were the numerous partnerships that have widely opened the floodgates to the private sector which stands for profits at the expense of ill health.
Clearly the practitioners in a bid to fast track strategy shared how they have countered this challenge in their various jurisdictions. The most memorable approach was to form coalitions and muster collective responsibility embanked with numerous community voices to their leaders in demand for sanity. I also got to learn that visual art is a tool of advocacy that appeals most to the youth and the young.
The conflation between treatment and prevention is problematic
Within the Global Health agenda, Universal Health Coverage (UHC) issues are being framed in terms of treatment solutions. Solutions that, for example, propose public private partnerships to accelerate access to pharmaceutical products. Jane Nalunga, the Country Director of SEATINI/Uganda described how reallocation of power in decision-making, funding and provision of health services from the state to private sector actors and donors continues the exclusion of communities from information, decisions and feedback regarding their health care. More evidently so, the UN General Assembly high level meeting, 2019, prevention was hardly mentioned but the justification of the need for private partners. Chris Owalla the Executive Director of Community Initiative Action Group Kenya (CIAGK) based in Kisumu, Kenya at one of the sessions questioned the narrative as to whether we are still in focus of the debate to help a people at the grass-root when we keep discussing how to make a UHC funded by private public partnerships. We ought to have taken more time questioning this assumption. However, the discussions soon turned to circular debates over engaging with “health harming” industries such as food and alcohol. This illustrates the situation at COPASAH, where civil society (the People’s Health Movement and a few other NGOs) felt they had to interrupt the plenary to have their voices heard, to help support the brilliant panelists points. My analysis is that civil society are in “an abusive relationship with industry”, Global Health is an uncomfortable third wheel in this long-term relationship between Public Health and trans-national corporations.
The commercial determinants of health are at the top of everyone’s intellectual agenda – but action is not being funded
The most energized and well attended session at COPASAH was the excellent People’s Health Movement-led session on the commercial determinants of health and political economy of health. Although the atmosphere was one of activism the audience contained a range of delegates, including those from the global governance of health list like the WHO. The discussions did not progress and likely only served to re-enforce pre-existing assumptions on both sides. While the importance of tackling the commercial determinants of health at the community level is widely agreed, as mentioned above this is not reflected in funding flows. This highlights the challenges for Global Health actors to implement research and projects that may displease their donors; donors who are beholden to private capital flows that may well be invested in the products that public health evidence now shows to be so harmful. In other words the political economy of Global Health in action. To my disappointment, the debate turned political and I really felt like my fellow community activists were denied the opportunity to process the information to make it actionable. It is at that point that I made the suggestion as a way forward that there is a need for PHM to continue simplifying the messages in their policy briefs and share the information widely on the pros and cons of the financial determinants of health and the political economy of health making it more actionable for grass-root consumption.
Global Health and the Neoliberal Global Political Economy
The governance and accountability in health is dominated by the ideology of neo-liberalism, which places the individual and free-market at the centre. It is important to view global health as part of a system that has increased inequality and inequity and strangely so it seems a fantasy to expect the opposite. The appropriation by many actors in the global health economy has distracted the understanding of the political economy within Global Health. There is a fear that by holding a symposium on governance and accountability in health, and self-congratulate ourselves on seeking to address the issues of governance and accountability hence the inequality, a box is ticked and it is business as usual. We need more governance and accountability analysis of Health systems and the community institutions. But who will fund it? Who will publish it?
The aim of COPASAH was to: “identify major bottlenecks, root causes and propose solutions from the grass-roots to the national and global level to accelerate implementation of proper health systems governance and accountability in health. Whilst the foreseeable objectives were fulfilled, it begs the question as why solutions to the root causes were not forthcoming. Further questions coming to mind were: should the symposium have further considered an elite UN dominated Global Health symposium to better interrogate the governance and accountability in health? I am not so sure.
To conclude, here is my observation and personal analysis to those who attended the symposium and would love to see change in the current status quo in Global Health.
1) The demand for access to information at the grass-roots needs to be demanded even at Global level. We need to interrupt proceeding to refrain from using words like business as usual. We need to demand that Aid through our global leaders is relaxed to serve at the grass-roots. The negotiations should be made public notice for communities to have meaning-full participation: It is important that communities demand collectively for protection from pandemics by the global health leaders, to fight infectious diseases, to find the cure for cancer if possible, an support nations as they work out a formula towards a Universal Health Coverage dully financed by national taxes and also be open to sharing the data generated.
2) There is an ardent need to continuously critique and work with the UN systems at all levels so that its engagement with the member states can periodically get reviewed on their safe-guarding norms and aspiring to global goals with evidence from the communities.
3) In the meantime, let’s use the data Global Health generates more smartly – to show what is not happening as well as what is. And to use more political economy analysis to help show why.
4) Let’s dump down the messages around strengthening community centered health systems, so that members of the public all over the world can understand the issues and causes of injustice. Let’s tell the stories behind numbers in ways that people can understand, communicated in forms they can utilize (clue: not case studies!).
5) Finally, and most importantly, let’s be inspired by people like the volunteers at the COPASAH secretariat in India to be champions, to not give up on what we believe in (for me, social equality, equity and social justice). But let’s also be realistic: Global Health is great for measuring things and improving health security; it is not necessarily the right place for people who want to tackle injustice, and change the world in the many ways it so urgently needs changing.
Denis Bukenya – PHM-Uganda, Human Rights Research Documentation Centre (HURIC),Uganda