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PHASA Workshop Report; Is there a better pill in the house? Civil Society action to treat the National Health Crisis

Below is the report of the PHASA workshop which was hosted by the People’s Health Movement at the PHASA conference on 19 September 2016 in East London, South Africa.

Is there a better pill in the house? Civil Society action to treat the National Health Crisis

The People’s Health Movement (PHM) held a workshop at the Public Health Association of South Africa (PHASA) Conference in East London on 19th September 2016 to explore the role of Civil Society action in health. The aim of the workshop was to examine the role of Civil Society in addressing the Health Crisis in South Africa, building on a joint Civil Society process involving provincial and a national health assembly. The workshop was led by David Sanders, Leslie London and Shehnaz Munshi. About 19 participants from a range of different sectors and organisations attended and participated.

Background

The workshop was prompted by a recognition that the South African health system continues to generate a number of challenges, which, taken together, represent a national crisis in health. Key policy initiatives, such as the National Health Insurance, the Re-Engineering of Primary Health Care, the establishment of the National Institute of Public Health of South Africa and quality improvement systems are all current – but it is unclear if they will be able to effectively address the current challenges, particularly of inequity in the health system and in the key social determinants of health. Even though high levels of civil society engagement accompanies South Africa’s democratisation, the recognition of the politics of health has faded over the subsequent decades, and currently civil society, student and workers unhappiness is evident in the scale of national protests around multiple issues, including health and its determinants.

The People’s Health Movement, in partnership with Section 27 and the Treatment Action Campaign, identified the need for Civil Society to unite to address these challenges. Six elements for action were provisionally identified in the partnership as a basis for initiating a national process of consultation and mobilisation: 1) Lack of meaningful community participation; 2) the crisis in human resources for health; 3) Inadequate leadership and management in the health system; 4) Ongoing Challenges facing programmes tackling HIV/AIDS & TB; 5) The Social Determinants of Health and 6) Privatisation of health care. Discussion documents on these elements were used to stimulate a national process of provincial assemblies held in all provinces, culminating in a National Health Assembly in June 2016, attended by 150 participants from 40 organisations and which developed a plan of action for Civil Society to campaign on the main challenges facing the health system.

This workshop shared the process and outcomes of the provincial and national health assemblies and presented an opportunity for PHASA participants to interrogate their social accountability and responsibility through health activism/advocacy.

The workshop aims were to enable participants to

  • Interrogate the role of civil society in building a responsive health system;
  • Interrogate current civil society initiatives in the health policy context in South Africa;
  • Identify opportunities for the Public Health community to engage the work of Civil Society in strengthening the health system;
  • Get involved in the work of PHM and other Civil Society organisations in health.
  • Identify how public health education can tap into health activism as engaged scholarship

Format

The workshop began an icebreaker exercise to make participants more familiar with examples of Civil Society action for health, in South Africa and globally. The icebreaker also helped to introduce participants to important civil society actors in health. Then, the workshop focused on a case study to explore stakeholders and strategies available to civil society for action on health. The last group activity then dissected the NHA outcome campaigns to explore both what advocacy could do for this area, but also to reflect on how this affects education and training. Two groups were assembled, one on Human Resources for Health and one on Social Determinants of Health. The Annexes 2 and 3 provide a more detailed account of the discussion.

Outcomes

  • We need to translate policies into practice. For example, there is an urgent need to clarify the policy on CHWs that give clear guidance on roles, accountability, training and conditions of service. Transformative leadership is needed to popularise the CHW concept. For SDH, we need strong intersectoral action to translate policy directives into practice.
  • Public health community can assist by generating evidence for supporting policy and its implementation. There is still a space to produce the cost-effectiveness data to persuade treasury about the case of CHWs; similarly, providing technical support to communities to monitor Social Determinants of Health will provide them with tools to lobby for change.
  • Public health practitioners can work with communities to support awareness raising – both in relation to CHWs and in relation to the Social Determinants of Health;
  • Our training curricula need to be transformed. For example, training programmes should integrate CHWs, so that graduates can effectively refer, engage and receive referrals to and from CHWs. Similarly, with regard to the SDHs, we need more teaching and training that enables graduates to be agents of change (advocacy skills), rather than to know about SDHs but to regard SDHs as beyond their remit.
  • We should think how to sharie good practice examples across the public health community, both with regard to CHWs and SDH.

Evaluation

We only had 6 evaluations returned from the 19 participants, so the feedback is not representative. However, of those who did return their evaluations forms, the feedback was overwhelmingly positive. All respondents agreed or strongly agreed that the workshop met its objectives, met their expectations, there was good participation and facilitation at the workshop, and that there was sufficient time for discussion. Respondents also agreed or strongly agreed that they got some good ideas from the workshop, will implement some of these ideas and would recommend the workshop to others.

Annex 1: Workshop Programme

Axnex 2: Report back – Group Human Resources for Health

Annex 3: Report back – Group Social Determinants of Health

Annex 4: Powerpoint (pdf): Is there a better pill in the house

Annex 5: Powerpoint (pdf): The role of Civil Society in the Health System

 

Annex 1: Programme

Is there a better pill in the house? Civil Society action to treat the National Health Crisis

We are seeing many national protests around multiple issues of failures of service delivery, corruption and inequality, also affecting health and its determinants. The challenges facing the South African health system represent a national crisis. However, even though high levels of civil society engagement accompanied South Africa’s democratisation, the recognition of the politics of health has faded over the subsequent decades. The People’s Health Movement, in partnership with Section 27 and the Treatment Action Campaign, identified the need for Civil Society to unite to address these challenges through a national process of provincial assemblies held in all provinces, culminating in a National Health Assembly in June 2016, attended by 150 participants from 40 organisations. The NHA mapped a plan of action for Civil Society to tackle these challenges facing the health system.

This workshop will share the process and outcomes of the provincial and national health assemblies and focus on the role of Civil Society in addressing the health system failings.

It aims to enable participants to

  • Interrogate the role of civil society in building a responsive health system;
  • Interrogate current civil society initiatives in the health policy context in South Africa;
  • Identify opportunities for the Public Health community to engage the work of Civil Society in strengthening the health system;
  • Get involved in the work of PHM and other Civil Society organisations in health.
  • Identify how public health education can tap into health activism as engaged scholarship

Facilitators:

David Sanders, UWC and People’s Health Movement, Bellville, 7535 Sandersdav5845@gmail.com

Leslie London, UCT and People’s Health Movement, Observatory, 7925, leslie.london@uct.ac.za

Shehnaz Munshi, Wits University and People’s Health Movement, Parktown, 2193

 

13h00 Icebreakers and introductions
13h15 Outline and overview of the workshop
13h30 The role of Civil Society in Health Systems
14h00 Groupwork
14h30 Tea break
15h00 The National Health Assembly process
15h30 Groupwork
16h00 Report back and discussion
16h30 Closure

 

Annex 2: Human resources for health:

The group was asked to comment on the challenges of Human Resources for Health as it affects Community Health Workers (CHWs). CHWs are key members of the broader health teams but our policies pay lip service to the important role of CHWs. Many CHWs are employed under very poor working conditions with lack of support. If South Africa is going to achieve universal coverage in health, it needs to take seriously what CHWs can bring. What should their roles and functions be? How can we address the challenges they face? To whom should they be accountable? How should they best be supported in our health system?

The group was asked to respond to the following questions:

  1. What do you think should be done to advance civil society action to secure a strong and progressive CHW presence in the health system:
    1. Which stakeholders/actors should be involved?
    2. How should we involve them?
    3. What challenges would need to be addressed in order to involve them?
  2. How can our educational programmes in public health engage with the actions of civil society advocating for community health workers in the health system?

 

Discussion in the group was as follows:

  • CHW are historically mostly funded by NPOs and work in communities
  • Training is heterogeneous, as is their scope of practice
  • Should be able to render comprehensive care, but most are ‘specialised’ to deliver vertical services
  • Payment is meagre (typically R1500-2000/month) and work is limited to 4.5 hours/day
  • Because they are not employed by the government, they are more vulnerable with regard to occupational health and safety and job security
  • How many are there?
    • 71000?
  • Group feedback/answer:
    • First we need to define what CHWs are (supposed to be)?
      • Lay or educated?
      • Paid or unpaid?
      • Standardized job description or free-form/variable?
      • Government or NPO?
      • Are they part of medical teams or the community?
      • Generalists or specialists?
      • Accountable to their communities or the Health Department?
      • Preventative or curative or both?
    • Take note: There is a policy being developed on community based service delivery, including scope of practice, training, employment and supervision
    • Solutions:
      • We need a clear CHW policy (how are they located in the health system?)
        • What is their career path, what is their role in the community?
        • NDOH has apparently decided: they should be part of health system
        • This is likely to be met with opposition where they are NPO based

How can we have a civil society response that aims to achieve a meaningful policy on CHWs?

  • Look to KZN at the problems had by Provincial DOH
    • After unfair labour practices, CHWs have been outsourced
    • Now a total disruption in services
    • Taking MEC to court
  • Engage with:
    • Communities
    • NDOH
    • Provincial departments
    • Treasury – perception that they hold the view that no cost effectiveness for CHWs has been demonstrated?
    • Professional bodies – should CHWs they have their own?
    • Evidence/Researchers
    • Labour experts (Basic Condition of Employment, OHS and/or medico-legal implications of sensitive information sharing)
    • The Media
  • Activities:
    • Grassroots
    • Politically accurate mobilization: General consensus is that they should unionize – by themselves or join an established union, e.g. HOSPERSA
    • Evidence gathering
      • Questioning the manner in which cost-effectiveness is calculated
    • Make CHWs indispensable to health systems
  • Aligning Medical curricula which should have a more PHC approach
    • CHW should input to the curriculum
    • Our graduates should know when and how to refer and also receive referrals
  • Why is there not more transformative stewardship from top to popularize the idea of CHWs?

Annex 3: Social Determinants of Health

The group was asked to comment on the challenges related to the Social Determinants of Health, which are much wider than the health services.  They are social, political, economic, environmental and cultural.  They need upstream interventions to promote health and prevent disease.  Many vested interests will want to continue selling products that are harmful to health, promote practices that maximise their ability to make profits and will seek to influence policies to suit their interests.  What should civil society do to tackle the social determinants of health?  How can we address upstream intervention and make sure government does not allow vested interests to shape our health?

Questions

  1. What do you think should be done to advance civil society action to address the social determinants of health?
    1. Which stakeholders/ actors should be involved?
    2. How should we involve them?
    3. What challenges would need to be addressed in order to involve them?
  2. How can our educational programmes in public health engage with the actions of civil society taking action to address the social determinants of health in the health system?

Discussion Summary:

Social determinants of health are not well addressed although there is much discussion about them, policies are not translated into actions to improve social determinants of health – instead it is left to individuals to decide implementation actions.

For example in sanitation – environmental health committees are set up by local government, are there committees?  Are there environmental health practitioners?  The fundamental questions are WHAT to do, WHO will do it, and DO they do it?

For example in nutrition, KZN has a good structure of nutritional support for districts and hospitals, but is still struggling with child malnutrition.

Another example, in EC, two children were malnourished in a home living with a grandmother and were identified after 4 years – there were no grants – why are DSD and DoH not working together?

Another example, Philani Nutrition in Khayelitsha and Zithulele EC practices positive deviance (Ingrid le Roux after ideas from Jerry & Monique Sternin – Tufts School of Nutrition/ Save the Children-Vietnam (see article from Fast Company here) where mothers who raise healthy children despite poverty share their strategies with other mothers.  This has been proven to improve and sustain nutritional status even for younger siblings 2 years after cooking classes as evaluated by the Harvard School of Public Health (Vietnam work).  “Act your way into a new way of thinking instead of think your way into a new way of acting” – the book on this idea: Power of Positive Deviance.

Is this approach victim-blaming when there are multinational forces at play?

Yet, there are still problems with child death in Zithulele as well as OR Tambo & King ?? Districts have extreme poverty.

On the other hand, South Africa is now among the top 5 countries in the world for obesity now!

Factors that could be contributing to malnutrition (DS)

Household food insecurity

Extreme poverty

Inadequate knowledge of Nutrition

Possible interventions include

Promotion of breastfeeding

Improving the weaning diet

Intersectoral action is lacking, instead work is organized in vertical silos, with no mandate, budget or human resources to substantively address issues of water/sanitation, food/nutrition, etc.

Action must be taken at both the individual / community level of implementation as well as higher levels of policy and advocacy analysis.

Extensive discussion on the need to educate ourselves as public health practicioners and communities, as otherwise there is no demand for change

The evidence is that policy change has significant effects  (Fran Baum) – so what are the policy levers that could be used? 

– increasing price of cigarettes, and banned smoking in public places (SA)

– sugary drinks

Concern re: extraction of money from the poor (Elroy Paulus) Black Sash has a current case on this

Also aggressive marketing and lobbying re: processed food, it doesn’t spoil.

Concern that people buying 4 Twiza, cigarettes and alcohol (contributes to injuries) yet don’t have money for food.  Another story re: no water to buy, only coke.  Corporates prioritizing profit over health.

Could this be a psychological self-destruction?  Internalization of oppressor / abuser?  Or is it that the government is prioritizing profit over people and encouraging fast food and other corporates who are actually damaging health?  Or something else?  McDonalds spends as much on lobbying advocacy for parliaments as it does on advertising.

Recommendations:

  • Awareness and Conscientization about the context of social determinants of health and their impact on health.  For example, what is the level of knowledge of communities / HCW about the current food environment?   Noted that conscientization and monitoring could be two sides of the same coin– community based participatory research has wonderful examples i.e. where teens did analyses of local food shops in a food desert –  the Good Neighbor program see  link to video. (This report on a CBPR partnership in San Francisco’s Bayview Hunters Point neighborhood documents the rise of a community food security policy in response to youth-involved research that found poor access to quality food in an economically disadvantaged area of the city.)
  • Community Monitoring (Communities + Technical Experts)
  • Policy and Advocacy Monitoring – also a Health in All Policies Analysis
  • Look to document and share examples of bad practice / good practice and innovations towards improving social determinants of health.

 

for education:

  • Expand teaching for under- and post-graduates in nutrition – currently extremely brief – i.e. 1 lecture
  • Advocacy & Activism for Public Health Practitioners

 

About Tinashe Njanji