Geneva Health Forum Archive

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Aspiring Towards a Framework Convention on Global Health.

Author(s) Lawrence Gostin1, Eric Friedman2.
Affiliation(s) 1Law Center, Georgetown University Law Center, Washington, DC, United States, 2Law Center, Georgetown University Law Center, Washington, DC, United States.
Country - ies of focus Global
Relevant to the conference tracks Advocacy and Communication
Summary The Framework Convention on Global Health (FCGH) is a proposed global health treaty that would be based in the right to health and aimed at closing immense global and domestic health inequities. A coalition of FCGH advocates established the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI), upon whose behalf we submit this abstract. The FCGH has earned growing support, including from UNAIDS. An FCGH Campaign will develop the content of the FCGH through inclusive, participatory, bottom-up processes, and will advocate for the treaty, based on agreed underlying principles. We encourage you to join the Campaign.
What challenges does your project address and why is it of importance? Amid much heralded improvements in global health over the past several decades, unconscionable health inequities stubbornly persist, and are the chief concern of the FCGH. There is a 24 year difference in life expectancy between sub-Saharan Africa and high-income countries. The health gaps between rich and poor within countries parallels those among countries. In the United States, Native Americans on the Pine Ridge Reservation in South Dakota have a life expectancy some 30 years below the U.S. national average. Beyond health equity, the FCGH would address a host of other problems of global governance for health. These include the lack of accountability within the global health system, poor coordination, and inadequate attention to such priorities as adequate sanitation and proper nutrition. The treaty would also respond to vagueness of key principles of the right to health, which undermine the potential of the right to health to be a forceful tool for accountability and guide for justice. And the treaty would respond to the dominance of other sectors and legal regimes, such as intellectual property and investment, over the right to health.
How have you addressed these challenges? Do you see a solution? We propose a Framework Convention on Global Health (FCGH), a global health treaty that would be based on the right to health with the chief aim of advancing health equity, domestically and globally. A FCGH would:• Establish guidelines for universally ensuring the conditions required for good health, covering health systems that provide quality health care and public health services that ensure health’s underlying determinants (such as nutritious food, sanitation, and clean water), along with the social determinants for health, and create guidelines for participatory, equitable national processes to adapt global standards and target country circumstances and priorities.
• Establish domestic and international health financing targets, frameworks, and policies to ensure sufficient health resources.
• Clarify right to health obligations, including obligations related to equity, participation, and accountability, utilizing maximum available resources towards rights, areas requiring immediate realization and the nature of progressive realisation, respecting and advancing the right to health in other states, and ensuring accountability for transnational corporations.
• Empower people to claim and enforce the right to health, build the capacities required to achieve this right, and ensure immediate and effective enforceability of the right to health.
• Enhance right to health accountability at local, national, and global levels, including a robust regime of compliance to the FCGH itself.
• Promote Health in All Policies and raise the priority of health in non-health regimes such as trade and investment, creating policy coherence for health.
• Improve international partner harmonization and alignment with national health strategies, ensure country ownership, and guarantee mutual accountability.As a framework convention, following adoption of the initial treaty which is the FCGH itself, parties to the treaty would later adopt protocols and additions to the treaty that states would need to separately ratify. These protocols could address issues that require further negotiation, perhaps because they are too controversial for the initial treaty, or require considerable levels of detail. This approach of continued development of global health law through the FCGH fits well with the complexity and evolving nature of global health, and will also ensure a continued priority to health equity for many years to come.
How do you know whether you have made a difference? Ultimately, our goal is to secure the treaty itself and to ensure its effective implementation. A robust regime of monitoring and evaluation would make it possible to gauge the difference that the treaty is making in people’s health. The treaty contents will enable educated speculation of the difference the treaty will make. For example, if it does match our vision and set ambitious standards on the universal conditions needed to be healthy, we will know that if ratified and implemented, the treaty stands to make a great difference. Similarly, if for example it includes measures that in other contexts have been proven to remove obstacles to health care for marginalized populations, then the treaty will make a difference. Once adopted, the number of countries ratifying it will also measure the difference the treaty stands to make. We will also see milestones along the way to adoption, such as statements of support or other measures states make to advance the treaty, such as sponsoring or voting for UN or World Health Assembly resolutions to draft an FCGH. A code of practice, a non-binding version of the FCGH, possibly through WHO, could be another step. Encompassing monitoring and evaluation, like the treaty itself, will make it possible to measure the difference it is making.The process leading to an FCGH can also bring real, if difficult to measure, benefits. These include networking and lesson sharing among civil society organizations working on the right to health, and progress towards more precisely defining key elements of the right to health, a central area of JALI’s agenda of FCGH content development. It is also possible that even before any form of formal adoption, civil society might agree to a common set of standards that an FCGH would incorporate and this could serve as a valuable tool in their advocacy. Similarly, such standards might make their way into international law through other means, such as UN human rights bodies (e.g., the Committee on Economic, Social and Cultural Rights) adopting them, or by being inserted into separate measures that the World Health Assembly, the United Nations, or individual countries adopt.
Have you or the project mobilized others and if so, who, why and how? Initial FCGH supporters joined JALI, and it is on behalf of this Steering Committee ( we submit this abstract. Though the idea of an FCGH is only several years old, the treaty already has mobilized high-level support. UNAIDS has been a vocal supporter of the FCGH, with Executive Director Michele Sidibé and his senior advisor Kent Buse “calling for a critical debate and for unprecedented social and political mobilization towards a framework convention on global health.” UN Secretary-General Ban Ki-moon implored “the AIDS response [to] be a beacon of global solidarity for health as a human right and set the stage for a future United Nations Framework Convention on Global Health.” The Director of Health, Population, and Nutrition at the World Bank, Tim Evans, sees great potential in the FCGH to “contribute to a badly needed reservoir of ingenuity to address" health inequities.”Members of the Partners in Population and Development, an inter-governmental body of 25 Southern countries that emerged from the 1994 International Conference on Population and Development, have called for their governments to endorse the FCGH. Endorsements for the FCGH have come from three UN human rights special rapporteurs (health, extreme poverty, and water and sanitation), Paul Farmer, and current and former Supreme/Constitutional Court justices from Colombia, South Africa, and Australia. And perhaps most significantly of all, increasing numbers of civil society organizations, including some of the most prominent national health and human rights organizations, including in South Africa, India, and Uganda, support the FCGH.Publications and key supporters have spread the word about the FCGH and brought attention to the treaty possibility. We believe many people and organizations are interested in the FCGH because of the potential they see in it – an instrument to addressing immense, and in some cases worsening, health inequities, the possibility particularly as binding international law improves accountability including through national courts, and is a means to respond to trade and other legal regimes that threaten to undermine health. Some civil society organizations are particularly interested in the organizing potential of the FCGH, a shared platform around which civil society advocating for the right to health can coalesce, helping to strengthen transnational solidarity and movement-building around the right to health.
When your donor funding runs out how will your idea continue to live? With the growing support for an FCGH, we believe the possibility does not rest on funding for any single entity. An important step to ensure the durability of the content development and advocacy towards an FCGH is the recent formation of an FCGH Campaign, a shared platform for organizations, individuals, and governments interested in helping develop the content of and advocating for an FCGH. This is creating broad ownership of the FCGH. Numerous publications and ongoing work on developing the content of the FCGH, and reaching out to organizations to engage in the FCGH, will also help ensure that the idea of the FCGH, and its real potential, and will persist regardless of funding. Also, we are working to start a UN or WHO process around the FCGH, a formal mechanism that would also ensure the persistence of the FCGH.

A solution to reducing maternal mortality? The role of community midwives

Author(s) Monika Christofori-Khadka1
Affiliation(s) 1International Cooperation, Swiss Red Cross, Bern, Switzerland.
Country - ies of focus Pakistan
Relevant to the conference tracks Health Workforce
Summary Over the last 12 years, many countries have tried to reduce the high rates of maternal mortality by 75 % as outlined in the MDGs. However, not all countries have been successful so far. One of the major bottlenecks to reach the goal is the lack of skilled birth attendants. The Swiss Red Cross has been supporting different countries in their endeavour to increase their workforce. The approaches range from scaling up the quantity and quality of the skilled birth attendants in rural areas to providing on-the job training and facilitating community integration. These measures have resulted in increased antenatal care and institutional deliveries and helped to reduce access barriers.
What challenges does your project address and why is it of importance? UNFPA's report (2011) states that 350,000 skilled midwives are needed to fully meet the needs of women around the world. In the light of meeting the MDGs, some countries have been investing in the training of skilled birth attendants (SBA) by scaling up their number and by scaling up the quality of their service. However, the SBAs often lack practical experience when it comes to deliveries and complicated cases. They rarely have the chance to be teamed up with an experienced midwife and are left alone to take important decisions and conduct deliveries under difficult circumstances. Other countries do not even foresee midwifery in their health system and doctors exclusively carry out deliveries. SBA's prefer to work in urban and semi-urban health facilities therefore there is a lack of SBA's in rural areas. At the community level, cultural restrictions may hamper the access of a pregnant woman to a health centre. Lack of resources, transport possibilities, decision-making power and a functional referral system are causes which contribute to life-threatening delays during pregnancy and childbirth.The SRC projects attempt to address these challenges in different countries of the world by using tailor-made approaches to strengthen community midwifery, their role and uptake.
How have you addressed these challenges? Do you see a solution? The SRC project in Laos aims to better prepare already trained community midwives for their assignments in rural health centres. The project focuses on the hands-on training and exposure to sufficient practical skills with on-the job trainings. A functioning mentoring system and continuous on the job supervision are important features to successfully introduce the SBA to their role and to the community. Qualified and confident staff will earn the trust of the community and thus increase the number of safe deliveries in the country. Alongside the human resources, the local health authorities are trained to collect health data regularly and accurately as well as use the analysis to feed back achievements of the community midwife model. In rural Pakistan, the SRC project scaled up the number of skilled birth attendants in rural health centers. Their role is to do regular home visits and be available 24 hours on-call for deliveries. They accompany a pregnant woman to the nearest hospital in case of complications and emergency. The on-call transport system with an ambulance and driver enables quick and safe transport. A midwife is based at the referral hospital and specially designated to receive referred cases from the rural areas in order to facilitate quick administration, treatment and procedures.In Honduras only doctors are allowed to conduct deliveries and the profession of midwife does not exist in the formal Honduran health system. While most health centers in the rural areas are not staffed with a doctor, SRC tries to enhance service delivery by providing special trainings to traditional birth attendants and selected women from community committees. The courses are endorsed by the Government and complete with an official examination. The focus of the course is on antenatal and postnatal care and on preparedness of the pregnant woman and her family for an institutional delivery. The birth attendants act as a bridge between the pregnant women in remote areas and the health system, but are also prepared for safe delivery if transport not possible.
How do you know whether you have made a difference? Before project commences, all SRC projects conduct a needs assessment and integrate a baseline survey in the initiation phase. Inbuilt into the project design is regular monitoring through health system management information systems (HMIS), reviewing of secondary health data as well as carrying out regular ‘Knowledge, Attitude and Practise’ surveys with the beneficiary community. Analysis of the data depicts the changes the projects have contributed. Individual interviews and case stories show the impact the project makes in a person's life. While the project in Laos is only at its initiation stage (we hope to have more data by April 2014), the Community Midwife project in Pakistan has already illustrated an increased uptake of antenatal care services by 50 % in basic health units and 33 % in the district hospital within only 6 months of project start. In two out of five basic health units the Institutional deliveries have increased three fold and in the district hospital by 61 %. Similar data has been received from Honduras, where 92% of pregnant women attend four antenatal care visits and institutional deliveries have increased about 30% in the intervention area.
Have you or the project mobilized others and if so, who, why and how? Since SRC projects usually work together with local Community Based Organisations or the local Red Cross Partner, volunteers play an important role. The volunteers assist to promote the health services and deliveries with skilled birth attendants. They also disseminate the rights of the patients and ensure that particularly the poor are aware of incentive programmes for institutionalised deliveries, e.g. the Health Equity Fund in Laos or the safe delivery package in Pakistan. In order to bridge the gap between health provider and community, SRC projects establish community committees, who regularly meet with the health providers and monitor their presence, discuss problems and develop solutions. The main aim is to build good rapport and accountability, which will enhance trust, increase provider performance and result in a higher utilisation rate of the health centre and its staff. In the communities, the community committee disseminates information about the services and encourages families to use skilled birth attendants. Special focus is given to mobilise male decision-makers and heads of households to increase their understanding and consent as to why deliveries with a skilled birth attendant are important. The families are encouraged to start with precautions in the early stages of pregnancy, i.e. start saving for delivery costs, arrange transport etc. Well accepted and interested female community members receive basic training to become an important link to the health services in the rural areas. In Honduras more than 80 female and two male members have participated in the trainings.Traditional birth attendants are another important group targeted by all SRC projects. They are included in the service delivery and serves as important links with the community. They accompany pregnant women to the health centres, call the midwives for home services and are important assistants during deliveries. In Honduras, due to the absence of midwifes, they play an important service role in family preparedness, antenatal care, detecting danger signs and facilitating the referral to the next SBA.
When your donor funding runs out how will your idea continue to live? All SRC projects are designed to obtain sustainability by the end of the project period. Sustainability is tackled from both ends: the community and the service provider. Anchoring the projects in the community aims at decreasing access barriers and creating sustainable structures which tackle the four delays in delivery. Similarly, a positive experience of a pregnant woman and her family in the health centre will have a long term impact upon her health seeking behaviour and that of her immediate neighbours and family. Promoting the right to health and facilitating social accountability structures empowers local communities to demand public service provision. At the service provider level, all projects work with the existing health system providing interventions which enhance quality and quantity of service provision. Advocacy from the community level to policy level are geared towards positive change. However, levels of sustainability vary. In countries where community approach is supported by respective Government policies for the health system and where providers are motivated and encouraged by the public service system sustainability is reached in a shorter time frame and with less effort than in countries where the Government and public staff are not motivated for change.The projects are embedded within the pre-existing health system structures of the governments. Except in Pakistan, all skilled birth attendants are employed by the government and thus will continue working in the future. However, in some countries the management of the community midwives is not yet clear as to the importance of their role. The community midwifes are transferred to replace nurses or other health staff and may end up in health centers without equipment or appreciation of their skills. The SRC projects are sensitizing the Ministries of Health and governmental line managers in the careful management of their community midwives.In Pakistan, the project is a pilot intervention which will be used to lobby the local government to redistribute their existing workforce to rural areas, introduce regular outreach and ensure a functional transport system through ambulances etc. Rigorous research, which accompanies the pilot, shall demonstrate the effectiveness of the project and lead to policy change as well as increased strict performance and attendance supervision.

Strengthening Health Systems and Democracy through the Empowerment of Rural Indigenous People in Guatemala

Author(s) Walter Flores1, Ismael Gomez2
Affiliation(s) 1Executive office, Center for the Study of Equity and Governance in Health Systems, Guatemala City, Guatemala, 2Field implementation, Center for the Study of Equity and Governance in Health Systems, Guatemala, Guatemala.
Country - ies of focus Guatemala
Relevant to the conference tracks Advocacy and Communication
Summary Based on both human rights and health systems frameworks, a coalition of CSOs have been implementing a participatory approach to empower rural indigenous citizens to monitor public policies and health care services, demand actions to improve equitable resource allocation and shift power relations at the municipal level. The premise of this work is that strengthening health systems must be part of a larger effort to redress historical discrimination of population groups. In addition, the political empowerment of indigenous populations is a key condition to an equitable and responsive health system. After 5 years the approach has shown important positive results.
What challenges does your project address and why is it of importance? Many health inequities are the expression of inequities of power in society. A history of discrimination, exploitation and 36 years of armed conflict in Guatemala has created unequal power relationships that place rural indigenous population at great disadvantage, suffering worse health outcomes than non-indigenous populations and facing many access barriers to existing services.
How have you addressed these challenges? Do you see a solution? Following a human rights framework, a coalition of civil society organizations led by Centro de Estudios para la Equidad y Gobernanza en los Sistemas de Salud (CEGSS), have been implementing a participatory-action research approach aimed to empower rural indigenous citizens to monitor public policies and health care services, demand actions to improve equitable resource allocation and a shift power relations at the  municipal level. The premise of this work is the understanding that in a context such as Guatemala, strengthening health systems must be part of a larger effort to redress historical discrimination. In addition, the political empowerment of indigenous population is a key condition to an equitable and responsive health system. The process includes the monitoring of health polices and services by community based indigenous organizations. The key characteristics are the following:
• Based on both a human rights framework and health systems strengthening.
• Citizens’ health boards carry-out the following activities:
– Surveying existing services to assess compliance with national standards (drugs availability, medical equipment, human resources)
– Document cases of families suffering hardship due to unmet healthcare needs
– Studying barriers to access (transport, discrimination, resource allocation)
– Submit a report to authorities
– Implement strategic advocacy to demand changes
How do you know whether you have made a difference? Through ethnographic research and in-depth case studies, we have documented that our approach has had a positive impact in improving the availability of services at municipal level. It has also improved the level of trust between community based organizations and health authorities. Community leaders that have been part of this process also report “empowerment” and a motivation to expand their work. The health system is strengthened by improving resource allocation to benefit highly marginalized rural areas at the same time that health personnel develop skills to negotiate and respond to the user of services need. Overall, this approach is also strengthening democracy and promoting the social inclusion of indigenous populations.
Have you or the project mobilized others and if so, who, why and how? Skills and knowledge to implement the approach have been transferred to other NGOs that work in different regions of the country. In addition, due to the relevance of the approach, we have managed to raise funding to expand the approach to 20 new rural indigenous municipalities of Guatemala.
We are also participating actively in several international networks (COPASAH: in which we are transferring our skills, knowledge and tools and also learning from other colleagues that participate in the networks.
When your donor funding runs out how will your idea continue to live? A central component of our approach is the capacity-building of indigenous community leaders engaged in accountability and equity work. Up to June 2013, more than 400 community leaders from 15 different rural municipalities have been trained on community monitoring and social accountability of public polices and services. We are also transferring the skills to other civil society organizations present in these 15 municipalities. Since those organizations already have a presence in those municipalities and do not receive financial support from us, it is expected that they will continue to provide technical assistance to the community leaders once the skills and knowledge transfer process is completed. We are also active members of COPASAH ( and TALEARN ( In both networks we are contributing to field building, hence the skills and knowledge shared in these two networks will remain with all the other member organizations

Limitations of Health Promotion Mechanisms: Pakistan

Author(s) Ayesha Aziz1.
Affiliation(s) Women's health, Rural Support Programmes Network, Islamabad, Pakistan.
Country - ies of focus Pakistan
Relevant to the conference tracks Advocacy and Communication
Summary To improve the maternal and child health indicators the government of Pakistan initiated the Lady Health Workers Programme in 1994. This study aims to investigate the role of the programme mechanisms in promoting health and empowering people. The research was conducted in purposively selected villages from the districts Thatta, Rajanpur and Ghizer. Qualitative methods were used to gather data for the study. Our findings highlight that the limited understanding and implementation of community mobilization, health promotion and empowerment strategies, exclusion of the lower socio-economic strata and the absence of in depth comprehension of indigenous spaces for dialogue limit the LHW programme’s success.
Background Pakistan has been struggling to improve the maternal, newborn and child health of its population for the last two decades. The government has initiated several maternal and child health (MNCH) programmes to address issues related to availability, affordability and access to MNCH services. Reduction in the country’s maternal and child mortality is still far from meeting the targets of the millennium development goals according to which the maternal mortality rate (MMR) of 380 per 100,000 live births was to be reduced by three-quarters and the infant mortality rate (IMR) of 76 per 1000 live births was to be reduced by two-thirds by 2015. However, the current MMR in 2010 was 260 per 100,000 live births and the IMR was 59 per 1000 live births. The National Programme for Family Planning and Primary Healthcare is one of the largest government health programmes. It was initiated in 1994 with the mandate of overcoming the financial and mobility barriers related to access and ensuring continuous availability of primary healthcare services at the doorsteps of rural communities. The most recent evaluation of this programme, conducted by the Oxford Policy Management in 2009, has revealed that despite all efforts of the programme there has been limited success in behavior change for health promotion.
Objectives Health promotion is considered a process of enabling people to increase control over and to improve their health. It is related to empowering people by developing skills of local leadership, strengthening community actions, creating supportive environment, reorienting health services and building healthy public policies. The National Programme for Family Planning and Primary Healthcare is widely known as the Lady Health Workers Programme as its prime workforce consists of community based Lady Health Workers (LHWs). The LHWs are responsible for advocacy, health education and creating awareness for promoting community health. Their work includes counseling, provision of family planning services, antenatal care and referrals, immunization, basic curative care and supporting community mobilization. There are a total of 90,000 LHWs employed in the programme across the country. Each LHW serves 1000 people living in the 100-200 households around her own house that is called the ‘health house’. For health promotion the LHWs are responsible for mobilizing the community into groups, particularly those of women. Over the years, the LHWs have gained a lot of respect and influence in their communities and their contribution in ensuring availability of affordable primary healthcare has been valuable.
This study aims to investigate the role of the LHW programme mechanisms and the LHWs in promoting health and empowering people, particularly the women and poor. The study will also explore the indigenous mechanisms and spaces for dialogue that exist in every community and endeavor to distinguish the impact of indigenous communication mechanisms and spaces on maternal and child health promotion from the programmatic ones.
Methodology The primary research question for this study was ‘in what ways do LHW programme mechanisms and spaces empower or inhibit women, poor persons and marginalized groups, particularly with respect to maternal and child health issues? The following refined research questions were defined from the primary research question.
1. What are the mechanisms and spaces formed by the LHW programme for promotion of MNCH?
2. How are the selected communities stratified? (ethnic groups, economic classes, castes, education status, gender and age)
3. What are the marginalized groups in the selected communities?
4. Who is included and who is excluded from the LHW programme mechanisms and spaces? And why?
5. What are the mechanisms of inclusion and/or exclusion in the LHW programme mechanisms and spaces?
6. What is the role of LHWs in engaging and empowering the women and poor?
7. What indigenous mechanisms and spaces for dialogue exist in the selected communities?
8. What is the impact of the indigenous and LHW programme mechanisms and spaces on raising awareness about health issues, availability of health services and entitlements of people for MNCH services?
9. What is the impact of the indigenous and LHW programme mechanisms and spaces on women’s mobilization and local accountability processes?
10. What lessons can be learned with respect to accountability and governance in the LHW programme and the identification, training and selection of the LHWs? To take into account the cross country geo-cultural differences, this research was conducted in a purposively selected LHW covered villages from the districts Thatta (delta), Rajanpur (plain) and Ghizer (mountainous). A comprehensive document review of relevant documents of the LHW programme was done and a total of 9 key- informant interviews (KIIs) were conducted with three LHW programme personnel in each village/district to gather information on the planned and implemented mechanisms for maternal and child health promotion. The community’s perspectives on the role of programmatic mechanisms and LHWs in health promotion was investigated by conducting 10 participatory reflection and analysis (PRA) based group discussions (5 with women’s group and 5 with men’s group) in each of the three selected villages. Indepth interviews with selected women were also conducted to distinguish the impact of indigenous communication mechanisms and spaces from the programmatic ones.
Results • Community mobilization mechanisms are utilized only for awareness raising
In all our study sites, LHWs were found to visit households on specific dates during the immunization campaigns, though they have a mandate to raise awareness and change attitudes by the formation of a women’s group and health committee in their catchment area. In each site, LHWs were found to conduct occasional awareness raising sessions on antenatal care and contraception. Communities in Thatta and Rajanpur did not know of any women’s group or health committee. In Ghizer some women informed us about a women’s group created by the LHW 2 years ago, but such group activities were no longer a part of the LHW’s routine work as she had a high work burden and was not held accountable for mobilization efforts.
• People from lower socio-economic strata were excluded and their women bore the highest burden of MNCH issues.
In villages of Thatta and Rajanpur Districts the community was stratified with respect to lineage that formed their caste identity, while in Ghizer it was stratified on the basis of religious sects. The men and women from the lower socio-economic strata were excluded from the awareness sessions as the LHWs were either relatives or friends of the better-off women and tended to complete their field activities with them without making much effort to ensure representation and participation of all strata. Due to lack of access to information and resources the poorest women in each site withstood the highest burden of MNCH issues. They related horrid stories of multiple young age pregnancies, miscarriages and even infant deaths. The most vulnerable women were those belonging to the poorest castes that led semi-nomadic lives in search of livelihoods. They were not even counted as women eligible for primary healthcare and family planning advice in LHWs’ registered catchment area population.
• Indigenous spaces for dialogue can serve as entry points for behavior change
In Ghizer, the place for congregational worship was used by women from the same religious sect to discuss and promote contraceptive usage. In Thatta and Rajanpur Districts, the agricultural activities and household gatherings were used to exchange information on contraceptive usage, but due to deeply ingrained patriarchal practices of the society, very few women could use this information for behavior change.
Conclusion Our findings highlight the limited understanding and implementation of community mobilization, health promotion and empowerment strategies in the LHW programme. This has restricted the focus of LHWs’ community mobilization activities to awareness raising, while their potential for promoting organized and sustainable community based collective efforts for building local partnerships and ensuring accountability of healthcare services remains unharnessed.
Social stratification determines people’s access to resources, livelihood, ownership of agricultural land and socio-economic status, therefore equitable access to information and health can be ensured by monitoring inclusion of the lower socio-economic strata and the semi-nomadic population groups in the community mobilization efforts.
The indigenous spaces for dialogue among women in all communities included communal places for washing clothes, collecting water and performing agricultural activities and the household gatherings for celebrating events. These spaces contribute to the construction of cultural norms and practices in a society. Therefore, in-depth comprehension of the indigenous spaces will allow the LHWs and their programme to capitalize upon existing opportunities for dialogue and behavior change for health promotion and empowerment.

Integrating Community Participation in Maternal and Newborn Health Services: Burkina Faso

Author(s) Janet Perkins1, Cecilia Capello2, Aminata Bargo3
Affiliation(s) 1Health Department, Enfants du Monde, Geneva, Switzerland, 2Health Department, Enfants du Monde, Geneva, Switzerland, 3Health Department, Fondation pour le Développement Communautaire/Burkina Faso , Ouagadougou, Burkina Faso.4
Country - ies of focus Burkina Faso
Relevant to the conference tracks Social Determinants and Human Rights
Summary Improving maternal and newborn health (MNH) in regions where women and newborns suffer most requires a rights-based approach which identifies and addresses the broader social determinants of health. In Burkina Faso, we are implementing a health promotion component within the national MNH strategy. A central feature is the institutionalization of community participation in the identification of priority MNH needs as well as the design of interventions. The result is a system in which data related to social determinants of health are collected and used within the health sector. This allows the health sector to participate in addressing these determinants and promotes the rights of community members.
What challenges does your project address and why is it of importance? Despite progress over the past two decades, women and newborns in Burkina Faso continue to face elevated risks related to pregnancy and childbirth. With a maternal mortality ratio of 300/100,000, a woman in Burkina Faso faces a 1 in 55 lifetime risk of death due to maternal causes. Thirty-eight of every 1,000 newborns fail to survive the first month of life. Effectively addressing MNH demands a rights-based approach to health programming that focuses on rooting out inequities and addressing social determinants of health.
Central to a rights-based approach is the promotion of meaningful participation of individuals and communities in the development and implementation of actions designed for their benefit. Participation is both an ends in and of itself, as participation is defined as a right, as well as a means of contributing to a process of empowerment. One of the aims of our program is to integrate participatory processes into health programming. This contributes to assisting the health services in becoming aware of and designing appropriate and tailored interventions to address challenges in MNH, including social determinants, as well as to give a voice to community members and ensure that they are able to participate and are empowered in the process.
How have you addressed these challenges? Do you see a solution? Since 2006, Enfants du Monde, a Swiss NGO, in collaboration with the local NGO Fondation pour le Développement Communautaire/Burkina Faso (FDC/BF), has been supporting Ministry of Health (MoH) in implementing a programme based on the World Health Organization’s framework for Working with Individuals, Families and Communities (IFC) to improve MNH. The IFC framework is designed to form a health promotion component of a broader MNH strategy, as it does in the Burkina Faso national strategy. One of the principal aims is to empower women, men, families and communities to improve MNH. A central component of the empowerment process is institutionalizing participatory processes in health planning.Notably, participatory community assessments (PCA) are conducted at the outset of district-level implementation. These assessments provide a platform for community members, with an emphasis on marginalized groups, to discuss MNH needs in the community and develop tailored interventions. During the PCAs, participants explore the broad array of factors, including social determinants that contribute to poor MNH. The ensuing results of these assessments are planned interventions which are appropriate and specific to the context as well as the initiation of the empowerment of community members as they assume influence in improving the health of their community.While participatory planning processes are not new in health programming, the IFC framework institutionalizes these processes within the broader health system to make community voices systematically represented and to allow for the systematic collection of information related to social determinants of MNH. With the endorsement of the national MoH, actors from within the sub-national MoH have been trained to conduct PCAs in collaboration with other actors working within MNH at the regional and district level. In this position, they have been able to assume the responsibility of listening to the voices of community members and of taking direct action in response to their participation. This process has created a mechanism by which community participation has been integrated within the health sector. This contributes to promoting participation, and thereby rights, of community members, and increases accountability and transparency in the health services. It allows for health inequities and socioeconomic determinants of health to be identified and addressed within the public health sector.
How do you know whether you have made a difference? To date, PCAs have been conducted in seven districts (Tenkodogo, Zabré, Kongoussi, Ouragaye, Barsalogho, and Sindou) over three regions. These assessments have effectively identified challenges related to MNH, many related to rights and socioeconomic determinants, that did not surface through more traditional, non-participatory situation analyses. These include: lack of knowledge of health behaviors during and following pregnancy; lack of awareness of danger signs during and following pregnancy; lack of planning for birth or potential complications; women’s inability to make the decision to seek health services autonomously or use family resources to pay for services due to low socioeconomic status; financial and transportation barriers to reaching health facilities; and lack of satisfaction in interactions with health care providers.
To address these priority concerns, community members, leaders and the health sector worked together to develop interventions. These interventions vary by district, but include health education activities (theatrical performances, culinary demonstrations, radio game shows, etc.), birth preparedness and complication readiness, mobilization of men and the broader community to increase their awareness of MNH rights and needs and enlist their participation in MNH actions, building maternity waiting homes and training health workers to build their capacities to interact with women.Preliminary results to date suggest the success of the processes and interventions. Notably, the IFC interventions have been directly integrated into the MNH action plans of each district. This mechanism has assured the institutionalization of community members’ participation in the planning of activities designed to benefit them. This has not only contributed to the promotion of their rights, but has also provided a way for the health sector to gather data and become involved in addressing the broader determinants of health, including social determinants. Where interventions have been implemented, health care providers have created links for exchanging information with communities. Male partners are accompanying women when receiving MNH services in greater numbers and health information system data has revealed an increase in utilization of MNH services. A current evaluation is assessing the degree to which the activities have contributed to change in MNH knowledge, attitudes and practices in these initial sites of implementation.
Have you or the project mobilized others and if so, who, why and how? We initiated the project based on the assumption that improving MNH cannot effectively be accomplished in a vacuum and requires the mobilization and action of a myriad of actors. As such we have mobilized a variety of agencies and sectors acting at the national, sub-national and district level. This process began with the introduction of the IFC framework at national level. Workshops were held with MoH, Ministry of Education, international organizations and others working on MNH at this level. These workshops were designed to help these actors understand the critical nature of working with and empowering individuals, families and communities and institutionalising mechanisms that allowed them to participate in reaching the goals laid out in the national MNH strategy and ultimately fulfill women’s maternal health rights. Actors from within MoH to be responsible for the IFC component at the national level were identified and their capacities built to lead these efforts.
At the same time, IFC committees, operating under MNH bodies, at sub-national and district level were formed. This structure of IFC committees has created a mechanism allowing for both horizontal and vertical communication. This has reinforced the institutionalization of community participation in MNH as actors at both the national and sub-national levels become aware of the specific needs expressed by community members as well as the social determinants of maternal and newborn health in play at the local level. They are then able to respond with centralized action when necessary and appropriate.
In addition, community members, leaders and groups have been mobilized to participate in MNH action. Notably, health care providers have created linkages for working with communities and for the exchange of information. They have contacted and begun working with community leaders, male partners, community health workers and village birth attendants. Through these links, actors in the community have become engaged in encouraging women to attend MNH services. They also transmit information from the health services to the community and gather information on an on-going basis in the community and relaying it back to the health services. This contributes to the realization of rights, including promoting community members’ rights to information and education and through ensuring accountability and transparency. It also provides a mechanism for continued community participation within the health sector.
When your donor funding runs out how will your idea continue to live? Sustainability of the program has been a priority since its inception and has therefore been implemented with a long term vision. To begin with, the IFC framework and its related interventions have been directly integrated into the national MNH strategy, as the health promotion component and fifth pillar of the national Plan for Reducing Maternal and Newborn Mortality: A Road Map. This has assured that it has never been implemented as a standalone, vertical program. In addition, the component is being implemented directly by MoH, with the support of outside actors, including NGOs and UNFPA. As a result MoH is directly responsible and accountable for its implementation. It has been institutionalized within the MNH program at all levels, ensuring that participatory processes themselves are integrated as well. Moreover, while the program is still financially supported primarily by exogenous actors (i.e. UNFPA, EdM), MoH understands that this funding will ultimately expire and has identified and begun implementing strategies for resource mobilization internally.
In addition, at its core, our project focuses on building the capacities of in-country actors. Notably EdM has no expatriate staff on the ground. Rather, locals are staffed as coordinators in regional offices. Likewise, FDC/BF is a local NGO, based and operating in Burkina Faso. Moreover, at every phase of IFC implementation, the focus remains on building the capacities of State and other actors to implement the framework and assume primary responsibility for interventions. This focus on capacity building of in-country actors prevents an over-reliance on outside actors and ensures local ownership of initiatives, thereby promoting sustainability.
Finally, the program has also launched processes of empowering women, men, families and communities. This empowerment is considered not only a means to an end, but also an end in and of itself. These exercises of working together have built the capacities of community members to collaborate in identifying their needs and designing methods to address these needs. The capacities of the health services have simultaneously been reinforced to include the participation of community members in health planning and services action. This bodes well for the sustainability of the idea as local actors have the capacity to participate and the health sector is equipped with the capacity to integrate and promote community participation.

Creating Healthy Work Environments by training Medical and Nursing Students: Nigeria

Author(s) Ezinna Enwereji1.
Affiliation(s) 1Community Medicine and Nursing Sciences, Abia State University, Uturu, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Advocacy and Communication
Summary There is mounting evidence that unhealthy work environments contribute to medical errors,
ineffective delivery of care, and conflict and stress among health professionals. This report describes steps taken to encourage good interprofessional and interpersonal relationships to reduce unhealthy work environments in hospitals. To guarantee this, a two day seminar which emphasised advocacy and effective communication as a panacea for quality services was held for medical and nursing students on clinical posting. The novelty of this procedure is that students approached each professional personally to evaluate difficulties and constraints in professional collaboration.
What challenges does your project address and why is it of importance? Exposing medical and nursing students to general practice and community healthcare services is common practice in health care training curricula. When students are posted for clinical experiences, particularly in community settings, non-academic staff also teach some procedures like laboratory and midwifery. But proponents of the hospital and biotechnology based paradigm, which is dominant in most academic environments, question both the scope and quality of training covered by non-academic staff especially where incentives are not given. This doubt causes interprofessional conflicts which adversely affect the quality of health care services rendered. There is mounting evidence that unhealthy work environments contribute to medical errors, ineffective delivery of care, conflict and stress among professionals. Negative relationship issues are real obstacles to the development of work environments where patients and their families can receive safe and excellent care. Also negative relationships induce hospital-acquired infections and other complications including patient readmission. Such demoralizing and unsafe conditions in workplaces must be addressed. Establishing healthy work environments ensures patient safety, staff retention, and quality student training.
How have you addressed these challenges? Do you see a solution? Setting up sustainable medical education activities in an unfriendly environment is a difficult task that calls for wisely selected functional steps. In addressing issues of poor interprofessional and interpersonal relationships commonly reported among health workers in hospitals, lecturers in charge of students’ clinical postings organised a two day seminar to acquaint newly posted students with holistic approaches to clinical experiences that enhance professional advancement. Organizing this seminar aligns with the University’s ethical obligations of establishing, maintaining and improving healthcare environments and employment conditions favourable to the values of medical and nursing students’ professions. In this seminar students were encouraged to assess the difficulties and constraints that influenced unhealthy work environments in hospital settings so as to proffer intervention. To ensure success the University authorities funded the training seminar. This report describes the steps taken to establish and maintain good interpersonal relationship among health workers so that they were enabled to provide quality health care services to clients.
During the seminar, emphasis was placed upon effective communication skills, professionalism, teamwork, mutually respectful relationships, fostering of true collaboration, decision making, and accountability as strategies required to guarantee healthy work environment and quality services in hospitals. In this project, skilled communication was seen as a two-way dialogue in which individuals would discuss and decide together way forward. Here health care workers were encouraged to imbibe the culture of developing among themselves, irrespective of their professions, communication skills (written, spoken and non-verbal) that are at parity with expert clinical skills. In this circumstance, civility, respect, and speaking with knowledge and authority were introduced as the health workers’ veritable tools for encouraging professional collaboration.
The aim of this project was to encourage the students to promote interprofessional and interpersonal relationships through effective communication so as to ensure successful teamwork during their clinical posting. The novelty of this procedure is that the students approached each professional in the hospital personally to evaluate difficulties and constraints that affect health care professionals’ collaboration.
How do you know whether you have made a difference? Using skilled communication to support ethical obligation of the University the trained students helped to improve their professional integrity and guaranteed trust between them and other health workers in the hospital. As a result the students offered quality services to patients assigned to them as evidenced by the number of patients who said they were satisfied with the quality of services they received. By this, students assured the patients of their safety and best interests, as they provided their services with competency and mastery, which dramatically altered the conflict-laden conditions of the hospital environment. There was increased awareness among professionals on how to achieve desirable outcomes for clients. It was noted that by emphasizing skilled communication as goodwill and mutual respect encouraged common understanding on the need for teamwork and advanced collaborative relationships among health professionals.
The analysis of the students’ intervention resulted in three major positive themes: (1) improved interprofessional interactions with other students; (2) increased interprofessional interactions with other health professionals and (3) better interprofessional interactions with the hospital authorities. The students demonstrated a new level of respect for health professionals outside their disciplines, and gained insight into how their own independent roles can blend with others’ roles, to enhance each other’s expertise. A good number of the students expressed appreciation and respect for professional roles stating how their exposures to various health professionals in different contexts have enabled them to understand and appreciate other health professionals’ roles.
The project has demonstrated that students’ learning experiences can be enhanced through engaging and integrating their services with other professionals in hospital setting. Exposing students to interprofessional learning in clinical posting assignments helped to increase the students’ understanding of professionalism, teamwork and determination to improve their service delivery models. As a result, interprofessional integration was regarded as the key strategy to improve the delivery and outcomes of health care services and promotion.
Have you or the project mobilized others and if so, who, why and how? A good proportion of the students, as well as some other professionals, recognized the need to adopt interprofessional training and work practices where two or more professionals learn about one another’s roles to improve collaboration and quality care services to clients. The fact that interprofessional collaboration encouraged better health care services by optimizing the skills of healthcare teams in case management and in reducing medical errors encountered, interprofessional practice became a topical issue in the University. As a result, the University has adopted interprofessional education as a method of preparing its future students for effective health care services during clinical experiences in the hospitals.
It is evident that adopting interprofessional education for training medical and nursing students will require systemic changes in healthcare policy goals, but the University has embraced this training model for these students. To show commitment, the University has budgeted funds for lecturers who will use this model to develop the students’ competencies for collaborative practice. The argument is that graduates on entering the workforce should be made aware of roles and responsibilities of other health care disciplines to avoid workplace conflicts, inefficient use of resources and ineffective patient care delivery. A collaborative approach is therefore critical in assisting the health workers to provide better patient care and safety. The advantage is that health care professionals will be enabled to widen the scope of their knowledge and skills as well as gain experiences in working and living amicably with other professionals. This pilot project has created healthy work environments that supported and fostered excellence in patient care services especially for patients needing acute and critical care services. To increase healthy work environments that would benefit everyone including patients, the following could be enacted:
• Identify the pressing problems in work environment.
• discuss with colleagues and find solutions to challenges encountered.
• ensure that work and health care environments are safe, healing, humane, and respectful of others rights and responsibilities
• voice grave concerns about deterioration in healthcare environments and affirm that safe and respectful environments require systems that support communication, collaboration, decision making, staffing, recognition and leadership.
When your donor funding runs out how will your idea continue to live? The University, having adopted the principle of interprofessional education for training future medical and nursing students to guarantee interdisciplinary collaboration and healthy work environments, has budgeted funds for this programme. Since the University is committed to this project, there will be continuous training of the students and budgeting for the execution of the project. This means that for each academic calendar the University will ensure that the students for clinical experience are adequately trained and monitored in the hospital where they are posted. This ensures that the project will be ongoing and build over time and also with the students and other participants, become the norm in the hospital. With synchronous ongoing collaborative work among healthcare professionals, patient and family needs satisfaction, and an improved staff relationship will be optimally achieved within the complexities of the healthcare system thereby reducing the negative impact of unhealthy work environment.
The continuous training and retraining of medical and nursing students on clinical exposure will provide opportunities for health team members to develop collaboration skills that ensure knowledge and competence as well as mutual concern for quality services to patients. Team members are motivated to master skilled communication development programs by focusing on strategies that enhance collaborative decision making. Program content would necessitate mutual goal setting, negotiation, facilitation, conflict management and performance improvement in health care services.

Feasibility of Implementing an Equitable Resource Allocation System in Bangladesh

Author(s): R. Huque1
Affiliation(s): 1Institute of Health Economics, University of Dhaka, Bangladesh
Keywords: Resource allocation, equity, feasibility, healthcare need

One of the key challenges, faced by Bangladesh health sector, is the high gap in health conditions between the rich and the poor, between male and female, and between populations living in different geographic areas. Evidence suggests that the current incremental approach of allocating healthcare resources from centre to local levels is one of the factors influencing the wide spread inequity in health status. To reduce inequity in health, Ministry of Health and Family Welfare (MOHFW) of Bangladesh, World Bank and many researchers advocate the modification of the current system towards a ‘needs-based system’. However, before introducing any such modification, it is important to understand the existing process of allocating healthcare resources from centre to peripheral level, and to assess the feasibility of implementing the ‘needs-based’ system -which is clearly lacking in Bangladesh.

Summary/Objectives: The aim of the present study is to analyse the existing resource allocation and budgetary process of Ministry of Health and Family Welfare of Bangladesh, and to assess the feasibility of implementing a needs-based resource allocation system for the health sector of Bangladesh. A total of twenty senior level policy makers within MOHFW and Planning Commission, who were involved in resource allocation and budgeting process, were interviewed for the study. Four focus group discussions were arranged with the same participants. A number of documents including GOB’s plans, budget statements, research reports, National Health Accounts, Public Expenditure Reviews were collected and reviewed.

It was revealed that (1) under the current system, allocation to different geographic areas is not linked to the relative needs (medical, social or economic) for resources of the population. This pattern of resource allocation does not ensure equity of access to services for people at equal needs. As a result, many people with higher need get lower amount of healthcare - the case of ‘inverse-care law’ of Gwatkin. (2) The artificial demarcation of the revenue and development budget, lack of coordination among the bodies responsible to prepare these budgets are negatively affecting the plan formulation and monitoring of sector activities. (3) Poor accountability, lack of leadership, incompetent workers, and high turnover of staff are negatively affecting the formulation and implementation of budgets. (4) The current allocation of MOHFW resources is manipulated by political pressure. Despite having a set norm of allocating resources based on capacity of the facility, measured by number of bed and staff, some facilities are receiving more resources than a similar type of facility, without any explanation or reasoning.

Lessons learned:

The study suggests that before adopting any sophisticated formula for allocating healthcare resources in Bangladesh as proposed by World Bank and MOHFW, the artificial demarcation of the revenue and development budgets should be abolished, budgeting skill and information base should be created, and consensus should be built among policy makers within Government of Bangladesh, development partners, and politicians.

Collaboration between Educational Institutions and Government Health Department: Successful Partnership in Building an Urban Health Centre in Ahmedabad City, Gujarat, India

Author(s): K. V. Ramani*1, D. V. Mavalankar1
Affiliation(s): 1Centre for Management of Health Services, Indian Institute of Management, Ahmedabad, India

Health for urban poor, access, affordability, equity, Indian Institute of Management (IIMA), Gujarat Government health department, Ahmedabad City, public private partnership (PPP), GIS


Urbanization is an important demographic shift worldwide. India has an urban population of 300 million, with the slum population in urban areas registering a 5 % growth over the last few years. Responding to the healthcare needs of the urban poor is therefore very essential, but government resources are limited and its management capacity inadequate to manage healthcare services satisfactorily. Private sector is very active and is seen by the community to be more responsive, though very costly. The Government of India is therefore promoting Public Private Partnerships (PPP) to provide healthcare services that are available, accessible, affordable and equitable. With a view to improve the delivery of urban health services, particularly for the poor and the vulnerable, the Indian Institute of Management, Ahmedabad (IIMA) has undertaken a project on ‘Primary Health Services for the Urban Poor’ jointly with the Department of Health, Gujarat State to establish a PPP model urban health centre in Ahmedabad city.


The main objective of the IIMA project mentioned above is to design, develop, and implement a working PPP model for improved urban healthcare service delivery in Ahmedabad city, which has a population of 3.5 million with 35% living in slums. The project involves estimating the community needs, coordination with government and non-government organizations, conceptualizing a PPP model, and a successful implementation of the PPP model in one of the wards in Ahmedabad city (Ahmedabad city is divided into 43 administrative regions called wards). By collaborating with the Gujarat Government Health Department, this project also aims at strengthening the management capacity of the government officers so as to enable them to replicate the IIMA model to other cities throughout Gujarat state.


The chosen sample ward, Vasna, did not have any government health facility, and so the poor people of Vasna ward were depending entirely on the expensive private sector for meeting their healthcare needs. The PPP model urban health centre, which IIMA helped the State Government to set up in Vasna ward, is today offering primary healthcare services, almost free of any user charges, to more than 100 outpatients per day. It provides access to 2/3rd of the slum population within a 1KM road distance. This new urban health centre is the first of its kind in India offering consultation, investigation, and medication under a single roof. The location for the Vasna urban health centre was made by relying on Geographic Information system (GIS) methodology. IIMA has also developed a legally binding MoU between the various partners for service delivery. Gujarat Government has adopted our PPP arrangement and has started planning for replicating the IIMA model of urban health centres throughout Gujarat state.

Lessons learned:

Establishing a PPP requires a legal framework acceptable to all the partners, commitment of resources, as well as clarity on the roles, responsibilities and accountability of all the partners to provide a given set of services at a desired level of quality and at affordable user charges. Formalizing such an arrangement between partners requires conceptualizing a framework for PPP to manage the delivery of health services effectively and efficiently. The success of our project largely depends on the efforts of IIMA, a leading academic institution in India, and the Government Health department, in bringing together a number of public and private partners for ensuring good quality, affordable and accessible primary healthcare services to the urban poor.

A Follow Up Study on the Quality of Alcohol Dependence Related Information on the Web

Author(s): Y. Khazaal*1, O. Coquard2, D. Zullino3
Affiliation(s): 1Psychiatry, University Hospitals of Geneva, Switzerland, 2Lausanne University Hospital, 3University Hospitals of Geneva, Switzerland
Keywords: Internet, quality indicators, healthcare, alcohol, addiction

Internet is frequently used as a source of information on health issues. This makes it is particularly important for websites to present high quality and accurate information on a health-related topic such as alcohol dependence. However, there has been a general concern about the quality of web-based health information designed for consumers. In a review evaluating the quality of consumer health information on the Internet, most papers conclude that quality was a problem. This finding holds true in the area of mental health. Most available studies on this topic have however a cross sectional design and little is now about the evolution of the quality of web-sites over time.


The objective of the present study is to evaluate a one year evolution of web-based information on alcohol dependence. Sites assessed in June 2006 were re-assessed in July 2007 using the same evaluation procedure. Websites were assessed with a standardized pro-forma designed to rate sites on the basis of accountability, presentation, interactivity, readability and content quality. ‘Health on the Net’ (HON) quality label, and DIS- CERN scale were also used.


Of the 45 websites identified in June 2006, 38 were still existed. A high reliability of scores was found for all components of the pro-forma (r= 0.77 to 0.95 p<0.01). By ANOVA for repeated measures, there was no time effect, no interaction between time and scale, no interaction between time and group (affiliation categories), and no interaction between time, group and scale. Distribution of the sites in term of affiliations remained exactly the same (government: 2.6%; non profit organization: 47.40%; University: 7.90%; individual: 21.2; unknown: 2.10%). Conclusions: The study highlights lack of evolution of web pages across a one year follow-up.

Lessons learned:

Despite some limitations, this study brings to evidence lack of evolution of web pages across a one year follow-up and highlight the good test-retest properties of the evaluating instruments used in the present study. Furthermore it seems that Universities and governments are poorly involved in the development of websites for general consumer.

Making the Right to health a Reality in the Context of Social Inequalities and Rapid Economic Change in Brazil

Author(s): V. S. P. Coelho*1, A. Shankland2
Affiliation(s): 1Citizenship and Development Group, Brazilian Centre of Analysis and Planning, Sao Paulo, Brazil, 2IDS, Falmer, United Kingdom

SUS, the brazilian public health system; rights; social excluded groups; decentralization; PSF Family Health Program; health councils, accountability


In the two decades since Brazil recognised access to healthcare as a Constitutional right, the country has undergone wide-ranging transformations that have left their mark on the profile of the population and on the country’s health system. Initially, a brief overview of the changes that have taken place in recent years in the socio-demographic and epidemiologic profile of the Brazilian population is presented, showing the challenges facing the healthcare system. We go on to present a brief overview of the system, which includes both the publicly-funded services provided by the SUS (Unified Healthcare System) and those financed and provided by the private sector. Our analysis concentrates on the public sector, which is the sole source of healthcare for approximately 70% of the country’s population.


We outline the chief mechanisms – programs, financing and management – that have ensured the SUS’s capacity to respond to the challenges pointed out previously. We argue that two of the key mechanisms are the establishment of transparent financing mechanisms for promoting universal coverage within a highly decentralised health system where most service delivery responsibilities lie at the municipal level, and the innovative approaches to democratic accountability.
Some 32% of Brazil’s population of 184 million people are considered to be living in poverty. Despite a recent decline in overall income inequality, indicators show expressive inequalities in both income and life expectancy between rural and urban populations, and between the population as a whole and minority ethnic populations, in particular Afro-descendent and indigenous groups. It should also be noted that 85% of Brazil’s population lives in cities, with metropolitan areas expanding rapidly throughout the country. In this context, a key challenge is to overcome urban bias in health system organisation and healthcare models, ensuring the realisation of the universal right to healthcare among minority populations living in remote rural areas where municipal service delivery capacity is weakest.


Since it was established in the late 1980s as a public health system with universal and unconditional coverage, the SUS has achieved a rapid expansion in access to services. A key driver of this expansion has been the system of direct central government transfers to the municipal level, tied to the delivery of priority packages such as the Family Health Program or PSF (Programa Saúde da Família). The statutory participation and accountability institutions, known as Health Councils (Conselhos de Saúde) have facilitated coordination between health system managers, service providers and civil society groups. However, both the transfer system and the accountability institutions have been less successful in guaranteeing service quality, and in particular in ensuring that service provision models such as the PSF are adapted to address the specific health needs of the most marginalised and vulnerable population groups. In this presentation we focus on the ways in which the SUS is dealing with these challenges, and the innovative approaches emerging from ongoing change processes such as the reforms in health service provision for indigenous peoples.