Authors : Olushayo Olu, Amos Petu, Martin Oyberedjo, Diane Muhongerwa.
Type of publication : Academic article
Date of publication : 15/09/2017
Implementation of new models of development cooperation has been on the increase lately. Coupled with this are calls for increased use of horizontal development cooperation mechanisms such as South-South Cooperation (SSC) as a mean to enhance aid effectiveness in the health sector of developing countries. The calls are fuelled by the often unfavourable terms of North-South Cooperation (NSC), amplified by the need for self-determination, solidarity, sustainable home-grown development and more aid effectiveness among countries of the global south. SSC is also seen as a tool for ensuring equity between developed and developing countries and an opportunity to overcome colonial aid legacy.
Historically, SSC referred to the process of exchanging knowledge and resources among countries of the global south. The High-level UN conference on SSC (2009) provides a more comprehensive operational definition of SSC which is ‘a process whereby two or more developing countries pursue their individual and/or shared national capacity development objectives through exchanges of knowledge, skills, resources and technical know-how and through regional and interregional collective actions, including partnerships involving Governments, regional organizations, civil society, academia and the private sector, for their individual and/or mutual benefit within and across regions’. Other form of development cooperation is the Triangular Cooperation (TC), a south-south partnership, led by two or more developing countries but supported by a developed country, multilateral organization or international foundation.
Recent public health events in Africa such as the recurrent outbreaks of endemic and emerging infectious diseases like Ebola, Cholera, Yellow Fever, Zika, Dengue and Rift Valley fever in areas which hitherto never experienced such have put to test, the capacity and knowledge to respond in the face of increasing incidence of non-communicable diseases and weak health systems. As such a call for a paradigm shift in development cooperation cannot be more apt at this time.
Cuba also deployed several Brigades of health workers including doctors, nurses, social workers, infection prevention and control specialists and health administrators to support the principally affected countries.
In this case series paper, based on World Health Organization (WHO) principle that cooperation among countries can be an effective tool to strengthen and accelerate health development, share knowledge and experiences to improve health-while also making the most of existing resources and capacities available within countries and across regions; we review recent experiences in application of SSC initiatives to two public health situations in Africa to demonstrate the veracity of this new paradigm.
Methods and case studies
Case study 1: the Ebola Virus Disease (EVD) outbreak in West Africa.
The 2014/15 Ebola Virus Disease (EVD) outbreak in West Africa infected more than 28,000 persons out of which 11,000 died. Available local experience, knowledge, logistic and human resources to manage these outbreaks were limited while diagnostic and admission capacities were overstretched. This sustained community transmission of the disease.
The African Union mobilized and deployed more than 850 health workers drawn from 18 African countries to Guinea, Liberia and Sierra Leone through its African Union Support for the Ebola Outbreak in West Africa programme while the Economic Communities of West African States deployed additional 150 West African health personnel. These health workers supported case management, infection prevention and control, active surveillance, contact tracing, community mobilization and outbreak coordination. Through these deployments experienced clinicians and nurses from Uganda and Democratic Republic of Congo, countries with long standing experience in EVD management were deployed to support outbreak response in the principally affected countries.
Similarly, China, South Africa and Nigeria (with support of the European Union) established level 4 EVD diagnostic laboratories in Liberia and Sierra Leone. Cuba also deployed several Brigades of health workers including doctors, nurses, social workers, infection prevention and control specialists and health administrators to support the principally affected countries. These deployments provided the much needed capacity which significantly contributed to the eventual control of the outbreak.
Case study 2: health system strengthening experience sharing between Rwanda and Mozambique.
In Mozambique, financing of health services delivery is largely dependent on donor funding which peaked in 2010. On the average, donor funding through sector budget support, projects and vertical funds such as United States President’s Emergency Plan for AIDS Relief and Global Fund account for more than 70% of the spending on health in the country while government expenditure on health reduced from 13% to 7% between 2006 and 2010.
On the other hand, Rwanda has made good progress in the financing of its health sector. The country has developed and is implementing robust health financing policies and strategic plans, enacted health insurance laws and introduced a community-based health insurance (CBHI) scheme which has over 80% national coverage. These boosted sustainable and equitable access to health services, including safety nets for the poor whilst reducing out of pocket expenditure. This enabled the country to improve its health services delivery mechanisms as well as provide bilateral technical support to a number of other African countries in the areas of health system strengthening and financing.
To this effect, a Mozambican delegation comprising of officials from the ministries of health, finance and economy, labour and social security undertook a study tour to Rwanda in October 2015 to share experiences and understudy the Rwanda model for financing national health services. During the study tour, the Mozambican delegation was enlightened on various mechanisms and strategies adopted by Rwanda to finance its health sector including tax-based and insurance funding and performance-based funding. Following the study tour, Mozambique initiated strategic actions such as finalization of health insurance schemes for public servants and the military, advocacy for health insurance subsidies to make the system sustainable and development of a proposal for pilot testing of CBHI in the country.
The debate is therefore not whether to use the SSC mechanisms for public health services strengthening in Africa or not but how to effectively use it. African countries could reap immense benefits such as cost savings through application of economy of scale strategies in the joint production or procurement of medical products, better bargaining power through joint negotiations, synergy in cross border collaboration and coordination of public health activities such as immunization campaigns, outbreak and humanitarian response. Other benefits include continuity in implementation of health programme across sub-regions through the use of regional commitments which are binding on participating countries, ownership and direct impact of actions on beneficiaries. The use of SSC for health could also be an opportunity to strengthen regional integration.
Clear opportunities for SSC among African countries could be demonstrated in the areas of diseases prevention and control, production of essential medicines, medical products, vaccines and harmonization of regulatory processes, institutional capacity building and health workforce development, direct delivery of specialized health services, public health experience sharing, cross border collaboration and coordination of services delivery and implementation of the international health regulations among others.
During the study tour, the Mozambican delegation was enlightened on various mechanisms and strategies adopted by Rwanda to finance its health sector including tax-based and insurance funding and performance-based funding.
Pitfalls such as poor coordination, inadequate political commitment, lack of conducive policy environments, language barrier and inadequate financing opportunities for SSC initiatives present a major challenge for the use of SSC mechanisms in Africa. Other challenges such as lack of evidence from implementation of SSC in other regions, lack of information required for effective monitoring and evaluation of outcomes and impact of SSC initiatives and a regional oversight mechanism for issues such as licensing of health workers, regulation of essential medicines and medical products all needs to be addressed in order to benefit from the vast opportunities offered by SSC.
Recommendations in terms of logistics
The effective and systematic use of SSC mechanisms to strengthen health systems and public health services delivery in Africa would thus require: 1) assessment and identification of common public health problems and objectives in the region to which SSC could be applied; 2) mapping of available financial and human resources which could be harnessed to support the implementation of SSC initiatives across the continent; 4) the inclusion of SSC in existing regional and countries policies would also be critical, with mechanisms for coordination, monitoring and evaluation of SSC/TC activities; 6) overcoming cultural and linguistic barriers to ensure optimum cooperation among countries especially those with similar historic and cultural roots.
Recommendations in terms of funding
Establishing a framework for effective implementation of the foregoing requires involvement of multiple stakeholders. The Regional Economic Communities, governments, private sector, the academia and the UN needs to be fully engaged to provide the overall platform for establishing SSC mechanisms. Public-private partnerships are crucial to bring the manufacturing sector on board in the areas of production and resource mobilization. National and regional public health organizations could provide the required technical and financial assistance to establish regional and national platforms for public health SSC [through enhanced cooperation].
The establishment of a fund for SSC similar to the African Public Health Emergency Fund (APHEF) in the regional banks such as the African Development Bank, as well as the incorporation of SSC mechanisms into existing funds such as APHEF could also be an opportunity to address the funding challenges associated with SSC implementation. Furthermore, increased advocacy to African countries to include funds for SSC in their health budgets would also be a valuable option.
Importantly, African countries as the main duty bearers of their health development agenda should provide the overall leadership for implementation of public health SSC initiatives. The establishment of the Africa Centres for Disease Control, and the recently launched SDG Africa Centre could provide a platform for developing capacity for and coordinating the increasing use of SSC mechanisms for public health services delivery on the continent. The community who are the ultimate beneficiaries of SSC initiatives, the civil society and local organizations who are present at the grassroots and can support community-based health initiatives also have critical roles to play.
The foregoing demonstrates that the need for a paradigm shift from vertical to horizontal development cooperation needs no further proof but a call to action. We therefore call on concerned stakeholders to support establishment of systems which could facilitate organized use of SSC mechanisms to strengthen public health services delivery in Africa.
Second, we call for designation of an African Centre of Excellence for international public health cooperation within an existing public health institution on the continent. The Centre should be tasked with conducting in-depth analysis of the enabling factors required for successful application of SSC to public health in Africa and to support coordination, research, knowledge sharing and establishment of a community of practice for SSC in public health. Lastly, we advocate for development of a regional mechanism for supervision, monitoring and evaluation of SSC and TC initiatives.
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