Junge Mütter warten im Stadtspital Bankim in Kamerun auf eine Sprechstunde. Photo: Simon Huber / © FAIRMED
FAIRMED's new challenge
FAIRMED, a Swiss Foundation, has over the past 15 years shifted its overall goal and focus from single-focused support to leprosy towards a more comprehensive “Health for the poorest”. Our vision is that no-one should suffer or die from preventable or treatable diseases. To ensure correct and adequate engagement towards this goal, we identify most marginalized, discriminated and/or vulnerable populations through mapping pockets of high endemic Neglected Tropical Diseases (NTD’s). Using the determinants of health framework, we analyze the challenges and opportunities that our beneficiaries face, and map out pathways towards equity in health. This is a critical point, on paper obvious but in reality a tough challenge: identify who is left behind and what mechanisms are responsible and actionable. FAIRMED has over a decade of real action on “Leaving no one behind”, in diverse settings in the Congo basin and the Indian subcontinent. We are thrilled to be joined by so many now and like to share pitfalls and opportunities that have come across our way.
Value For Money
To really leave no-one behind, one needs courage and determination in “Value for money” and “quick impact” times – through careful and focused use of human and financial resources versus blunt efficiency.
Resist to only pick ripe or low hanging fruits - go for real change
With that courage one has to make radical choices in working with and for the most vulnerable, discriminated and/or excluded people. This is likely not going to be in the areas where you know one will get a quick, loud and large bang for your or your donor’s buck, likely not going to be the fast track from seed to fruits on trees – but the trees will stand strong by the depth of their roots. The Baka tribe of Cameroun and similar populations in the region are particularly vulnerable, and suffer from various elements of social exclusion; including slavery and forced removal from their traditional living space – the forest. They suffer disproportionally from a number of NTD’s such as leprosy, yaws and Buruli ulcer. Typically, they constitute about 15-25% of local communities, and many support programs could easily target the more accessible population around the Baka community and manage to improve the overall health status. But since the Baka are “most left behind” FAIRMED opted to have a specific focus on equity in health for the Baka’s.
Die ethnische Minderheit der Aka erhält vom lokalen Gesundheitssystem in der Zentralafrikanischen Republik nur wenig Unterstützung. Photo: Simon Huber / © FAIRMED
People centered, multisectorial
Leaving behind no-one brings us to realize this no-one is a someone, a person. Just as we acknowledge people are more than cases of diagnosed disease entities, we should also acknowledge people cannot be reduced to their health status and needs. Health care is only one element deciding health status, and often it is a minor factor. We need to take into account social determinants of health, and act on them (We Need Action on Social Determinants of Health – but Do We Want It, too? International Journal of Health Policy Management 2016, 5(6), 379–382); and start working multisectorial in earnest. In the concrete example of the Baka’s, lack of citizenship, insufficient education and limited agricultural opportunities are important drivers of inequity, leading to unequal health outcomes and overall wellbeing. As health organization, our expertise and main contribution remains in the health sector; but without collaboration with and inputs from other sectors, any progress in terms of health status would be severely compromised by the general socio-economic challenges the Baka’s face.
Local diagnosis and action
Public health must be local (Public health is local, The Lancet Public Health, Volume 2, No. 9, e387, September 2017). Only then can one really focus on the needs of the vulnerable, and tackle inequity. We have to carefully consider where and by whom the not leaving anyone behind will actually happen. It is not in plush UN Board room seats, nor in comfortable FAIRMED offices. It is out in the communities and on the street, by communities that exercise their rights, have a voice, and are inclusive for those that risk to be left behind. In the health sector, the intermediaries between neglected people and the health system are those that can broadly be defined under Community Health Workers. They are people like the ASHA’s in India – it is no coincidence that they are called Social Health Activist: aiming to play a role in creating the awareness on health and its social determinants.
Inequity stems from local and global asymmetric power relationships, and leaving no one behind on the way to equal and fair changes in life often means we need to challenge the balance in these relationships. We easily talk about empowering the poor, but rarely remember that work on the other side of the balance is equally important: disempower and keep accountable local and global elite’s. FAIRMED has developed a participation and inclusion approach in West African health setting through work with health committees. Representational targets and limits are negotiated and its implementation reported. To ensure effective representation we measure and build capacity for effectively influencing agenda and decisions and their implementation. We have applied this with ethnic minorities, people living with a handicap, gender and refugee status as a yardstick. Whilst there is no guarantee for success, we have seen remarkable change, for example in East Cameroon, where representatives of the mainly Central African refugee community not only got elected and effectively represented their source group, but also managed to get appointed to managerial positions in the health committee. Imagine this for refugee settings in Western Europe!
Eine freiwillige Gesundheitsmitarbeiterin (Accredited Social Health Activist) untersucht eine Lepra-Betroffene im indischen Bezirk Maharashtra. Photo: Simon Huber / © FAIRMED
Inclusive thinking on access
Leaving no one behind also asks for innovative ways of thinking about access. Often the health actors most trusted and visited by marginalized populations are themselves marginalized by the formal health system. Traditional healers are often overseen or actively worked against by health officials. As part of our health system strengthening in the Bankim district of Cameroon FAIRMED, together with partners, demonstrated the benefits of collaboration, amongst others with the traditional healers and their association. Collaboration contracts were established between the health service and healers with mutual rights and responsibilities, specifically for Buruli Ulcer cases. Early case detection and final treatment outcomes tremendously improved and whilst we only targeted to have 10 contracts, the district ended up with formal collaboration with 65 traditional healers.
Using NTDs as indicator of inequity, an litmus test for UHC
Presence of NTD’s allows us to define which populations are suffering from inequity. Focusing on neglected populations, with a broad multisectorial analysis of needs and underlying determinants, allows us to design pertinent initiatives that will have impact on livelihoods of those that are left behind. Decreasing the burden of NTDs is an important litmus test for Universal Health Coverage (UHC) (Global health policy and neglected tropical diseases: Then, now, and in the years to come. PLOS, Neglected Tropical Diseases, September 2017), the broader Sustainable Development Goals (SDG’s) (The cross-cutting contribution of the end of neglected tropical diseases to the sustainable development goals. BioMed Central: Infectious Diseases of Poverty (2017) 6:73), and the usefulness of the slogan “Leave no one behind”. FAIRMED will use decreased NTD burden as a proxy indicator at higher levels in our new 2018-2021 global program approach, starting with projects designed as from quarter 4 in 2017.
Historic Opportunity
If we manage to make a dent in NTD morbidity and mortality, we will have served the ones furthest behind; making sure that neglected people get the care they need, and not the one that is still available after anyone else has grabbed their share. For too long we have worked for the poor but had to see that the largest part of our efforts went to the richer quintiles (who indeed also have needs!). Now, the new paradigm shows us that by first serving the ones left behind for too long, will assure that we reach the high level goal. “Leave no one behind” offers us the historic opportunity to identify the most in need, to focus energy, resources on the poorest, and at the same time deliver essential progress against global priority concepts. Let’s not miss this chance to ensure that no person – regardless of ethnicity, gender, geography, disability, race or other status – is denied basic economic opportunities and human rights (High Level Panel Releases Recommendations for World's Next Development Agenda. High-level Panel the Post-2015 Development Agenda).
References
- We Need Action on Social Determinants of Health – but Do We Want It, too? International Journal of Health Policy Management 2016, 5(6), 379–382: http://www.ijhpm.com/article_3168_9ec6a29f74ac082c80ee159beb17bca6.pdf
- Public health is local, The Lancet Public Health, Volume 2, No. 9, e387, September 2017: http://dx.doi.org/10.1016/S2468-2667(17)30170-6
- Global health policy and neglected tropical diseases: Then, now, and in the years to come. PLOS, Neglected Tropical Diseases, September 2017: https://doi.org/10.1371/journal.pntd.0005759
- The cross-cutting contribution of the end of neglected tropical diseases to the sustainable development goals. BioMed Central: Infectious Diseases of Poverty (2017) 6:73: https://doi.org/10.1186/s40249-017-0288-0
- High Level Panel Releases Recommendations for World's Next Development Agenda. High-level Panel the Post-2015 Development Agenda: http://www.post2015hlp.org/featured/high-level-panel-releases-recommendations-for-worlds-next-development-agenda/
