Memorandum by Merlin
ABOUT MERLIN
1. Merlin is the only UK specialist agency,
which responds worldwide with vital healthcare and medical relief
for vulnerable people caught up in natural disasters, conflict,
disease and health system collapse. Merlin's aim is to ensure
that vulnerable people who are excluded from exercising their
right to health have equitable access to appropriate and effective
healthcare.
2. This aim is inspired and underpinned
by the World Health Organisation (WHO) declaration[31]
that "the enjoyment of the highest attainable standard of
health is one of the fundamental rights of every human being without
discrimination of race, religion, political belief, economic or
social condition". In support of this aim, Merlin works in
partnership with global, national and local health agencies and
communities to strengthen health systems and build community resilience
to better prevent, mitigate and respond to health outcomes.
THE ISSUES
3. The following represents a consolidated
response to some of the key issues raised by the Inquiry.
PRINCIPAL BLOCKAGES
4. From Merlin's perspective the challenges
faced, in achieving progress towards prevention and control of
the three major diseases (TB, Malaria and HIV) in particular,
and by that measure the Millennium Development Goals (MDGs), are
determined in large part by the capacity of national health systems.
Although cost effective solutions are available for the prevention
and treatment of these diseases, for example insecticide treated
nets for the prevention of malaria and the provision of anti-retroviral
therapy for HIV, the inability of many heath systems to plan,
support and deliver essential health services will nonetheless
result in poor health outcomes.
5. Merlin's experiences within the context
of fragile states support that view that at present many health
systems simply do not have the resource capacity to support the
scale up of the solutions needed to address the continued high
burden of communicable disease. Central to this poor resource
capacity, is the lack of investment in human resources for health
(and in particular health staff who are skilled in communicable
disease surveillance, prevention and control), and the need for
increased and predictable donor financing to address the investment
shortfalls of recent years.
Human Resources for Health
6. From Merlin's perspective, early investment
in strengthening human resources will be critical to securing
future progress against the MDGs and promote health system development,
Evidence shows that the quantity and quality of health workers
is positively associated with essential health interventions including
immunication and primary health care (WHO,2006). Further the 2006
World Health Report (ibid), confirms that countries experiencing
the greatest difficulties in achieving the MDGs face absolute
shortfalls in their health workforces.
7. A review of human resources for health
in two of Merlin's key programmes in Liberia and Kenya in 2007
highlights the critical role that human resources play in a functioning
health system—particularly in difficult or fragile environments
where the workforce may have been exposed to extreme pressures
such as conflict and long-term underinvestment in the health sector.
Key issues identified at the country level by Merlin programmes
include:
— the lack of qualified human resources
especially in remote areas (urban concentration and rural deficits);
— poor remuneration of staff contributing
to their movement/migration to better paid options often outside
the area or country;
— low levels of general education (especially
of woman in some countries) which restricts the numbers which
can be trained up to join the health workforce;
— the lack of frameworks in place for
supervision and on-the-job training and quality management; and
— the lack of investment in staff training
and development by government and international donors.
8. These findings are borne out by the WHO
report which calls on its Member States to show national leadership
in three strategic areas: by improving the poor performance and
working conditions of health workers; through the provision of
better information to inform strategic planning and better education;
and, through strengthening core institutions, policy frameworks
and leadership and management development. However, despite the
WHO's leadership in this area, further effort is required to translate
policy approaches to action on the ground.
Financing Health Systems
9. The significant burden of disease in
developing countries from HIV, TB and malaria places enormous
pressures on already weakened and under financed health systems
(World Bank, 2006)—the incidence of TB in Sub-Sahara Africa
is the highest in the World and 90% of all Malaria deaths in 2003
were also in this region (WHO, 2003). If investment in human resource
capacity is to be sustainable, developing countries will require
increased, predictable and longer term financing by the international
donor community and a commitment to promoting longer term support
for health systems by Intergovernmental organisations. In Eastern
DRC, Merlin has been supporting the health system for more than
10 years, during conflict and a series of ensuing humanitarian
crisis. The absence of long term, predictable financing severely
constrains International NGOs ability to support the Ministry
of Health in strategic planning and provide services to those
most in need.
10. Merlin would like to see new proposals
put forward for funding mechanisms that are longer term, encourage
risk and support innovation. Intergovernmental organisations have
a significant role to play in facilitating greater awareness of
the challenges faced by health systems and in promoting longer
term financing instruments. Mechanisms such as those proposed
by the Good Humanitarian Donorship (GHD) initiative aimed increasing
the flexibility and predictability of funding are positive steps
in this direction.
11. While long term financing for national
health systems remains a key concern, the growing plethora of
global health initiatives channelling vast sums into disease and
intervention specific health programmes sits in stark contrast.
There is significant on-going debate about the value of such initiatives,
but what is recognised is that with more than 90 global health
initiatives at present, including GAVI and the Global Fund for
HIV, Malaria and TB, efforts are needed at global level to rationalise
this number and mitigate the impact vertical programming on health
systems.
12. Merlin's experiences of the Global Fund
to date have been mixed. In DRC, a Global Fund programme in Maniema
Province, Eastern DRC has required setting up parallel primary
health care structures. Administration, supervision, and logistics
capacities as well as clinical care run alongside pre-existing
services missing the opportunity to support the development of
capacity within the pre-existing system. In addition there have
been issues with the unpredictability of the funding to support
ARVs leaving both recipients as well as Merlin staff in an uncertain
and difficult position and preventing new entrants to the programme
being admitted. In contrast, in Nyanza Province Kenya, Merlin
is working under the auspices of the Global Fund, in partnership
with the Ministry of Health, to build the capacity of health facilities
to provide effective diagnosis and treatment of malaria. The programme
is directed at supporting the Ministry of Health to deliver services
in accordance with Kenyan national policy.
13. This lack of support for national led
systems is frequently highlighted as a failure of some health
initiatives. In addition, the proliferation of Initiatives places
considerable strain on the management capacities of developing
countries and can act as a drain on precious (human) resources;
diverting priorities away from where they are needed most to "disease
specific" interventions. At present global initiatives are
not accountable to national health systems and the considerable
level of funding not sustainable in the long term by developing
countries national budgets. Although significant steps in terms
of reducing the burden of disease are being taken by the Global
Fund and others arguably this must go hand in hand with support
for national health systems. IGOs, and in particular WHO must
seek to advocate for stronger resonance between the interventions
of global health initiatives and the strategic plans of national
health systems. A first step has been taken; in September 2007,
UN agencies and the WHO supported the launch the International
Health Partnership, aimed at improving the way that developing
countries and international donors work together to support national
health plans. IGOs should seek to promote these links wherever
possible.
AVIAN INFLUENZA
14. The WHO has designed a Global Influenza
Preparedness Plan to facilitate planning, preparedness and response.
However, while there is a plethora of guidelines and initiatives
in place at Intergovernmental level, Merlin is concerned about
how this might translate at national level, particularly in difficult
environments and fragile states, where national planning is weak
and there is great variability in terms of national planning and
capacity to respond.
THE IMPACT
OF TUBERCULOSIS
Tuberculosis is a major health concern in Kenya;
recent data from Merlin's programmes in the Western Highlands
and Lake Victoria region indicate that Kenya has amongst the highest
TB prevalence in the World at 884/100,000. Half of those with
TB are also HIV positive. In Merlin's experience in Kenya, the
rising incidence of TB can be attributed to: the high prevalence
of HIV and AIDS; the poor economic situation of people living
with HIV and AIDS; low case detection rates due to poor diagnostic
capacity as a result of a poor training, an absence of quality
control procedures and equipment; and, poor access to diagnostic
facilities for patients. In terms of access to essential drugs
within the health system, while this can be a challenge, the difficulty
from Merlin's experience lies in the capacity to effectively diagnose
TB owing to shortages in essential diagnostic reagents due to
problems in the distribution system especially from national to
facility level.
REFERENCES
WHO (2003) World Health Report 2003—shaping
the future.
WHO (2006) World Health Report 2006—working
together for health.
World Bank (2006) Health Financing Revisited.
January 2008
31 As reflected in the WHO constitution (1946),
Alma Ata Declaration (1976) and World Health Assembly (1998). Back
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