Innovations in Supporting Local Health Systems for Global Women’s Health docx

On June 5–7, 2005, sixty leaders from around the world gathered at WyeRiver, Maryland for a path breaking meeting entitled “Innovations in Supporting Local Health Systems for Global Wome

Innovations in Supporting

Local Health Systems

for Global Women’s Health

Summary Report of the Wye River, MD Conference

SP O N S O R S

Realizing Rights: The Ethical Globalization Initiative (EGI) is a project

led by former President of Ireland and United Nations High Commissionerfor Human Rights Mary Robinson, and is a partnership of the AspenInstitute, Columbia University, and the International Council on HumanRights Policy EGI’s mission is to mobilize and influence political, economicand civil society leaders in order to tackle global inequities by connectinghuman security, human development and human rights

The Council of Women World Leaders is a network of current and former

prime ministers, presidents and cabinet ministers whose mission is to mobilizethe highest–level women leaders globally for collective action on issues ofcritical importance to women and equitable development Through its networks,summits, and partnerships, the Council promotes good governance and gen-der equality, and enhances the experience of democracy globally by increasingthe number, effectiveness, and visibility of women who lead their countries

Columbia University Mailman School of Public Health is the only accredited

school of public health in New York City and is among the first in the nation.Its students and multidisciplinary faculty members engage in research, bothlocally and globally, concentrating on biostatistics, environmental health sci-ences, epidemiology, health policy and management, population and familyhealth, and sociomedical sciences In the field of global health, the MailmanSchool has played a leadership role in improving delivery of health servicesthrough such programs as its Averting Maternal Death and Disability( AMDD) program, its MTCT–Plus Initiative and other AIDS programs,and through its involvement in the UN Millennium Project Task Forces onchild health and maternal health, HIV/AIDS, and malaria

P H O T O C R E D I T S

Front cover © Jeremy Hartley/Panos Opposite page © 2002 WHO/P Virot Page 4 © 2002 WHO/P Virot Page 5 (top left) © 2003 Julia Griner/CARE Page 5 (bottom left) © 2003 Otto Guzman, Courtesy of Photoshare Page 8 (bottom) © 2001 Josh Estey/CARE

Page 10 © 2004 Karen Robinson/Panos

Page 14 (left) © 2001 Josh Estey/CARE Page 15 (right) © 2002 WHO/P Virot Page 16 (top) © Jeremy Horner/Panos Page 18 (top) © 2002 WHO/P Virot Page 19 (left) © 1999 Martin Adler/Panos Page 19 (right) © 2004 Jasmine, Courtesy of Photoshare

On June 5–7, 2005, sixty leaders from around the world gathered at Wye

River, Maryland for a path breaking meeting entitled “Innovations in Supporting

Local Health Systems for Global Women’s Health: A Leader’s Symposium.” This diversegroup of participants, ranging from cabinet ministers to advocates, academics

to local practitioners, shared a common goal: to shine a bright spotlight onurgent challenges in global women’s health and the critical need to pioneerinnovations in strengthening local health systems to address those challenges.The diverse group focused on learning from one another and identifyingareas for further action with a particular focus on the role that political lead-ers can play in creating positive change Clear themes emerged and the ener-

gy and momentum generated in the meeting culminated in the Wye River Call

to Action for Global Women’s Healthdeveloped by the participants and quently endorsed by leaders the world over

subse-Co–hosted by Realizing Rights: The Ethical Globalization Initiative, theCouncil of Women World Leaders, and the Columbia University MailmanSchool of Public Health, the meeting addressed the most fundamental chal-lenges facing women’s health Participants shared their experiences of whatpolicies have proven successful in providing access to health care, and com-mitted themselves to develop and promote leadership in implementing healthcare policies that effectively provide fundamental services to women Theydiscussed creative efforts to promote, manage, support and monitor localhealth care systems in poor countries, with a particular focus on provision

of care to reduce maternal mortality and HIV/AIDS, and on reproductivehealth services and rights

This report extracts the key cross–cutting themes arising from the meeting’sstimulating presentations and rich discussions which together provided

the rationale for the Wye River Call to Action It draws out of the meeting

best practice examples and innovative and creative next steps that can betaken Finally the report profiles a number of meeting participants, high-lighting the important work for women’s health that is being carried out today in every region of the world

The Meeting

“ This conference is

extraordinary because it

affirms what does work,

what can be done, and

now we just have to get

the right people to do it.”

— Marian Wright Edelman

President and Founder

Children’s Defense Fund

the Wye River Call to Action for Global Women’s Health, and the

examples of good practice provided in this report will support all levels ofleadership to recognize women’s basic right to health and the central role

of ensuring strong local health systems in fulfilling these rights To add yourname or that of your institution to the Wye River Call to Action, please go

to www.realizingrights.org or send an email to peggy.clark@aspeninst.org

AC K N O W L E D G E M E N T S

The conference organizers are deeply grateful to the following foundations

for their generous support of “Innovations in Supporting Local Health Systems for

Global Women’s Health: A Leader’s Symposium.”

n The Bill & Melinda Gates Foundation

This report was prepared by Helen de Pinho, Elizabeth Keller and Greg Behrman

“ Scaling up — ensuring

that health care is accessible

to and used by all those

who need it — also means

tackling the social, economic

and political context in

which people live and in

which health institutions

are embedded.”

— Lynn Freedman, et al, Who’s Got the Power?

Transforming Health Systems for Women and Children,

UN Millennium Project, Task Force Report

on Child Health and Maternal Health, 2005

We have the power to explore the planets and walk the moon We have the power to coax green from the deserts We have the power to map the human genome.

Yet in the year 2005, in millions of communities in every corner of the globe,people are suffering because those with political power have failed to meettheir most basic responsibilities That failure is seen in the crisis of local healthsystems that do not work, that exclude the poor, abuse and marginalize women,sow distrust and feed corruption The result is societies marked by profoundinsecurity, by deep and growing inequities, and by the unacceptable toll onthe health and well–being of girls and women

Every minute of every day:

with HIV/AIDS;

n Countless women and girls suffer the health consequences of malnutrition, chronic and communicable diseases that disproportionately affect women, gender–based violence, harmful traditional practices, and war and civil conflict

As political and civil society leaders, we come together to express our outrage

at this carnage and to solidify our commitment to work together for change

We call for a profound shift in the priorities that shape policies and resource allocations globally, nationally and locally.

We call for universal access to health care:

n Universal coverage of critical health interventions for women and girls requires strong health systems that ensure access, equity, and financial protection

n Health systems are more than delivery systems for technical interventions They are core social institutions that lie at the heart

of the poverty reduction agenda They are fundamental building blocks of secure and democratic societies

We call for systemic changes to build strong health systems:

n Funding of health systems must be increased through predictable, sustained and long–term investments, nationally and globally

n User fees for primary health care must be abolished, financial barriers

The Wye River Call to Action for

Global Women’s Health

June 7th 2005

n Countries, rich and poor, must confront urgently the crisis of

human resources: increase training, ensure that mid–level cadres

of health workers are expanded and empowered, provide adequate

and fair compensation for all health workers, and take measures to

stem the exodus of scarce health workers from the public sector

to strengthen health systems, improve women’s health, and establish tolerance and respect for women’s decisions in all matters pertaining

to their health and well being

of health systems and to the uncompromising protection of the health and rights of women and girls

We call for these priorities to be reflected in poverty reduction and development strategies:

n Political leaders must recognize the critical importance of women’s health and empowerment, and of health systems to achieving the

Millennium Development Goals (MDGs), and

Population and Development) target of universal access to

reproductive health by 2015 as an additional target to MDG 5

These commitments are not optional

Women have a human right to health and to access to health care

Women are vital to the future development of their countries — as workers,

as caregivers for their families, as stewards of the environment, as technologicalinnovators, and as political leaders at all levels

Women are citizens with the right and responsibility to participate meaningfully

in the decisions that affect their lives and to demand accountability from thepeople and institutions that have the duty to fulfill these rights

Women are entitled to no less

Let us work for no less

Allan Rosenfield

Dean

Columbia University Mailman School of Public Health

We Call for Universal Access

to Health Care

Dr Pascoal Mocumbi

WHO Goodwill Ambassador for the Commission on Social Determinants for Health

High Representative, European & Developing Countries Clinical Trials

Former Prime Minister of Mozambique

As far back as he can remember, Pascoal Mocumbi dreamed of being a physician Growing up in then–colonial Mozambique,

Dr Mocumbi could not have imagined where his childhood yearning would take him.

After completing his medical training and residency in Switzerland, Dr.

Mocumbi returned to Mozambique in

1975, the year his native country would finally achieve independence The colo- nial experience would leave a legacy of

We Call for Universal Access

to Health Care

nUniversal coverage of critical health interventions for women and girls requires strong health systems that ensure access, equity, and financial protection.

nHealth systems are more than delivery systems for technical interventions They are core social institutions that lie at the heart

of the poverty reduction agenda They are fundamental building blocks of secure and democratic societies

Wye River Call to Action for Global Women’s Health

In much of the developing world, health systems at the local level are

fundamentally failing to sustain and improve the lives of women In many

cases women are the last to receive adequate health care and are dying because

of it Women are dying because they do not have access to emergency obstetric

care when they require it Women are at risk because their nation, province

or village has not placed sufficient priority on ensuring that they are protected

from the threat of contracting HIV/AIDS Women are suffering because they

must bear the burden when anyone in the household is sick, and there is no

doctor, nurse, or caregiver to turn to

The statistics are well known and staggering And yet, in many countries the

figures continue to worsen Each year 500,000–600,000 women die in

pregnancy and childbirth In some parts of Sub–Saharan Africa, 1 in 6

women die in child birth, while in United States the lifetime risk is as low

as 1 in 84001 HIV/AIDS statistics tell an equally disturbing story of

dis-parity In parts of Africa, over 35% of the adult population — 1 in 3 adults

— is infected with HIV2 The number of women contracting the disease is

also on the rise For example, in Botswana, twice as many women as men,

ages 25 to 29, are living with AIDS3

We know the interventions that can save most women’s lives If every

woman had access to essential maternal care, 74% of maternal deaths could

be prevented4 If all women had access to self–controlled means of HIV/

AIDS protection and were in a position within society to use these methods,

millions of HIV/AIDS deaths could be prevented Thus, we do not so much

need new technology, as we need to ensure universal access, utilization and equity.

But ensuring universal access, utilization and equity means that our health

services cannot continue to function as “business as usual.” Fundamental

change is necessary We must rethink the link between poverty and health

and understand the essential role that health systems play in society, in

poverty–reduction and in overall development

Poverty is not just a state of want Poverty is also fundamentally about

the relationships that people have with structures of power Health

sys-tems are core social institutions that function as one of the most important

and pervasive structures of power in any society Participatory poverty

assessments conducted in scores of countries around the world demonstrate

over and over again that neglect, abuse and exclusion by the health system

dislocation with profound repercussions

for the health of Mozambique’s state and

its people

When Dr Mocumbi returned, he

found all the Portuguese leaving the

country and only ten fully trained and

qualified local physicians for a nation

whose population numbered almost 10

million people In 1980, he was named

Minister of Health In 1987, he was

appointed Foreign Minister and spent his

tenure trying to end a gruesome civil war.

He achieved peace in 1992 and, two

years later, Dr Pascoal Mocumbi became the Prime Minister of Mozambique.

Peace allowed Dr Mocumbi to usher

in a period of economic expansion, but it also opened up Mozambique’s borders and transportation corridors, unobstructed arteries in which HIV/AIDS would flourish.

In 1994, Mozambique’s adult infection rate was 5 percent Dr Mocumbi esti- mates that today it is 13.5 percent and still on an upward trajectory Together with Malaria and TB, HIV/AIDS is one of the three communicable diseases that he

points to as Mozambique’s single est health challenge These three dis- eases are increasing maternal mortality and child mortality rates, and the burden

great-on women as primary caregivers is becoming almost unimaginable

During his tenure as Prime Minister,

Dr Mocumbi gleaned a critical insight: health is elemental to development There could be no economic advancement

has come to be part of the very experience of what it is to be poor in much

of the world today Conversely, the ability to assert a right to health and tohealth care and to have those rights fulfilled through access to a functioning,responsive health system is an asset of citizenship5,6 Thus health systems arefundamental building blocks of secure and democratic societies

Conventional approaches to health in poor countries focus on disease–specificinterventions and their cost effectiveness, implemented via the path of leastresistance with a strong emphasis on short term results The upshot is that sys-temic problems which underlie poor health, failing health systems, and healthinequity are circumvented Long–term, sustainable strategies are rarely devel-oped or deployed The crisis may change its spots, expressing itself in differentdiseases, populations or geographic areas, but it essentially continues unabated

The most fundamental challenge is to sustain the political pressure andleadership required over the long term to strengthen and restore health systems — health systems that will not only deliver technical interventionseffectively and equitably, but also promote democratic development andpoverty–reduction, and fulfill human rights This means recognizing that:

n Health and health systems are profoundly political Poor health isnot a random event — it follows the fault lines of disadvantage in access to power and resources in society7, 8

n The right to health is a fundamental value and an international legal obligation that should shape the way decisions are taken and policies developed Over 70% of all nations have ratified theInternational Covenant on Economic, Social and Cultural Rights obligating governments to progressively realize the right to health

n The problem is global It implicates not only issues of development aid, but also global structural problems such as “brain drain,”

indebtedness, and intellectual property regimes

n Disease–specific programs are critical but do not work without local–level problem solving, implementation, and attention to sustainability Conditions must be created to make local–level decision making and problem solving functional and legitimate

Local political leaders must have and use tools of accountability

to ensure that local systems work for all

There are no excuses — we need to assert broad vision, be bold and take action.

Continued from page 07

when those needed to work, to raise

families, to educate, to pass on values

were dying or sick in such large numbers.

Upon voluntarily leaving his seat of power

in February 2004, Dr Mocumbi became

High Representative of the European

& Developing Countries Clinical Trials

Partnership Secretariat, a new partnership

between Europe and Africa to advance

health in Africa.

With international funding, Dr.

Mocumbi has already seen national ership in pockets of Africa come together

lead-to refine strategies lead-to improve health, and with local ingenuity, he avers, much more

is possible For example, an effort to train non–physicians to deliver care has the potential, Dr Mocumbi believes, to help plug a gaping and deleterious hole in human resources capacity Nurses with more than five years of experience and medical assistants with more than three

years of experience, with additional ing, will be able to dramatically increase the medical and surgical services offered

train-to those in need in Mozambique It’s a tall order, but with ingenuity, partnership and adherence to what Dr Pascoal Mocumbi holds a fundamental truth — that health is a human right — millions of lives may be saved.

The government of Mexico City, Mexico believes that access to health care is a human right, and should be universal and free to those who cannot afford to pay

In Mexico City the mayor has made health care accessible to all, and has garnered the broad support of the City’s leaders and citizens for this unique effort9 When the City’s popular mayor, Andres Manuel López Obrador, came to power, he faced two significant challenges to keeping his campaign promise of free health care to poorer families First, the public health system was fragmented It covered only 60% of the population and was adminis- tered by the central government Second, widespread political corruption had undermined public services, undermining public faith in the quality of the public health system

Mayor Obrador was able to keep his campaign promise of removing economic obstacles to health care and providing social insurance by embracing the consti- tutionally–protected right to health and restructuring the existing, but deteriorat- ing, health institutions Mexico City’s Secretary of Health, Asa Christina Laurell, attributes much of the program’s success

to the strong political and financial mitment “You cannot have a rich govern- ment and poor people,” she explains.

com-Indeed, financing for this program has been sustained by cutting superfluous government spending; all high govern- ment officials accepted a 15% salary cut and funding for unnecessary technologies

was slashed This has created a savings

of $200 million in the first year and $300 million over the next three years Further,

it has saved the poor — those who can least afford to pay for medical services — approximately $200 million.

The results of the program have been tremendous People living in Mexico City now have better access to more expen- sive services, and the poor, especially women, have benefited the most from the program Importantly, despite the City’s aging population, the mortality rate there has decreased by 5% in the last four years And as of December 2004, some 710,000 of the 900,000 low–income families that qualify for free care had registered for the program.

Presented by:

Dr Asa Cristina Laurell

Secretary of Health, Mexico City

Government, Mexico

Ensuring Inclusive and

Equitable Health Services at

a Local Level — The Case

of Mexico City

nCountries, rich and poor, must confront urgently the crisis of human resources: increase training, ensure that mid–level cadres

of health workers are expanded and empowered, provide adequate and fair compensation for all health workers, and take measures

to stem the exodus of scarce health workers from the public sector.

n Countries must adopt and implement laws, regulations and policies to strengthen health systems, improve women’s health, and establish tolerance and respect for women’s decisions in all matters pertaining to their health and well being.

nHIV programs and policies must be oriented to the strengthening

of health systems and to the uncompromising protection of the health and rights of women and girls.