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By Rupa Chinai The Global Forum for Health Research held in Mumbai in September emphasised how health research that is linked to community response can help bridge the gap between policy and delivery of services
Six of Rashida Bee's family members died of cancer in the years following the Bhopal gas disaster of 1984. Rashida, aged 49, herself suffers from breathlessness, hypertension, headache and other exposure-related problems. A worker at the government-run stationery production centre in Bhopal, Rashida found that many worker families were similarly affected.. According to Rashida, President of the Bhopal Gas Affected Women Stationery Workers Union and winner of the Goldman environmental prize in 2004, the turning point in the struggle of Bhopal’s gas victims came when civil society organisations joined hands with them in documenting the health of the affected people. When this information was shared with the community, it created an understanding of what was happening to their bodies and empowered the women of Bhopal to sustain their 20-year-long struggle for justice. "Researchers focus on getting statistical data but often miss out on obtaining qualitative information through interaction with the community,” said Dr Ravi Narayan, global secretariat coordinator of the People’s Health Movement. “Research that strengthens the case of what communities want and spurs them to social action is the new political paradigm, evidence of which is emerging in the countries of Asia and Africa, and in Mexico.” International scientists, around 700 from 90 countries, who gathered in Mumbai September 12-16, 2005 at the Global Forum for Health Research to debate issues of poverty, equity and health research, would have done well to look at some of these southern experiences on how health research that is linked to community response could help in bridging the disconnect between policy and delivery of services. While the Global Forum aimed at bridging the ‘10/90 Gap’ -- a reference to the fact that 10% of all global health research funding is allocated to 90% of the world's disease burden -- the overwhelming focus at the Forum was on technology -- drugs, vaccines or diagnostics. Through some presentations and ‘marketplace’ discussions, a southern perspective did however emerge to question contemporary development thinking and allocation of resources that would make a difference to women like Rashida Bee. Said Lot Nyirenda, a scientist with Research for Equity and Community Health Trust in Malawi and a delegate at the Forum, “We have a saying in Malawi: For a man to be alive, he has to eat. If we do not talk about food, we have to stop talking about health.” The overwhelming concern of sub-Saharan African countries like Malawi is the desperate need for farm inputs; food security and self-sufficiency; learning methods of rainwater harvesting to tackle drought; debt relief (government spending on health, education and agriculture has ground to a halt) and issues of governance (creating systems of accountability that tackle corruption), Nyirenda said. "Policies for research and equity need to be developed in a manner that is participatory, country-specific, conscious of issues of race, language, gender, age, geographical differences and poverty. It should aim at reaching the most marginalised segments of the population by ensuring mechanisms that provide proof of delivery,” Nyirenda said. Providing some key insights on international trends that have not yet impacted India, the Forum highlighted the outcry against user fees and withdrawal of public sector support. Research evidence such as the 15 Asian countries EQUITAP (Equity in Asia-Pacific Health System) Study revealed the failure of this strategy in generating public revenue while inflicting high out-of-pocket expenditure for the poor, plunging them into indebtedness and deeper poverty. “While even the World Bank admits this failure, it is silent about the need for retraction of this policy in India,” said Ravi Duggal, Centre for Enquiry Into Health and Allied Themes, Mumbai. Stephen Matlin, Executive Director of the Global Forum for Health Research, said that many Asian countries fail to provide universal access and free services and the limited resources that are spent on health are not well targeted. “A relatively large proportion of the public resources benefit the better-off rather than the poor in society. It is true there have been many reversals in policies but this is a shift finally in the right direction. Cost recovery has been harmful for a number of countries. New evidence indicates the need to eliminate user fees and provide free access to the poor,” he said. Pertinent to the issue of how public money is spent, is the example of the state of Kerala in India which shows declining support for the public sector: In 1986 it had spent 11% of planned expenditure for health infrastructure development. In 2003 it dropped to 6.5% with the bulk of the money spent on recurrent expenditure like salaries. “With Kerala having reached that curve in demographic transition -- there are more elderly suffering non-communicable diseases in rural areas -- access to drugs for diabetes and blood pressure comes from out-of-pocket payment. These drugs are not available in 70% of the primary health centres. Meanwhile the growing urban-rural divide is perpetuated, with rural areas barely receiving 20% of the health budget, said Arun B. Bahuleyan of Stree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, during his poster presentation at the Forum. Di McIntyre, Associate Professor, Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa, stressed that research conducted in developing countries needs to look at other options of finance for health services or education. While existing studies demonstrate the nature of the problem, evidence from successful models (Sri Lanka, Malaysia, Hong Kong) has not yet indicated how linkages at the ground level are created to ensure delivery of services, she said. “Beyond the mechanics of technology, finance and management, that operate on quick-fix and pre-determined solutions, we need a better understanding of the health of our health system,” said Lucy Gilson, Associate Professor, Centre for Health Policy, School of Public Health, Johannesburg. The inability of health systems to deliver services comes down to the “politics of implementation”, with top-down planning creating resistance to change by programme implementors. People do want to make a difference and we have to understand what prevents them,” she said. InfoChange News & Features, October 2005
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