Health systems advocacy from inside the story

Elisa Veini

‘A good health system finds people where they are, it is easily accessible when and how people need it,’ stated Amanda Banda during the first Global Health Café, organized by ViceVersa in partnership with Wemos and other civil society organizations last Monday. Earlier that day, we spoke with her at Wemos’ office.

Amanda flew in straight from Dublin, where she participated in the 4th WHO Global Conference on Human Resources for Health, and from Amsterdam she will continue to Maputo, Mozambique for her next meetings, supporting CSOs’ engagement in health financing advocacy. The tight time schedule is illustrative of Amanda’s scope of work as the advocacy coordinator for the African region at Medécins Sans Frontiers.


For the past few years, Johannesburg has been Amanda’s foothold from where she has tackled urgent global health issues such as shortage of health workers and weak national health systems in African countries. A decade ago, she set up a health systems advocacy unit in Malawi, her home country, together with Wemos’ director Mariëlle Bemelmans, who was also working for MSF there.


She can easily tell what the top priorities are: there should be more health workers available, and they should be better trained and receive a decent salary. They also should be more evenly distributed, so that also the rural areas – which is where still most people live in Africa – are covered.


But it is in the communities that she learns what the issues are really about, Amanda says. Wherever she travels, she always pays a visit to the communities in rural areas and talks with health workers and patients. ‘It is my way to understand where the need is greatest,’ she says.


Can you give an example of what you have learned from the communities?

‘A healthcare student originating from the poverty-ridden rural areas in Malawi told me his personal story, when I asked about his motivation to train to become a health worker in the rural community,  “It was,” he said, “when my sister died while queuing up at the health centre. To get there, we had walked for three hours. We arrived at seven, and at two o’clock in the afternoon she died in front of me. She had not yet seen a healthcare worker yet because of the long ques, as a result of shortages of staff. Perhaps if there were enough health care workers, she could have been seen in time to save her life,” he wondered. ’


What, then, should governments do to change the situation?

‘It goes without saying that governments should invest more in health systems, and should donors too. The present situation is still far from this. International funding is not enough, and the little there is goes to earmarked projects, and most governments lack the resources for the wider health systems strengthening and only in some few cases where governments can afford to do more, they lack the will to increase their health expenditure.  Their hands are tied behind their backs and cannot increase the fiscal space to hire more health workers, despite huge vacancy rates.’


Can you talk a bit about the real needs of the health workers, and the patients? Do their needs match? 

‘It is important to understand all sides of the story. Patients need quality care, access to drugs and diagnostics that are easily accessible to them and do deserve the best the system can offer.  From the health workers’ point of view, all they want is the basics, good living and working conditions, supplies and diagnostics to enable them to do their job, which you don’t find especially in rural areas. In trying to improve access to quality care, both donors and governments need to look at the patient as well as health worker perspectives.  Despite long working hours and burnouts, some health workers are still committed to saving lives and serving their communities. A nurse told me: “I have seen many health workers come and go because the living conditions are unbearable, but I often feel sad and wonder even if the last health worker leaves, who will be left at the health centre to treat the patients.”’


So both the health workers and the patients are actually only asking for decent care in decent circumstances. Where does the money that is available then go?

‘In HIV/aids programmes, we see a lot of donor support prioritizing drugs and commodities and less of the wider health system strengthening. Governments often have to make tough choices with limited donor resources: to purchase drugs or invest in systems strengthening components and community programs.’


‘With other governments, we notice the rising interest in other trendy and ‘sexy’ programmes like sexual and reproductive health that focus on programmes and activities without necessarily investing in health systems strengthening. Those same programmes require a strong functioning health system and we just wonder why we are not getting results for the investment made.’


How about the role of the international community, the WHO?

‘In HIV/aids, the WHO policy directions are clear, science has given us the best tools, but putting the plans into action is a major challenge for many countries. National budgets are often simply not sufficient to cover all the costs of running health systems, international donors are still badly needed to support the implementation of the best of what science has given us.’


‘The WHO has an agenda-setting role and it provides important guidelines, and international donors have the money to realize them in practise. They should work in pair with WHO and governments.’


Reunion of ex-colleagues Amanda Banda and Wemos director Mariëlle Bemelmans in Amsterdam.


Read more about Global Health Café and our work on Human Resources for Health

Read the article about the Global Health Café on Vice Versa (Dutch)

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