Reporting from GIZ’s regional health and social protection conference in Malawi
On March 26-27, about 120 GIZ health and social protection experts and counterparts from 10 African countries gathered in Lilongwe for two days of lively and substantive discussions. They grappled with a broad spectrum of current health and social protection system challenges – and left inspired, with new ideas about how to address them, cross-sectorally, in their ongoing work.
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The Conference programme
‘Resilience is not about immediate results, but about being a learning system,’ said Alexis Bigeard, WHO’s Regional Health Financing Policy Advisor, when asked during the closing panel about his main takeaway from the conference. Michael Adelhardt, head of GIZ’s Competence Center Health and Social Protection, agreed: ‘I like the concept of resilience as capacity for adaptive learning. The challenges we discussed over the past two days, from population growth and antimicrobial resistance to climate change-related disasters and epidemic outbreaks, are all calling for a systems approach and for cooperation across sectors.’
Ethel Kapyepye, Chief Director of Safe Motherhood at Malawi’s Ministry of Health and Population, concurred and underlined the importance of national leadership: ‘We are all passionate about population health. It is government’s responsibility to bring partners across sectors together to make it happen.’ Thomas Staiger, Deputy Head of Mission and representative of the Federal Ministry for Economic Cooperation and Development (BMZ) at the German Embassy in Malawi, summed up the conference’s central learning in a nutshell: ‘In the SDG era, we should move beyond sectoral divisions and budgets. The question, however, is how.’
While there are no easy answers to this question, the concepts and approaches presented in the keynotes and technical sessions, and the rich discussions they inspired, helped to open up new perspectives and generate ideas for the future. Some of the highlights of the proceedings are summarised below.
A warm welcome to Malawi
Lilongwe’s futuristic new International Conference Center sparkled in the bright morning sunshine as delegates arrived from their nearby hotels to register, meet and greet their colleagues, and prepare for the first day of the conference.
The meeting’s host, Ruth Hildebrandt, speaker of the sector network and outgoing head of the GIZ health programme in Malawi, kicked off a round of welcome addresses, followed by Ingar Duering, acting GIZ country director, and Torsten Jellestad, director of KfW’s Malawi office. ‘Africa is facing many challenges in a rapidly changing world,’ said Duering, ‘and Malawi has some experience in coping with them – something you will certainly discuss these next two days.’
Kerstin Nagels, Director of the Division Economic and Social Development, Employment at GIZ, expressed the network’s solidarity with Malawians affected by the recent cyclone and floods. ‘GIZ regards it as one of its core tasks to help make African households more resilient against the consequences of such disasters’, she said. ‘To do this, and to reach the SDGs, we need to make even greater efforts to think, and work, across sectors.’
Thomas Staiger, the Deputy Head of Mission and representative of BMZ at the German Embassy in Malawi, pointed out that in recent years Germany has intensified its partnership with Africa. Health, education and social protection are the foundations for BMZ’s Marshall Plan for Africa, and its three pillars – trade and employment, peace and security, democracy and the rule of law – are all essential components of resilience.
Finally, Ethel Kapyepye, the Chief Director for Safe Motherhood at Malawi’s Ministry of Health and Population, extended a warm welcome to conference delegates: ‘Health has been at the core of our cooperation with Germany since it started in 1967, so we are glad you decided to hold this conference in Malawi. May it be successful and allow colleagues from different African countries to learn from one another.’
An invitation to collaborate on health systems strengthening for Universal Health Coverage
In his keynote address, Alexis Bigeard, WHO Afro’s Regional Advisor for Health Financing, outlined the linkages between health system strengthening and Universal Health Coverage (UHC) and invited GIZ health advisors to collaborate more closely with WHO at country level. With respect to health’s contributions to the 2030 agenda, he pointed out that ‘health actions are not limited to SDG 3, but are essential for the achievement of all 17 SDGs’.
UHC, the global goal currently pursued by all health actors, implies that all people have access to the health services they need, of sufficient quality to be effective, without being exposed to financial hardship. The means to achieve this are strengthened health systems, i.e. all organisations and resources required to maintain or restore health, encompassing governance, financing, workforce, information, medical products and service delivery.
According to recent reports from Harvard and Columbia Universities, there is broad evidence that investing in health is investing in human potential. Nonetheless there is a dramatic shortfall in the resources needed to achieve sustained progress to meet SDG 3. In addition to the major health risk of infectious diseases in lower-income countries, the burden of non-communicable diseases, which are largely preventable, is also increasing, costing countries an estimated 10% of their GDP and accounting for almost 60% of current health spending.
Bigeard presented the WHO/AFRO Framework of Action as a basis for intensified collaboration between WHO’s country offices, GIZ and African ministries of health. In the scoping process envisaged by the framework, governments identify the bottlenecks that hinder attainment of UHC targets and then negotiate how WHO and other partners, including GIZ, could best target their UHC support. ‘I look forward to learning more about GIZ’s work and hope to find openings for more collaboration at country level.’
An investment case for epidemic preparedness
In a session on the economic implications of disease outbreaks and the investment case for epidemic preparedness, Damien Bishop and Mariatou Turay-Rohde of GIZ Liberia put a spotlight on the close link between the state of countries’ epidemic preparedness, their health systems and their economies – and on ways in which GIZ can help to strengthen all three at once. They gave a global overview of countries’ vulnerability to epidemic outbreaks and of the devastating economic, health system and social impacts of past epidemic outbreaks in countries which were not sufficiently prepared for them. The West African Ebola epidemic is a case in point. While in 2015 the United States, the United Kingdom, Germany and the World Bank spent over 3 billion EUR on the response, the three affected countries still lost over 11,000 human lives, between 1% (Guinea) and 8% (Liberia) of their health workers and an estimated 2 billion EUR in their GDP. Investments, agricultural production and cross-border trade slowed down or came to a halt, leading to the collapse of large numbers of small- and medium-sized enterprises and food shortages in affected areas.
To improve the resilience of Liberia’s health system, German development cooperation through GIZ started in 2016 to support Liberia in strengthening its disease surveillance and response, improving its health care infrastructure and laboratory services, building a strong and gender-balanced health workforce and boosting management capacities across all levels of the health system.
According to the GIZ Liberia team, investing in epidemic preparedness is a cost-effective way to protect human lives, safeguard livelihoods and create a positive environment for local and international investors. The direct and indirect benefits such investments generate are considerably greater than the potential costs incurred in the absence of preparedness and should therefore be seen as an essential element on the pathway towards UHC.
Ensuring value for money in health through public finance reforms
Two GIZ health financing experts, Thorsten Behrendt of the Sector Initiative Universal Health Coverage and Kai Strähler-Pohl, the new head of the health programme in Malawi, highlighted the need for more dialogue between partner countries’ ministries of health and ministries of finance to ensure sustainable funding for UHC. Budget negotiations are highly political and often ministries of health fail to secure adequate budget allocations for health-sector priorities.
The release and actual use of funds tend to be the weakest components of the budget cycle. The commitment, authorisation and actual execution of payments require proactive coordination between ministries and agencies and often this does does not take place. Available data from sub-Saharan African countries show that, as a consequence, between 10% and 30% of allocated health budgets go unspent.
Many countries’ health systems therefore suffer from low budget allocations, mismatch between budgets and priorities, and underspending. In addition, ‘passive purchasing’ of services is still very common in many African countries. It means that health facilities receive funds without consideration of their performance, which undermines the efficiency and quality of health services.
According to Behrendt and Strähler-Pohl, the new concept of programme-based budgeting can help to align ministries’ budget allocations with sector priorities. It clearly links inputs to objectives, outputs and wider policy goals, allows for strategic purchasing, and incentivises accountability for performance at all levels of the health system. In line with the cross-sectoral orientation of the conference, they invited GIZ health experts supporting UHC processes in Africa to join them in forming a Community of Practice with development experts working on public finance reforms to jointly learn from implementation in order to generate guidance on sustainable financing for UHC.
Health as economic force and employment driver
In a session on human resources for health, presentations from GIZ experts working with ministries of health and other partners in Ethiopia, Malawi, Liberia and Cameroon showed how high this topic currently is on the German development agenda. As the kick-off presentations by Esther Werling and Ruth Hildebrandt on the international and macroeconomic context showed, there are good reasons for this.
According to Werling, Sector Initiative Universal Health Coverage, recent data from the International Labour Organization (ILO) provide strong arguments for investments in the health workforce, not just as a basis for improving population health but also for bolstering countries’ trade and GDP and the creation of inclusive, gender-equitable employment. In addition to doctors, nurses, midwives, dentists, pharmaceutical and laboratory technicians, and community health workers, health systems also employ administrative, IT and cleaning staff and boost industries which produce medicines, medical devices and technologies as well as laboratory equipment and consumables. Every newly-created health worker post thus translates into the creation of 2.3 other posts, with 70% of global health services being delivered by women. As such, in many countries the health sector is the largest employer – and yet a global shortfall of 18 million health workers is projected by 2030.
While the so-called ‘brain drain’ of trained health workers from lower- to high-income countries is often deplored, a more nuanced perspective is called for. Besides south-north there is also substantial north-south, south-south, intra-regional, temporary and circular migration, with nearly all countries being both source and destination to varying degrees, with developing countries’ health diaspora contributing approximately USD 400 billion to their countries’ GDPs. Against this background, it is high time for governments worldwide to develop policies for integrating foreign health professionals, and to recognise human resources for health (HRH) as a global good in relation to which multiple justified interests must be balanced across individuals and countries.
Hildebrandt described the period between 2006 and 2016 as a ‘health workforce decade.’ It began with the recognition of a shared challenge, continued with its analysis in the 2006 World Health Report and the establishment of a Global Health Workforce Alliance and Forum, and resulted in the formulation of a Global Strategy by the World Health Assembly in 2016. Today, the focus has shifted from pushing the training of more doctors and nurses to the design of country-specific strategies based on the given demand and supply of different cadres of health workers, as well as on the countries’ actual capacity to absorb and fund them. For an adequate health workforce composition WHO recommends 85% primary care health workers who should work with community health workers to boost access in rural areas, 14% secondary care workers and only about 1% tertiary care workers, such as specialist doctors.
In light of the economic force of human resources for health on the one hand, and the reality of health workforce migration on the other hand, Werling and Hildebrandt proposed that GIZ should continue to focus on this topic, both in its bilateral projects and in its multilateral consultations, aiming for sustainable country-specific strategies as well as for regional cooperation and continent-spanning mobility partnerships.
German health and social protection projects across Africa are digitalising
The second conference day started with a keynote presentation by Karl Stroetmann, digital health specialist and Senior Research Fellow with empirica Communication & Technology Research in Germany. Stroetmann highlighted the fact that digitalising health and social protection systems is much less about IT than about making processes more efficient, transparent and collaborative and about enabling exponential learning. While digitalisation increases quality, safety and efficiency of service delivery, it can also provide quick and up-to-date information to managers, political decision makers and service providers alike. There is a risk, however, of fragmentation and duplication of efforts with different partner-funded digital tools operating in parallel without an overarching interoperability framework ensuring their complementarity and alignment with national policy objectives.
To avoid this situation, Stroetmann underlined the need for countries to develop legally-rooted digital health policies and strategies, and, more importantly, a practical roadmap and action plan breaking these down into actions to be taken by different players within an agreed timeframe. One open digital health platform and an interoperability framework should be established to link all digital applications, each contributing to, and benefitting from, the resulting digital ecosystem. Stroetmann referred delegates to his GIZ-commissioned study ‘Digital Health Ecosystem for African Countries’, as well as to the BMZ case study ‘Digitalising Nepal’s health sector’, which shows how GIZ digital health experts can effectively support these processes.
For the rest of the morning, health and social protection colleagues from Malawi, Nigeria, Sierra Leone, Guinea, Liberia and South Africa and GIZ head office in Bonn shared experiences of implementing digital approaches including the establishment of social registries for facilitating access to, and ensuring alignment between, social services; setting up national and regional disease surveillance systems; a mobile app to provide youth-oriented health information; and the creation of national health workforce registers; an online tracking tool monitoring the national and regional implementation of international agreements for sexual and reproductive health and rights (SRHR) across Sub-Saharan Africa and an online clinic finder, showing partner organizations’SRHR activities on an interactive map all over South Africa. Evidently, the times when digitalisation was something foreign and new for GIZ’s health and social protection community are long over. Nonetheless everyone found it useful to exchange on typical mistakes and unhlefpul developments that seem to proliferate when governments and development partners rush into digitalisation processes without carefully balancing benefits, costs and options. Binod Mahanty and Frauke Rössner, Technical Advisor with the Programme to Foster Innovation, Learning and Evidence (PROFILE), reminded colleagues during their joint workshop with the ICR-Projects Global Alliances for the International Conference on Population and Development and Global Alliances for Social Protection of the Digital Investment Principles which should guide development partners in their decisions about support for digital tools. Collaboration (principle 1) and early quantification of costs (principle 3) should be particularly kept in mind as these have shown to be key for successful implementation.
Creating environments where youth can think, create and innovate
The final session of the conference focused on youth, health and employment, highlighting approaches and experiences from German-supported interventions to foster health and social protection among young people. It kicked off with a keynote address from Tikhala Itaye, Malawian youth consultant, television personality and activist on sexual and reproductive health and rights, who set the stage by calling for investments in education, health and entrepreneurship opportunities that can help young people grow and thrive: ‘We need to create learning environments where young people don’t just follow a set curriculum, but where they are encouraged to think, create and innovate.’
Viktor Siebert and Massa Massey from GIZ Liberia picked up this thread in their presentation about career guidance counselling in Liberia. Although Africa’s health workforce is growing, it is not growing fast enough to deliver the services envisioned under the SDGs. Liberia, for example, currently has 11.8 core health workers per 10,000 people – just over one-quarter of the health worker density which will be needed to meet the SDGs. Expanding employment opportunities in the health sector would not just help to attain UHC targets (SDG 3), it would also contribute to goals in education (SDG 4), economic growth (SDG 8), particularly in rural areas, and gender equality (SDG 5). In Liberia the latter is particularly important: Liberia’s health workforce is dominated by men, particularly in the higher-paid professions. Bringing more women into the health workforce could help to reduce health workforce attrition, improve women’s economic empowerment, and lead to more equal income opportunities.
Traditionally efforts to develop human resources for health have tended to focus on demand-side (spending on health) or supply-side (quality of education) factors, but have paid less attention to active labour market policy instruments that can match the two sides. In Liberia, GIZ has stepped into this gap by focusing on career guidance for young people as an intervention which can improve the quantity, quality and composition of Africa’s health workforce in the medium term. In partnership with county-level health and education authorities in five counties in Southeast Liberia, the programme works in 17 secondary schools to provide young people – and particularly girls – with information about job opportunities, the world of work, and educational and training pathways into careers, particularly those in the health sector. Activities include individual and group career counselling, Career Days and shadowing opportunities, the establishment of Girls Clubs, and outreach events in the community. The effects of these opportunities on the individual participants are profound. At the end of their presentation, Siebert and Massey showed an interview with a twelfth-grade girl from Greenville, Liberia who has been shadowing a laboratory technician at the local hospital for the past six months. Her moving story convinced everyone present of the exceptional importance of career counselling for girls, particularly those living in rural and underserved areas.
Other experiences from German-supported projects were featured in a parallel session. Colleagues from GIZ Guinea presented their experiences with implementation of the Join-In Circuit to promote HIV prevention and improve sexual and reproductive health among young people. Two presentations from Malawi followed, one on interventions for youth in the Social Protection Programme and one on youth-friendly health services.
Time for a new way of working
To round off a rich and inspiring conference programme, facilitator Marketa Zelenka invited partner government representatives Ethel Kapyepye, Malawi’s Chief Director of Safe Motherhood, and Elsie Ilorie of Nigeria’s Center of Disease Control, as well as Thomas Staiger of the German Embassy, Alexis Bigeard of WHO/AFRO, Holger Neuweger of GIZ’s Africa department and Michael Adelhardt of GIZ’s Competence Center Health and Social Protection to join her on the podium to share what they would take away from the past two days. Following the exchange captured at the start of this article, Zelenka invited conference delegates to join the discussion.
‘We talked a lot about multisectorality these past two days,’ volunteered Thorsten Behrendt, ‘but we still conceptualise our projects by sector. Is this not something to discuss with BMZ?’ ‘If we talked more about social determinants of health and less about healthcare, the opportunities for collaboration with other sectors would be obvious,’ concurred Kirstin Grosse Frie, Advisor with the GIZ University and Hospital Partnership Initiative. Elsie Ilorie and Ethel Kapyepye suggested to replace the sectoral focus with one that considered households’ and families’ needs. ‘When you look at the typical rural household and its needs, be it in terms of health, education, water or nutrition, it becomes very obvious that sectoral boundaries make little sense.’
Nodding in agreement, Thomas Staiger explained, ‘At BMZ we are currently engaged in a process called BMZ 2030 where we look at just these questions. Your feedback from the ground matters for us. In my view we should start focussing on problems, instead of sectors.’ Kerstin Nagels, Head of GIZ’s Sectoral Department, said that he had literally taken the words out of her mouth. ‘It is indeed time for us to move towards problem-centered programming. How can we best address the greater challenges of our time by bringing different sectoral contributions together? Once we figure this out, we start moving the 2030 agenda.’
Anna von Roenne and Karen Birdsall
March 2019