The health of nations: what unions can add

TUC submission to the DFID consultation on a new health strategy

Introduction

The TUC welcomes the opportunity to take part in the current consultation process on the new health strategy and appreciates the need for fresh thinking on it in the light of increasing emphasis on human resource development and related issues.

Three out of eight Millennium Development Goals (MDGs) are directly related to health. A well-planned, well-funded national strategy, backed by political will, is essential in any meaningful effort to increase access for the poor. Moreover, in the long-term, the achievement of MDGs in health is integral to the success of others, which emphasises the need for a holistic approach to health issues. Moreover, national strategies in health and education need to be developed with the active participation of trade unions, fully integrated into the national macro-economic planning process, implemented and sustained over time with predictable internal and external resources.

The trade union movement recognises the importance of health and nutrition in human resources development and long-term human welfare. It holds that health is a basic human right as set out in the UN Declaration of Human Rights and that the provision of affordable health care for all citizens is essentially the responsibility of the state.

Trade unionists are instrumental in ensuring adequate and appropriate health and safety measures in the workplace, thereby contributing to the prevention of accidents and hazards. In addition, they protect and promote the rights and the interests of the workforce in the health sector and enhance the functional integrity of the health care system. Trade unions also make a useful contribution to the improvement of health care through dissemination of information and advice and delivery of health care through their institutions and structures in the workplace, as exemplified in the campaign against the spread of HIV/AIDS in many developing countries. They also fulfil a vital function in defending the employment and human rights of people living with HIV/AIDS and other diseases.

The TUC is the voice of people at work in Britain, and we have 64 affiliated trade unions with 6.4 million members. We are part of the global union family with a membership of 155 million, 40% of who are women, in 154 countries and territories on all five continents. This submission is substantially based on contributions from our affiliates with interests in the health sector and especially Amicus and Unison. We hope that our observations and concerns will be adequately reflected, and the role of trade unions in improving the effectiveness and efficiency of the sector will be appropriately acknowledged, in the new health strategy.

Answers to the consultation questions

1 What are the most effective ways to support countries' efforts to scale up universal access to essential health services, especially the poorest and the most vulnerable?

The provision of essential health care for all citizens should be the responsibility of the state. This can be most effectively and equitably achieved through the establishment of a comprehensive and integrated national health system accessible to all. A substantial proportion of health expenditure should be funded through taxation. Countries such Sri Lanka and Costa Rica have long provided affordable health care for their citizens. Despite the many shortcomings in their systems, the countries concerned have made tremendous headway in terms of key development indicators. Industrialised countries like the UK that now provide direct budget support for some governments in developing countries should consider stipulating that part of the funds be allocated to vital public services such as health.

Governments need to adopt a holistic approach to health and ensure coherence and consistence in the formulation and implementation of policies in different sectors of the economy, as some short-term policy options can have long-term adverse effects on the health of a nation. Many developing countries rely heavily on tax revenues from excise duties on tobacco and alcohols and do not make meaningful efforts to curb consumption. In 2003-2004, the revenue from the excise duty accounted for 16.6% of total government revenue from indirect taxes in Uganda. Asbestos is widely used as roofing material in developing countries despite its proven harmful effects on health. More effective enforcement of traffic laws and regulations could reduce road accidents, thereby freeing up part of valuable resources currently used for medical emergencies.

The enforcement of health and safety measures at work leaves a great deal to be desired in many developing countries. Victims of industrial accidents and occupational diseases are very often workers from poor and vulnerable communities. The ILO estimates that some 4% of the world's gross domestic product is lost through occupational injury, disease and death. There is need for effective enforcement of occupational health and measures on both economic and social grounds.

2 What are the most effective ways to support countries' efforts to build and retain their health workforce?

There is need and scope for increasing the institutional capacity for training health professionals, not only doctors and nurses and other professionals allied to medicine, but also other health staff. In many developing countries, though not in all, there are students who have completed secondary education in sufficient numbers, some of whom can be trained to become health professionals with technical and financial support from developed countries.

A recent WHO study pointed out that most doctors and nurses leave their home countries on economic and safety grounds. It is therefore imperative that pay and working conditions of health professionals are improved wherever possible. Trade unions and professional bodies point out that health professionals often complain about irregularities in making appointments, transfers and promotions. The elimination of irregularities should encourage some of them to stay in their home countries. Furthermore, health unions point out that in many countries career prospects are often bleak or non-existent, which often encourage doctors and nurses to seek employment in developed countries.

It is also necessary to eliminate current bias in favour of education and training of professional categories - doctors, nurses and midwives. More education and training opportunities should be made available for personnel in ancillary and support services, thereby giving them opportunities for improving their career prospects. It will also go a long way in improving the effectiveness and efficiency of existing resources within health systems.

Trade unions and professional bodies are in a position to facilitate exchange/twinning programmes for health professionals, where possible and appropriate, so that they are given the opportunities to acquire knowledge, expertise and training.

In all these areas, donor governments should consider adjusting their funding for governments to create incentives (and provide the resources) for investment in health workers, and should also support the development and involvement of health unions to ensure that wages and conditions are improved, that career progression can be developed and provided equitably, to promote non-professional routes into health work, and to exchange information.

3 What action needs to be taken to meet the off-track development targets child, maternal and reproductive health?

The improvement of primary health care facilities, especially, in inner city and rural areas is, perhaps, the most effective way of dealing with these issues. In Burkina Faso, only 38% of births were attended by skilled health staff in 2002 while maternal mortality was as high as one in a hundred for the same year [1] . There is an acute shortage of primary health care professionals in many developing countries. Moreover, health professionals are concentrated in urban areas or in the capital.

Schools can play an important role in the dissemination of information and advice on health. Basic information on nutrition, food handling, health and sanitation, refuse collection and disposal can be easily integrated into school curricula.

Trade unions also can make a critical contribution to the dissemination of information and advice on reproductive health and related issues through their institutions, structures and networks. Immunisation and family planning advice can be made available to workers, their families and communities through workplace structures. It is important to point out that in many developing countries where there is no universal access to health facilities, workplace health centres already provide some of these services. Support from the UK Government can expand and improve them, as well as supporting the involvement of trade unions.

Mass media like television, radio and newspapers could be used to disseminate information on health nutrition and sanitation.

4 In 2004 in Taking Action, we set out how the UK would contribute to a more effective response to the prevention and treatment of HIV/AIDS. Should we be doing more?

DFID should support workplace action carried out by the international trade union movement on HIV/AIDS for the following reasons:

• The international trade union movement and national trade union centres are keen to get involved in action on HIV/AIDS, which they consider to be a workplace issue, as it affects labour and its productivity.
• Many workplaces have infrastructure for training and education purposes that can be used for effective dissemination of information on HIV/AIDS while existing institutions and structures like Works Councils, Health and Safety Committees, Study Circles etc can provide fora for awareness-raising campaigns.
• Workers are likely to be more receptive to the message when trade unionists, employers, governments are actively involved in it.
• Many national trade union centres, especially in Africa, are already involved in HIV/AIDS testing, treatment, care and support programme in partnership with governments, employers and community-based organisations.
• HIV/AIDS has a direct bearing on some themes of particular relevance to trade union concerns - gender equality, racism, and disability. Trade unions can play a crucial role in developing policies and procedures in collaboration with employers in order to eliminate discrimination on the basis of real or perceived HIV/AIDS status, as fear of stigmatisation, marginalisation and discrimination prevents workers from seeking testing, counselling, treatment and care.

5 How should we respond to the health challenges in conflict and post-conflict environments and fragile states?

Governments need to work closely, where possible and appropriate, with trade unions and other civil society organisations that have the capacity to provide health care through their structures, institutions and networks. A number of health unions in Sri Lanka were actively involved in the provision of health care for Tsunami victims and many of them are still carrying on some of the work they initiated in January 2005.

It is also necessary for governments to provide more support for the work carried out by organisations with medical expertise like Médecins sans Frontières, Médecins du Monde and Red Cross and local NGOs with medical expertise.

Preventive care assumes even greater importance in conflict situations and fragile states. Immunisation programmes can be carried out in collaboration with the international organisations like the WHO and in partnership with trade unions in the health sector. The support of the local or international celebrities can be solicited, which often ensures the co-operation of belligerent parties in a conflict situation. Polio vaccination in areas affected by armed conflict is a good example in this regard.

Last, but not least, it is essential that the capacity of local institutions and structures be built and strengthened so that they are able to cope with the challenges effectively until outside assistance arrives.

6 How can the accountability of recipient government to their people for the more effective use of health resources be improved?

Country ownership needs to be broadened and firmly based on a consensus between all stakeholders in society and not just between state agents. Trade unions and other professional organisations in the health sector should be actively involved in the management of health resources. There is wastage and under-utilisation of valuable resources, which cannot be effectively dealt with without the active support of workers in the health sector.

The proper maintenance of equipment - diagnostic devices -should be given priority. The training and education of personnel necessary for keeping hospital equipment in good order is often neglected in developing countries, which reduces the efficiency and effectiveness of health care systems.

The impact of health interventions can only be gauged in the long-term. Therefore it is essential that robust monitoring and reporting mechanisms in which trade unions and other professional bodies participate effectively be put in place in agreement with the recipient governments so that outputs could be measured in terms of agreed indicators. Civil society organisations are in a position to gather information on the quality and effectiveness of health interventions at local level. Trade unions made a significant contribution to the implementation of important health reforms in post-apartheid South Africa and should be consulted across the developing world in all areas of health reform.

7 How can the performance and coherence of international health architecture be improved to deliver better health care for poor people?

The achievement of objectives in health and nutrition is central to success in other areas, which makes it imperative that international financial institutions, development agencies and other UN specialised agencies work in partnership with one another. Privatisation of vital public services in many developing countries carried out on the recommendations of international financial institutions has resulted in the deterioration of vital public services on which poor and vulnerable communities depend. For instance, water privatisation in Dar-es-Salaam resulted in deterioration in the service to the consumer, according to the Government of Tanzania, which intervened to terminate the contract. Policy decisions on public expenditure taken by governments on the advice of international financial institutions have had adverse effects on health services, and those institutions should stop pressing governments to privatise or liberalise public services..

It is essential to ensure co-ordination of policies between all member organisations of the UN family in order, not only to avoid conflict in approach and objectives and duplication of effort, but also to ensure complementarity between interventions by different agencies. Co-ordination needs to take place at all levels- institutional, country, sector and project. All their objectives should be consistent with the goal of the national health strategy, which, in turn, should be fully integrated into a national macroeconomic strategy.

8 Where should we focus efforts for maximum gain in addressing the broader determinants of health?

There is an important two-way causal link between ill health and poverty. In fact, the most serious impediment to the improvement of health and nutrition is poverty, the root cause of which is often the lack of decent employment opportunities and low productivity. Priority should therefore be given to the creation of opportunities for decent work [2] as defined by the ILO and supported by the EU.

Ensuring food security for poor and vulnerable communities should also be part of an overall strategy. Access to clean water, sanitation and proper refuse collection and disposal are very serious issues in developing countries. Development assistance programmes have often neglected these issues, although they are vital to the development of proper primary health care facilities. In many developing countries, environmental health has often been a neglected area and needs to be moved up on the agenda.

Advances in education will pave the way for human resources development, not only in the health sector but also in all other sectors and lead to synergy between them.

It is also important that governments pay proper attention to the preventive care through curbing consumption of alcohol and tobacco [3] .)

9 Are there gaps in DFID's response to the current and future health challenges?

Occupational injuries and diseases have a profound impact on productivity and economic and social welfare of a nation and prevention of industrial accidents and occupational diseases should be an important element of an overall health strategy. More emphasis needs to be placed on the need for appropriate legislation on occupational health and safety and on the effective enforcement of existing laws and regulations. Unions have a key role to play in health and safety at work, especially in representing the workforce through workplace safety representatives. DFID should be investing in the development of better occupational safety and health and the development of workers' self-organisation in this field.

Industrialised nations like the UK should put more pressure on pharmaceutical companies on the need for reducing prices of essential drugs and for allowing developing countries to produce generic alternatives for them.

They should also provide financial support and technical expertise for the development of medical research facilities in developing countries. Currently, many developing countries are not in position to carry out research into diseases and social problems which are having devastating impact on the health of their citizens.

10 What should be the priority areas for research in improving the health of poor people?

There is not adequate research into tropical diseases (African sleeping sickness, dengue fever, leishnaniasis, river blindness, lymphatic filariasis etc) with high prevalence in developing countries. MSF points out that only 15 new drugs were registered for tropical diseases in the past 25 years.

It is also necessary to conduct research into more economical and innovative ways of improving nutrition, hygiene, sanitation, water purification and refuse collection and disposal.

The past two decades have witnessed natural disasters and armed conflict on an unprecedented scale. The provision of emergency medical care in the wake of disasters is a major challenge and warrants research into more effective ways of saving lives in natural disasters and prolonged armed conflict situations.

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[1] Reproductive Health Indicators, World Bank

[2] Decent work was defined as a basic human right by the UN in 1948 (see below) - essentially it means good jobs with fair pay and rights at work. "Everyone has the right to work, to free choice of employment, to just and favourable conditions of work and to protection against unemployment. Everyone, without any discrimination, has the right to equal pay for equal work. Everyone who works has the right to just and favourable remuneration ensuring for himself and his family an existence worthy of human dignity, and supplemented, if necessary, by other means of social protection." (Universal Declaration of Human Rights, Paris 1948, art. 23)

[3] In Sri Lanka, the prevalence of smoking among female adults is estimated at 2%, as opposed to 26% among adult males. The difference between life expectancy between males and females in Sri Lanka about 6 years (2004. Health authorities attribute part of the difference to non-smoking among women.