Rene Loewenson works for the Training and Research Support Centre (TARSC) and the regional Network on Equity in Health in Southern Africa, a network of professionals, civil society members, policy makers, state officials and others within the region who have come together as an equity catalyst, to promote and realize shared values of equity and social justice in health. Ramona Lenz from medico talked with her about health literacy, Aid dependence in a globalized world and the importance of regional networks in the field of health.
Ramona: You are working on different levels to promote the right to health: on the local or national level with TARSC in Zimbabwe, and then with EQUINET on the regional level in East and Southern Africa, and you are also active on the global level in terms of global health. I would like to learn how you combine all these levels. My first question concerns the local or national level of Zimbabwe where you promote “health literacy”. Could you first of all explain what “health literacy” means?
Rene: To put it a little bit more broadly by ‘you’, you mean not me as an individual, but as part of an institution and network of actors! TARSC works on various dimensions of social participation in health. And health literacy is one element of that. It goes beyond people being informed and knowing about health issues, to also knowing the way their health systems work. And it’s building knowledge in such a way that people are empowered to act on that knowledge, through the way that they share experience and information, and through how they use new information towards action around issues. So it’s more of an empowering approach, it’s knowledge for action. It links with other things that we do at TARSC where we for example link research to action, in participatory action research, where we facilitate processes for communities to organize their own knowledge and bring in new information to transform the conditions that are problematic for their health. Of course, not all those conditions are within the boundaries of community control at the local level. Where they are potentially within community control, such as with waste disposal, environmental issues, issues related to their local health services, or the way their health workers treat them, all these kinds of things could be addressed at the local level through processes like health literacy and participatory action research; or through community monitoring where people collect local evidence on what is going on in their health conditions and put it together to inform and engage even at national level.
Ramona: What do you consider to be your most important achievements in the last years in Zimbabwe?
Rene: For TARSC this is not new work in Zimbabwe. In Zimbabwe we have been working with Community Working Group on Health and in Zimbabwe on the health literacy program for many years – since late 1990s. Community Working Group on Health has been the main lead organization in taking it forward in Zimbabwe. We have simply worked with them to write materials, to train their trainers, and provide technical support. In the region we have also worked with Malawi Equity-Network, in Botswana with the Botswana trade unions as well as with BONELA, the network of people living with HIV. We have worked in Zambia with the Ministry of Health, and in Uganda with HEPS, the civil society coalition on health. So we have been working on health literacy in a number of other countries. We have found a growing acknowledgement of the need for more than just social mobilization, a realisation that communities need to be much more empowered in their relationship with the health system. In both Zimbabwe and in Zambia the program has been taken up as a national program, in Zambia by the Ministry of Health and in Zimbabwe by Community Working Group on Health in cooperation with the Ministry of Health. It’s getting support from the people in the health system because they also recognize that an informed and empowered community is the center of a well-functioning health system.
Ramona: And which is the main challenge that you see for the future?
Rene: Different countries have different challenges. At grassroots level people are preoccupied with many things for their survival, and face challenges from many different social determinants of health. All of those challenges impact on any programs underway and raise issues of how to build sustainability, including by embedding within processes that don’t depend on projects and that are institutionalized, as is happening with health literacy in Zambia and Zimbabwe. It’s also not always the case that the health system welcomes an empowered community, though, since it is challenged by people who know what they are talking about. You can get conflict in those situations. However, what we often find is that the methodologies themselves encourage communication between the frontline health workers and the local community. They tend to be less conflictual than where communities are working on their own and not communicating with frontline health workers.
Ramona: Tell me a bit about EQUINET. You bring together people from 16 different countries in Southern and Eastern Africa.
Rene: Yes. EQUINET is a consortium of institutions. TARSC is a member of EQUINET and we function as the secretariat but we are in a co-operation with a number of other institutions in EQUINET in the consortium. These institutions are based within the eastern and southern African region. For example in Cape Town there is University of Cape Town, also in South Africa there is the University of Limpopo, in Zimbabwe there is Community Working Group on Health, there is also a regional organization called SEATINI which works on trade and globalization issues, in Malawi there are organizations like REACH Trust who work on HIV/AIDS issues, in Tanzania there is Ifakara Health Institute which works on district health systems, in Uganda there is Center for Health, Rights and Development which work on human rights and health issue, in Kenya, Mozambique and other countries there are others. Institutions in the consortium lead in different areas of work. The University of Limpopo leads on the health worker related work on issues on health worker attention and migration. Cape Town has been leading on health financing, CWGH leads on social empowerment, in TARSC we lead on the equity analysis and the crosscutting areas of work. So different institutions are taking leadership in different areas, in quite diverse areas of work.
Ramona: What does the exchange bring about? What is the main effect of the regional networking?
Rene: By having different institutions in the region leading but bringing on board other institutions in other countries in the region, what you find is that we have a way of sharing capacities. For example there might be very good health economic capacities in one country but there might be better legal capacities in another country. So leadership grows where the capacities are, but regional networking means it can spread across the whole region. You don’t find everything centered in one country. We are able to come together … because equity is a multidisciplinary issue. It’s not based on one discipline only. It also brings together different constituencies. We have a parliamentary network that has linked within EQUINET, people from government, civil society, and technical people. To address issues of inequality you have to really bring on board all the constituencies, and people with different experience and different positions in the systems that we are dealing with. And it’s not only in the health system that we need this. There are people working on, food or trade or other issues. By working at a regional level we are able to exchange experiences within the region, to gather evidence more widely than in one country, and to engage as a region on issues. An issue like health worker migration, for example, is not just affecting one country. It’s affecting the region as a whole. So we work with regional organizations like SADC or the ECSA Health Community, to support regional policy dialogue, so that health issues negotiated at global level use evidence that comes from within the region.
Ramona: This is an important point. What is the main challenge in combining the regional or even the local and the global level? Since you are working on all these levels, what are you confronted with in combining all these levels?
Rene: The regional level is very important for making the link from national to global levels. You need a national level which is sensitive to the local and taking on board evidence from the local, and a regional level which is able to manage the diversity of national environments, because our countries and region are very diverse. For example, Malawi and South Africa are very different countries. So if you have a region which is able to integrate this diversity and able to bring out shared regional dimensions across this diversity, then I think when we engage globally, we are more effective in bringing a more bottom-up global engagement. For example local people’s access to medicines, to anti-retrovirals, was taken through national and then regional agendas and many countries within the region went into the global platforms in a more united way on these issues. The same has happened around certain trade issues, such as in the initial engagement on health worker migration. But it also doesn’t necessarily work all the time and is sometimes undermined. For example in the economic partnership agreements between the EU and the African region, the EU has tended to pick and choose particular countries and not to reinforce the existing regional blocks. Tensions or competition may also grow between countries in the region, and there may be stronger links between African organisations and international organizations than with partner organizations within the region. Partly this has also to do with communication and internet. Sometimes it’s easier for someone in Uganda to speak to someone in the UK than it is to speak to someone in Tanzania because of the communication system. We have a lot of things that are weakening our ability to build up bottom-up integration within the region but it’s something which we see as a central element of our work in EQUINET. So for example in our website, part of what we do is to make available material produced in the region, that sometimes sits in libraries in the region and isn’t know within the region, so that you can find them online and you can use them when we are building up issues and positions and so on.
Ramona: Okay. Two last questions then. How important is development aid for the region?
Rene: Obviously financial accountability or accountable use of external funds is an important issue– no question on that. But we have a much wider perspective. Our concern is that more resources are flowing out of the region than are flowing into the region. We are losing a lot of resources from the region in many, many different ways. We have a discussion paper that shows how this is happening. Further, before we look at external funders, we need to get better control of the resources that we have within the region and be more effective in how we use them for the populations of the region. In a way this is a much bigger issue than that of external funds coming in, because of the volume of wealth being lost. For example we export our food, our fish, our bio diversity and our seed stock and are moving toward crops and production patterns that are dependent on markets and inputs from outside our continent and region. So you find that even in areas of countries with very high agricultural production, you are also getting high levels of malnutrition. The way to solve that is not sending in food aid but to ask: What is happening to our capacity to produce food for ourselves in the region?
Ramona: So the issue of resources is very central.
Rene: It’s very central. Our health agenda is not just about following the flow of external funds in, it’s about being more self-determined, about the way how we use our own resources to improve the health and the economic wellbeing of the populations in the region. We have the resources.
Ramona: One last question: You started to collaborate with medico. What do you expect from medico and from the collaboration with medico? What can this collaboration bring about?
Rene: We are in a globalizing world with values and rights that are universal. We understand that medico shares our values and understanding of health rights. So we see it as a relationship where we are trying to work out what that means for people in our respective regions, in East and Southern Africa and in Europe, and therefore globally? How do we then engage interest to interest? We don’t think that we have identical interests. We are in different parts of the world positioning differently on globalization, but if there are the same values and the same perspective of people’s rights, how do we then realign those different interests, so that we come up with ways that address those values and those rights at a more global level? That’s something we hope to build with medico.
Ramona: Thank you very much.