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Authors Dirk Van Der Roost and Tim Roosen With collaboration of Annuschka Vandewalle, Wim Leysens, Mart Leys, Ariel Montesdeoca, Helene Van Acker, Guy Peeters, Patrick Verertbruggen, Rik Thys, Lieve Daeren, Toon Bongaerts, Bart Criel Pictures Sarah Peeters, Chantal Hovens, Thomas Vervisch Published by fos - socialistische solidariteit Grasmarkt 105/46 | 1000 Brussel tel 02 552 03 00 | fax 02 552 02 96 | Design HERA Printer Drukkerij Bulckens September 2011, HERA and fos - socialistische solidariteit

Evaluation of fos health programmes

Table of contents Introduction and methodology ................................................................................5 Abbreviations and acronyms .................................................................................. 6 1 Health, 1.1 1.2. 1.3. 1.4.

healthcare and social protection in the world ............................................ 7 Global health.......................................................................................... 7 Primary health care as a mobilizing concept ............................................. 9 Social protection, a right for all ..............................................................10 Universal access to health .....................................................................11

2 Some international trends explored ....................................................................12 2.1. Health is high on the international political agenda ..................................12 2.2. Primary health care gets a second life ....................................................14 2.3. The social determinants of health ...........................................................16 2.4. Social protection as an instrument for a fairer society ..............................17 2.5. People and medicines ............................................................................18 2.6. The new international context of development cooperation ......................20 3 The vision of fos ..............................................................................................21 3.1 What does fos stand for? .......................................................................21 3.2 An innovative vision for health ...............................................................22 3.3 Health within the broader strategy of fos and the socialist and NGO movement ...................................................................................25 3.4 Towards a global social contract? ...........................................................26 4 fos in 4.1. 4.2. 4.3. 4.4. 4.5. 4.6.

the South ...............................................................................................27 An ambitious health programme ............................................................27 The promotion of social security in Peru .................................................28 Mutual associations: a case study of Nicaragua .......................................30 Defending the right to health in Ecuador and South Africa .......................34 Basic work with communities in Mozambique and Cuba ...........................36 Access to medicines in Central America ..................................................39

Conclusion…………………………………………………………………………………………………………40 Endnotes …………………………………………………………………………………………………………42 Annexes ..............................................................................................................43 Annex 1: Definitions on health and social protection .......................................43 Annex 2: Comparative table and some numbers from partner countries ...........44 Annex 3: Some reference documents .............................................................46

Evaluation of fos health programmes


Introduction Health is a right, worldwide. Yet in most countries health care remains a privilege for the rich. Doctors are only available in cities and the majority of health care is supplied by commercial providers. More than thirty years ago, representatives from nearly all countries, led by the World Health Organization, signed the Alma Ata Declaration. Primary Health Care was therein put forward as a strategy to achieve health for all. Thirty years later there is, at the international level including within the World Health Organization, renewed attention to access to qualitative health which no longer exclude large groups of people.


This is the premise of the fos health programmes. fos needs to continue reminding governments of their responsibility to implement this right. fos has in the past 20 years worked in Latin America and more recently in southern Africa on ways to increase access to health. The experiences are very different, because the context and the political will are different, but also because partner organizations and fos-associates bring various ideas and use different strategies. The skill is to regularly review these choices with the vision and ambition of the organization and where necessary make adjustments.

Methodology fos has therefore called on the external research agency HERA ― Health Research for Action ― to assess

all of the health programmes funded by the DGD. They carried out an overall evaluation, a critical questioning of the initial choices that fos made over the course of the years in terms of its overall health approach and programmes. This questioning of the meaning and relevance of our operation and the effectiveness of the chosen strategies should allow to improve our operations and to make informed choices. The research team was composed of experts from Belgium and from the different partner countries. Dirk Van der Roost, a researcher at the Institute for Tropical Medicine, and secretary of the health network “Be-cause Health”, coordinated the evaluation. In Nicaragua, the evaluation conducted by Michael Forsch, in the Andes (Peru, Bolivia and Ecuador) HERA called on the team of Dr. Juan Arroyo Laguna, Eco. Manuel Mendoza and MSc. Engelbert Barreto, and in South Africa on Mazibuko K. Jara. Dirk Van der Roost did several local studies, both in Mozambique and Cuba. Specific management and consultative committees were set up for this study in the different countries composed of members of fos partner organizations, fos-associates and local researchers. These committees prepared the evaluation questions and provided feedback on the findings of the evaluation.

Evaluation of fos health programmes


How to read this document? This document presents the findings of the analysis conducted by HERA and provides an overview of the

fos health working in the field. It contains a snapshot of the health programmes in 2009-2010. It also gi-

ves an insight into the questions and the ways forward in the coming years.

For a full understanding of the nuances of fos’ work in health, we recommend reading the full document. The first and second chapters introduce the necessary concepts to frame both the current fos health programmes as well as its aspirations for the future. The background and vision of fos, including the ambitions for a global social contract are described in chapter 3 ― the vision of fos. Do you prefer a quick overview of fos’ work, or are you specifically interested in the work of the mutual associations in Nicaragua, please consult chapter 4 ― fos in the South.

Evaluation of fos health programmes

Abbreviations and acronyms



General Federation of Belgian Labour


Association Internationale de la Mutualité




Community Health Workers


Federación de Mujeres Cubanas (Federation of Cuban Women)


Global Alliance for Vaccine Initiative


Global Health Initiative


Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome


International Labour Organization


International Monetary Fund


Institute for Tropical Medicine, Antwerp, Belgium


Junta Nacional del Café (Federation of small coffee farmers, Peru) Millennium Development Goals


Non Governmental Organization


President‟s Emergency Plan for AIDS Relief


Primary Health Care


People‟s Health Movement


Poverty Reduction Strategy Paper


Different Socialist Party


Strategies and Tools against Social Exclusion and Poverty


Sector Wide Approach


Trade Related Intellectual Property Rights


União de Camponeses de Manica (subsistence farmer‟s organization in Mozambique)


United Nations


Joint United Nations Programme on HIV/AIDS


United Nations Children‟s Fund


National Federation of Socialist Mutual Insurances


World Bank


Women on Farms Project, South Africa


World Health Organization

Evaluation of fos health programmes

Health, healthcare and social protection in the world 1.1 Global Health Overall people today are healthier and living longer than they used to and there has been substantial progress in health over recent decades. However, progress between countries in the north and south has been very unequal and now there is also ample evidence of growing health inequalities within countries. This is exemplified by the infant mortality rate and the maternal mortality rate.

Child mortality is highest in developing countries where a child is 13 times more likely to die before the age of five than a child in an industrialized country. Half of total global infant mortality occurs in sub Saharan Africa where one in six children die before the age of five. Mortality is highest among children in rural areas, in poor families and families with poorly educated mothers.

In 2007 9.2 million children died world wide before their fifth birthday. Most of these children died in the South from diseases that could easily have been prevented or treated.

The following table show an encouraging decline in infant mortality but highlights the inequalities between the industrialized and non industrialized countries.

7 Figure 1: A marked reduction in under-five infant mortality per 1,000 infants in all regions, 1990-2009

Source: Unicef, 2010 Evaluation of fos health programmes


In 2005, more than 500,000 women died worldwide during pregnancy, childbirth or the post-partum period. No fewer than 86 percent of these deaths occurred in Sub-Saharan Africa and South Asia. One woman in 20 dies in Sub-Saharan Africa from complications during pregnancy and childbirth. There are many factors which affect the MMR including provision of more skilled health workers. In 2006, 61 percent of deliveries worldwide were carried out under supervision of a trained health professional. In South Asia this was 40 percent, and in Sub-Saharan Africa 47 percent. Teenage pregnancies also contribute to high maternal mortality. Teenage mothers and their babies have a higher chance of dying during or shortly after childbirth. The number of teenage pregnancies between 1990 and 2000 declined slowly in almost every region. This decrease has largely stagnated since 2000. Teenage pregnancies are particularly common in Sub-Saharan Africa.

Evaluation of fos health programmes

It is obvious that a person can only live healthily with enough food, clean water, a roof over their head and opportunities for training, etc. There is a well-established link between poverty and poor health. Globally about 2.5 billion people live on an income of less than two dollars a day (World Bank figures, 2005), which is incompatible with a dignified life. In Sub-Saharan Africa and South Asia respectively, 50 percent and 40 percent of the population live below the so-called „absolute poverty lineâ€&#x; of $1.25 a day. A globalized economy favours rich people and widens the gap between rich and poor even further, although it also offers possibilities to address this issue. A powerful way to make a real difference is to provide social protection, which is an answer to the biggest global questions and a solution that fos is exploring here.

1.2 Primary health care as a mobilizing concept In 1978, representatives from nearly every country in the world led by WHO and UNICEF signed the Alma Ata Declaration, defining the principles, values and components of the concept of primary health care (PHC). This concept is based on the analysis that approximately 90 percent of health problems can be prevented or treated simply and with a relatively limited budget. „Primary health care‟ should therefore be understood as an attempt to meet essential, most basic health needs. The declaration emphasizes the importance of involving communities and endorses a comprehensive and social vision of health. It also emphasises disease prevention through means such as a healthy diet, clean drinking water and sanitation, health education and vaccination. The Alma Ata declaration has for years influenced thinking about accessible health systems in the world but was rarely consistently implemented because of structural weaknesses in poor countries, and because of a change in leadership at the principal organizations, especially UNICEF and the WHO. In the 1980s and 1990s, governments in the South made fierce cuts to social sectors influenced by the „restructuring plans‟ of the International Monetary Fund (IMF) and World Bank (WB).

These had serious consequences for social services and the privatization wave that followed had no real benefit for the poor. One very complex issue in the South is how to provide care in remote and isolated areas. Following the example of the „barefoot doctors‟ in China, the Alma Ata Declaration advocated for the wider involvement of community health workers (CHW), as a way of providing care in remote and isolated areas. This was easier said than done and many projects with CHW failed when foreign aid dried up. However, few alternatives seem to work and the concept has received renewed attention in recent years, with successes we can learn from (see 2.2). In 2008, the 30th anniversary of the declaration was celebrated and it received renewed the attention from health activists around the world. At the same time, the relatively new concept of the „social determinants of health‟,was developed.

Evaluation of fos health programmes


1.3 Social protection, a right for all Social protection is a broad concept encompassing public systems as well as community and initiatives:   


Public systems of social security; Mandatory or voluntary private initiatives, such as private pension funds, mutual health organisations; Communal or associative social services.

Social security is the protection that society provides to its members through a series of public measures:   

The compensation for a substantial reduction in earnings due to various risks (sickness, maternity, occupational accidents, unemployment, disability, old age and death of the breadwinner); Provision of affordable and high-quality health care; The granting of benefits to families with children.

The International Labour Organization (ILO) translates this into five basic objectives which are: 


   

The insured and universal access to health services; The proper substitution of lost income; Secured funding for basic needs; The social integration or reintegration; The redistribution of wealth.

To achieve these objectives, social security systems need to rely on internationally recognized principles, based on an ethical position: Solidarity, Universality, Equality, Adequacy, Integrity, Participation, Compulsory affiliation, Uniformity, Responsibility of government, Justice, Fairness, and Respect for acquired rights or rights in the course of being acquired. The main functions of a social security system are: 

Ensuring guaranteed minimum income with respect to income changes and providing social and health services that allow a dignified life;

Ensuring the replacement of income and the preservation of purchasing power.

Evaluation of fos health programmes

The concept of social security is based on the principle of communal risk. The cost of social security is financed through compulsory contributions from employers and/or the employee, with or without government subsidies. The mandatory nature of contributions is important as it builds solidarity and ensures adequate resources for the entire community. An important part of social protection is health care. In Belgium this has historically grown to be a system of social health insurance with compulsory contributions from employers and employees. Both public and private actors are involved, but the ultimate responsibility for provision rests with the government. An alternative to health insurance is to establish a universal system in which the government finances a uniform set of benefits that apply to all inhabitants of the country regardless of economic status or work history. This universal system operates in many countries in Europe, for example in the United Kingdom and Scandinavia. According to ILO calculations, 2 percent of the global income is sufficient to provide access to a minimum package of social protection for everyone in the world.

1.4 Universal access to health Universal access to health, according to the WHO, is access to key promotional, preventive, curative and rehabilitative health interventions at a feasible cost for the individual, and through which equitable access to health care is achieved for all.

Universal access is, without doubt, the framework needed to provide equitable opportunities to a healthy life for all. However, universal access to healthcare, on its own, is insufficient to obtain health and equal opportunities for health for all. The roots of health inequality lie in social conditions which go beyond health care provision, and which need to be addressed at a broader social level. The 2008 world health report of the WHO describes the three dimensions of universal access to health care (see figure 2):  

Breadth: the proportion of the population that is reached; Depth: the care package that is covered by health insurance. It has a broad range from a minimum set up to high quality care; Height: the share of the costs covered by health insurance. In Belgium, this is usually 75 percent.

Recent reports from the WHO and the ILO present some striking figures: 

Every year approximately 150 million people have financial difficulties due to medical expenses.

Medical expenses annually drive 100 million people below the poverty line

75 percent of the world‟s population can only access a proper care package by taking a serious financial risk.

These figures do not even take into account the countless people for whom a hospital is simply unavailable, or who because of their poverty are unable or unwilling to access care.


Figure 2: The dimensions of universal access to health care

Source: WHO, 2008 World Health Report Evaluation of fos health programmes

2 Some international trends explored International health policy has evolved enormously over recent years. The concept of global health is becoming more important and the following are key issues.

2.1 Health is high on the international political agenda


The year 2000 marked a turning point in the political interest in global health. This was first of all facilitated by the struggle of civil society and organizations like the Joint United Nations Programme on HIV/AIDS (UNAIDS) to create awareness of the seriousness of the HIV/AIDS pandemic in the world, especially in Sub-Saharan Africa. The right to treatment was claimed. The HIV/AIDS Conference in Durban in July 2000, the summit of the G8 countries in the same month in Okinawa, and the special session of the United Nations (UN) on HIV/ AIDS in June 2001 were key moments. Subsequently, the political focus has expanded to other major pandemics such as malaria and tuberculosis and to a lesser extent the so-called „neglected‟ tropical infectious diseases.

Millennium Development Goals (MDG)

In September 2001 the UN endorsed the Millennium Development Goals (MDGs), which are eight discrete goals with 21 measurable targets to be monitored using 60 indicators. Three of the eight goals are directly related to health and most of the other MDGs relate to social determinants of health. Contrary to proposals for the education MDGs, the health objectives do not concentrate on strengthening health systems in general. Instead, the health-related ambitions are based on specific and limited targets and indicators with respect to certain diseases and problems, incurring the risk that no structural and sustainable results will be obtained. Reproductive health and rights were not originally included and though corrected in 2005, it remains more in theory than in practice.

Eradicate extreme poverty and hunger

Achieve universal primary education

Promote gender equality and empower women

Reduce child mortality rates

Improve maternal health

Combat HIV/AIDS, malaria, and other diseases

Ensure environmental sustainability

Develop a global partnership for development

This increased political attention during the first years of the millennium was translated into a list of new global initiatives (Global Health Initiatives, GHI) and a significant increase in development funds for health, especially for HIV/AIDS (see figure 3). The following key initiatives merit mention:    

Evaluation of fos health programmes

The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund); The Global Alliance for Vaccines and Vaccination (GAVI); U.S. President's Emergency Plan for AIDS Relief (PEPFAR); Multi-country HIV/AIDS programme of the WB.

Figure 3: Total funding for AIDS in low and middle income countries

$ 17.4

$ 17,0


$15.9 $15.6 15.0 $ 14,3

$ 14.4

$ 12,8


US$ billion



Signing of De cle ration of Com m itm e nt on HIV/AIDS, UNGASS


$ 09,9

$8.3 7.5

HIP+ $6.1

World Bank MAP launch


5.0 $3.2 UNAIDS 2.5 $0.3


Gate s Foundation


$0.9 $0.5 $1.4


The Global Fund

0.0 1996














Source UNAIDS, 2010

In addition, the Bill and Melinda Gates Foundation focuses on global health, and is currently one of the largest donors in this field. It particularly funds and promotes the development of new drugs and vaccines.

In Latin America, the impact of these initiatives is less dominant, though, the advent of the Global Fund has, for example, completely changed the fight against HIV/AIDS and tuberculosis in Nicaragua.

The many efforts depicted above have had tangible results: in 2000 only a few hundred thousand AIDS patients received expensive AIDS drugs; in 2010 this reached 6 million and the price for primary drugs has dropped dramatically.

The explosion of these new initiatives and the partial privatization of international health care financing suggest that the leadership role of the WHO has become more complex than ever and is under pressure. While the WHO was also an instigator of this change – with the first GHI, „Roll Back Malaria‟, established by Gro Harlem Brundtlandt at the end of the nineties – it is now struggling to fulfil its normative role and position itself within the current complex architecture of global health.

The vast majority of these initiatives focus on infectious diseases which are combated largely through specific vertical programmes, cutting across government policies. In many cases, particularly in Africa, this actually weakens the general health care system, but in other cases it has been a lever to improve the health system. The GHIs are increasingly aware of this problem, and attempt – although very modestly – to create „positive synergies‟ between the vertical development programmes and general health systems.

Evaluation of fos health programmes


2.2 Primary health care gets a second life The 2008 World Health Report “Primary health care, now more than ever”, affirms the vision and the principles of Alma Ata (see 1.2) and suggests four general reforms for health care around the world: 

Reforms in favour of universal access, with principles being to promote justice and solidarity and to eradicate exclusion;

Reform of health services according to the needs and expectations of people and communities;

A focus on health implications and needs in all areas of policy and society to ensure there is an integrated approach to health;

Reform of the global health leadership in an inclusive manner, with room for participation and openness to negotiations rather than confrontation. Modern leadership needs to face the complexity of current health systems.

Following on from the Alma Ata Declaration, the report explores how to make these changes by examining the processes and the strategic aspect of the reforms rather than confining itself to a vision and general principles. Subsequently in May 2009, the World Health Assembly adopted an important resolution by consensus in favour of primary health care(1).


The role of community health workers in primary health care The use and training of community health workers (CHWs) is a somewhat controversial component in the development of primary health care. Using CHWs was introduced as a strategy to resolve the growing shortage of health workers, especially in low income countries. Working with members of the community to provide certain basic health care services to the local community is a concept that has existed for 50 years. There have been numerous experiences around the world with programmes ranging from large-scale national programmes to small-scale initiatives emerging from within the communities themselves. The umbrella term „community health worker‟ includes a variety of „assistants in health promotion‟. CHWs are selected from and work within their own communities. International generalizations about the profile of health workers are difficult because they may be both men and women, young and old, literate and illiterate. It is more important to recognize that the definition of community health worker must comply with local societal and cultural norms and practices in order to Evaluation of fos health programmes

ensure acceptance by and involvement of the community. The role and activities of CHWs vary hugely over time, within and between countries and among programmes. CHWs sometimes perform a wide range of different tasks such as preventive, curative and/or developmental work, while in other cases they are employed for very specific interventions.

Worldwide the experiences are diverse, but there is a consensus on several matters: 1. CHWs can make a valuable contribution to the development of the community and, more specifically, improve the access of communities to primary health care. There is strong evidence that CHWs can take actions that lead to improved health outcomes, especially, but not only, in the field of child care. Although they can perform effective interventions, this is certainly not systematic and the quality of care they provide may also be limited. 2. CHWs must be carefully selected, properly trained and – most importantly – receive appropriate and ongoing support. Large-scale CHW systems require a substantial investment in training, management, control and logistics. 3. Community programs with CHWs are neither a panacea for weak health systems nor a cheap way to provide health care to populations with little access to health services. Many programs have failed in the past because of unrealistic expectations, poor planning and underestimation of the effort and contribution required to make it work. This has unnecessarily undermined and damaged the credibility of the concept. 4. Because of the nature of the work, community programmes can be vulnerable when using CHWs unless CHWs act appropriately and are strongly embedded in the communities themselves. When this is not the case, they are at the geographical and organizational periphery of the formal health system, exposed to the mood of policy changes without the means to lobby, and are hence often vulnerable. Community Health Programmes thrive in mobilized communities but have difficulty where they are given the responsibility for encouraging and mobilizing the communities. Examples of successful programmes can be easily found in the wake of community mobilization efforts, or as part of a major political reform, as seen in Brazil and China.

A fundamental challenge is to institutionalize and standardize community participation. To date, the largest and most successful programme in this regard is the Brazilian Family Health Programme, which integrates CHWs in to its health services and has institutionalised health promotion committees as part of the municipal health services to support social participation. This means that community participation is not a choice, but an integral part of the public responsibility for providing health care. 5. Finally, the question of whether CHWs should be volunteers or paid in some way remains controversial. There is almost no evidence that volunteering for long periods can be maintained: CHWs are generally poor, they need and expect an income. Although many programmes expect that CHWs only use a small part of their time for health-related tasks so that they have enough time to pursue other livelihood activities, the needs of the community often require a full-time commitment. In fact, precisely because of what they are, CHWs generally provide services in environments where formal healthcare is inaccessible and people are poor. This complicates the issue of funding by the community, which is rarely successful unless institutionalized as in China.

Given the current pressure on health systems and their proven inability to respond appropriately, studies have outlined that community health programmes in poor countries are neither cheap nor easy to run but remain a good investment. The alternative is no care for poor people living in geographically and institutionally remote areas.

In the next pages, we will explore two of the proposed reforms: universal access to health as a component of social protection and the integral vision of health.

Evaluation of fos health programmes


2.3 The social determinants of health In August 2008, after five years of research, the WHO Commission on Social Determinants of Health presented its report, “Closing the gap in one generation, health equity through action on the social determinants of health”. The report uses a holistic approach to analyse the social determinants of health (see figure 4) and identifies three principles for action:


Improve daily living conditions;

Achieve (re)distribution of power, money and resources, the structural determinants of inequality;

Monitor various aspects, evaluate actions, expand the scientific basis, train the relevant human resources, and the influence public opinion.

For the first time since Alma Ata, a high level UN Committee has positioned itself strongly against inequality, expressing the need for political action at all levels to fight the root causes of these inequalities.

The alternative World Health Report „Global Health Watch II‟ of the People's Health Movement (PHM), was published around the same time and presents a very similar structural analysis of the global problems as the aforementioned UN Commission. Along with the WHO report of 2008, it is remarkable that these three world-class reports expose so many similarities(2).

The 'social determinants' are the bridge between health and the broad political, social, environmental and developmental context.

The analysis provides an interesting conceptual framework in which to test policies and to set out actions. Providing social protection is one of the key social determinants.

Figure 4: The social determinants of health inequalities

Source: Closing the gap in a generation, WHO, 2008 Evaluation of fos health programmes

2.4 Social protection as an instrument for a fairer society Social protection includes all public and private initiatives of transferring income or consumption to the poor and vulnerable people, hence protecting them against loss of income and increasing the social status and rights of marginalized groups.

The 2010 World Health Report was dedicated to universal access and suggests the following proposals(6): 

Give a higher priority to health;

This broad interpretation has encouraged many important social initiatives and measures:

Create and release more financial resources in each country, e.g. by taxing alcohol and tobacco (among other measures, of course);

Preventive measures, such as pension schemes, health insurance, income diversification;

Keep vulnerable individuals and groups from falling into the poverty trap;

Promotional measures, such as microcredit, income stabilization packages;

Protective measures, such as social services, care for the disabled, community health care.

Establish new mechanisms for international solidarity: most promising is the potential new mechanism for taxing international financial transactions;

Work on the expansion and increased efficiency of health systems.

Achieve lower prices for medicines.

Different types of intervention can give substance to these measures including social assistance, social security systems, and social services. When bringing about social change(4), „transformative‟ action is vital to building better social protection. Consistent, transformative social policy is based on the belief that each person deserves a decent life and civil society has an important role to play. When we look at the classic interpretation of social protection in the international community, we note that this has for many years been the exclusive domain of the ILO. Some milestones include: 

„The Global Campaign on Social Security and Coverage for All‟, launched in 2003;

The Global Extension of Social Security (GESS) Platform: an electronic meeting place, launched in 2008.

Belgium was the main funder of the Strategies and Tools against Social Exclusion and Poverty (STEP) programme, an important executive arm of the ILO, active in approximately 30 countries. It supported among others the coordination of community initiatives for mutual health services in West Africa. In 2005, the World Health Assembly for the first time discussed this issue and reached an agreement, which resulted in the resolution on „Social Health Insurance‟(5).The May 2009 resolution of the World Health Assembly on primary health care again advocates for universal coverage, social protection and justice.

In line with what is happening in several countries, this evolution contributes to a global momentum on this topic at the government. There is a clear need for cross-governmental dialogue, particularly between Ministries of Labour and Finance. The ILO and WHO have already combined their efforts and aim to work together to establish a global „Social Protection Floor'. Civil society organisations are also active. The World Social Forum is the main channel by which NGOs and social movements, unions and mutual health services exchange ideas and experiences. Belgian mutual health services work together with the umbrella organisation „Association Internationale de la Mutualité‟ (AIM). The People's Health Movement is the pioneer among the NGOs. In December 2010, the Government of Brazil organized the first World Conference for the establishment of universal social protection systems. This was the first time the South took the lead at a global level. The recent financial crisis influences this story in different ways. On the one hand, we see that systems of social protection have largely absorbed the impact of the financial crisis (although they were also under pressure). On the other hand, the crisis limits the possibilities and the political will to undertake important new steps towards a better social protection and hence mobilization of new financial resources.

Evaluation of fos health programmes



2.5 People and medicines Global health personnel The global need for additional health personnel is estimated at 3.5 million just to reach the MDGs. The needs of the ageing North, which give rise to large migration flows, have not been considered in these calculations. The migration of health personnel in recent decades has increased with globalization, especially from low-wage countries with already fragile health systems(7). The crisis caused by the AIDS epidemic has only made this situation worse, but has at the same time also alerted the world to the serious shortage of health personnel, especially in eastern and southern Africa.

Evaluation of fos health programmes

In 2004, the World Health Assembly adopted a resolution which recommended compiling a code of conduct for the international recruitment of health personnel, which code was finally accepted in by consensus at the 2010 World Health Assembly. The code is balanced, voluntary and non enforceable and considers both the rights of individuals to migrate, as well as measures to make the medical profession in the South more attractive. Each country takes responsibility for its implementation, but there is certainly also a role for the international community.

Global pharmaceuticals There are enormous challenges in the field of pharmaceuticals. From fos‟ perspective the major issues are(8): 

The need to develop new drugs, especially to combat great epidemics and neglected diseases, and to respond to the increasing resistance to antibiotics. The WHO established an Intergovernmental Working Group in 2006, which proposed a number of innovative ways to promote the development of new drugs for neglected diseases. At the World Health Assembly in 2010, countries including Brazil suggested that the mechanism should go beyond the traditional mechanisms of the free market;

The availability of cheap drugs (especially generic drugs) of good quality for low-income countries. There are generic drugs for most diseases. This is more problematic in the case of HIV and other epidemics, when more expensive patented drugs are needed. There is a political agreement (Doha 2001) to call upon the exceptions in the Trade Related Intellectual Property Rights (TRIPS) if a public health emergency occurs. In fact, the international civil society accuses the EU of wanting to be more restrictive in its bilateral trade negotiations;

The problem of counterfeit and substandard drugs. The WHO is making an effort in this field by “pre-qualifying” drugs for three diseases (HIV/AIDS, malaria and tuberculosis), which is a step in the right direction. However, there is no international mechanism to ensure the good quality of most generic drugs in the South. On the other hand, negotiations about a fight against counterfeit drugs (anti-counterfeit trade agreement, „Acta‟) have started. These negotiations are controversial, and are perceived by countries like India and Brazil and the international civil society as a means to protect intellectual property, against the TRIPS exceptions;

The distribution channels for drugs in lowincome countries remain a logistical and managerial challenge;

The rational prescription and use of drugs is the shared responsibility of care providers, patients and the government.

Evaluation of fos health programmes


2.6 The new international context of development cooperation The Paris Declaration (2005) provides some guidelines which all development cooperation agencies should follow. This declaration is the international response to the problems of inefficiency and lack of sustainability of development projects which have not achieved real change. Even though it was a concept which was conceived of and developed in the North, the principles of the Paris Declaration are valuable, certainly in the current development context. Most European countries are making efforts to put these guidelines into practice, but there is still a large gap between these fine principles and actual practice. More than ever, the time is right for the north and the south to work together to formulate ideas and develop and international development strategy.


Evaluation of fos health programmes

The five principles of the Paris Declaration (2005): 

'Ownership' of the development vision and efforts by the partner country

Coordination of international aid (Harmonisation)

Alignment of national policies and procedures

Mutual accountability

Results-based management


The vision of fos 3.1 What does fos stand for?

fos has its roots in the socialist movement. The supporters of the unions (ABBV-FGTB), the socialist mutual insurance (UNMS - NVSM), the Socialist Party (sp.a) and the many socialist-inspired cultural, youth and women's organizations are the grassroots of our organization. The struggle for better working conditions and wages for workers, better living conditions and social service provision for their families has always had an international dimension.

fos places people at the centre of development

and considers this focus incompatible with the pursuit of unlimited economic growth, in terms of accumulation of capital and survival of the fittest. fos wants a sustainable economic, social and political system that ensures: 

Equitable distribution of resources, both between rich and poor countries and within each state;

Absolute priority for fulfilling the basic needs of all people in the North and South and for poverty reduction;

Respect for the universal human rights, including respect for rights of women and labour;

Extensive public participation of the population at all political decision-making levels and an economy that is subject to a democratic political system;

An economy which develops with respect for the planet we live on, and which indemnifies the generations of tomorrow;

Fair world trade where the producers receive a fair price for their produce;

Drastic reduction in military spending in the North and the South;

Non-military resolutions to conflicts;

Respect for the preservation of cultural diversity;

An active government that subscribes to, implement and promote these principles.

In its efforts to achieve greater equality fos supports pro active organisations and social movements, which will unite around group interests, collect information and build capacity to ensure their voices will be heard when important decisions are being made.

fos is active in Central America (El Salvador, Honduras, Nicaragua), in Cuba, in the Andean region (Bolivia, Ecuador and Peru), in Southern Africa (Angola, Mozambique, Namibia, Zimbabwe and South Africa), in Ghana and in Palestine.

Evaluation of fos health programmes


3.2 An innovative vision of health fos‟ health programme promotes the fundamental right to health. Using a human rights approach which

contrasts with the „market approach‟, where „health‟ as a marketable product is a commodity like cars, computers or any other consumable. fos‟ starting point is people‟s needs , which are best expressed by progressive social movements. fos does not provide medical care but analyses health from the people‟s perspective, from the „demand‟ side as opposed to the „supply‟ of care.

More specifically, fos seeks to improve access to a qualitative system of social protection in health. fos does this by following wherever possible the local, national, regional and international trends towards universal coverage through health insurance. This means: 

To support and promote community initiatives and/or public health insurance systems;

Health promotion and claiming the right to quality health care and adequate social protection. Priorities are identified according to the analysis of the social determinants of health;

Access to affordable and good quality medicines, enabled by civil society;

Support for primary health care services for excluded communities. This option is especially applicable in partner countries where health insurance systems are not developed. These services should be organized from the community and connect with a public health system.

22 Principles of the health programmes: 

Use universal access as a mobilizing concept;

Start by analysing the exclusion of large groups in society;

Analyse the social determinants of health. This can inspire the identification of priorities and how causes are addressed;

Assume the responsibility of state and government to ensure access to health care;

Believe that fragmented health systems lead to wastage of scarce resources and reaffirm social inequality;

Advocate for the community as agents of their own health;

Promote an institutional and community culture that takes „gender‟ into account;

Examine opportunities to be incorporated into existing processes or to reorient these;

Use the opportunities to have an impact at national level through targeted interventions, strategic processes and lobbying;

Use the power of national and international alliances.

Evaluation of fos health programmes

Let us explore these elements further: Improve access to qualitative social protection in health through the promotion of community initiatives and/or public health insurance systems The topic of social health insurance sits high on the political agenda in many middle-income countries and even in some of the poorest countries. There is a real opportunity for fos to respond to these in Latin America and South Africa. In Central America, fos has initially chosen a community approach through mutual health services and intends to align these mutual services with the national social security system. A basis for cooperation and action exists, when partners express a clear demand for integration into a social insurance system obtained through a participatory diagnosis of existing health problems. In this case it is important to properly analyse both health systems and health insurance and protection systems and then develop a vision for reform.

fos supports specific projects in several countries

together with, and for, organizations who have joined the health insurance programme through collective membership. Their local experience therefore informs the national proposals to improve the whole system.

’ 23 August 2009, Sunday Times, South-Africa

From the participatory analysis of the Women on Farms Project in South Africa, HIV/AIDS and sexual abuse were identified as the dominant problem. It was therefore logical to focus on these issues. Preventive educational activities and health information are also important elements and are usually embraced by mutual associations in Belgium as part of their social mission. Establishing a relationship is therefore straightforward.

Access to essential and qualitative drugs is a broad and complex problem and fos follows this closely

both in the North and the South. In the South collaboration, fos takes up strategic opportunities. Some examples are: 

The Social Marketing of Drugs in Central America, where much is happening in this area. Social marketing of drugs can be considered as a means to strengthen social protection. Operationally, it also helps to interlink local initiatives of social marketing of drugs with the mutual associations;

Civilian control upon the quality of access to medicines;

Supporting and promoting access to specific products/methods, such as family planning and/or AIDS prevention when other (religious) social networks do not offer these services.

The promotion of health and claiming rights Health and development are interrelated. A participatory diagnosis together with beneficiaries and partners, based in everyday life experiences, is the foundation for action. However, health promotion is a very broad concept and the entry point for fos is the connection with social protection.

fos‟ partners claim the right to good quality health care. The mutual association in Nicaragua consi-

ders the quality of care given to people a very important added value, and thus the subject of negotiation with care providers. In Ecuador, the decision was taken to proceed, in dialogue with the provincial government, from an informal and sporadic campaign for the right to health, to a system of „social control‟. Hence, an isolated „complaint‟ became the basis for the formulation of widerscale recommendations.

Evaluation of fos health programmes


Primary healthcare at the community level With the role of community health workers in basic health care being reassessed (see 2.2), it is useful to learn from past experiences. For example, the support of primary health care in excluded communities in Mozambique gives an operational interpretation to the concept of health promotion. With this concept, fos and its partners respond to the four reforms promoted by the WHO: universal access to health (general objective), patientcentred care (as an activity in the context of health promotion and social monitoring), leadership in health (leadership in social movements, holding authorities accountable), and a general policy for the health of the population (formulating concrete alternatives).

In its approach to projects, fos concentrates on „strategic‟ interventions, which link three levels: 

The community level;

The „meso-level‟, member organizations and movements that are regionally and nationally active;

Advocacy at local, regional and national levels.

Experiences from the local level can be 'transferred' to inform and formulate and ultimately advocate for policy change at a higher level. fos‟ partners are all members of networks and alliances, strengthening potential linkages.

fos thus attempts, although with limited resources, to be a ‘strategic’ catalyst for social processes that are supported by social movements.


Evaluation of fos health programmes

3.3 Health within the broader strategy of fos and the socialist and NGO movement fos tries to coordinate its operations in the North and the South.

This work is undertaken in partnership with, principally, the National Federation of Socialist Mutual Insurances (UNMS - NVSM) and provincial mutual associations, as well as organisations such as Multipharma and P&V insurance company.

fos also networks with the following Belgian players: 

Masmut: the Belgian Platform for Micro Health Insurance and Mutual Associations aims to strengthen the relevance and effectiveness of micro-insurance and other institutions in the South. The Platform brings together Belgian actors working in the field of access to health care in developing countries and builds on their specific and complementary experience and expertise; The Platform for Action on Health and Solidarity, where unions also participate. The Platform links up Belgium‟s national health care and the international context;

Be-cause health: the Belgian platform for international health and health care that unites almost all actors in this area, and focuses on providing advice, knowledge sharing and collaboration. Be-cause health also makes cross connections with the other platform initiatives;

The connection with fos‟ second major theme of „decent work‟ also deserves attention. Social protection is one of the main pillars of „decent work‟, and in trade union work receives systematic attention. In addition to the health elements of fos‟ programmes, more health aspects can be integrated into „decent work‟, such as access by workers to social security, occupational health and health and safety at work. Opportunities in this field are systematically studied, fuelled by a lively dialogue between the departments of fos and with its partners. Exclusion from the right to health primarily appears to affect farmers, women and informal workers. United in member organizations, fos plays a role in counteracting this exclusion. The two elements of the fos-programme are therefore complementary with opportunities for synergy, particularly as those who are unable to exercise their right to health are often also those unable to access their right to decent work.

Evaluation of fos health programmes


3.4 Towards a global social contract? We believe that a world with less inequality will be socially „healthier‟ and will have fewer tensions (Wilkinson and Pickett 2009). We can consider development cooperation as a way to redistribute wealth (both social and financial) internationally. We believe a contract can be made between countries that have their own commitments and the international community that is prepared to support this structurally and in the long term. This support is primarily for the development of policies and mechanisms of social protection. Is that not always the case for international cooperation? Not really, it is actually particularly innovative to have contractual commitment on both sides as well as the understanding that sustained and steady support will be necessary in countries that already have very low public budgets.


Interview with Guy Peeters and Patrick Verertbruggen, UNMS - NVSM What is the role and commitment of the socialist mutual association in the international realm? Our commitment is to continue to defend human dignity and social rights beyond our borders. A right to health and health care for everyone is our priority. We shape this international solidarity together with other partners from the socialist movement. Our health fund actively participates in international forums such as AIM (Association Internationale de la Mutualité) in Belgium and as co-founder and member of MASMUT (solidarity platform).

What do you see as possible relationships/ opportunities between experiences with health insurance in Belgium and in the South? While there is no blueprint for social protection applicable to all countries, Belgium‟s model of social security and statutory health is instructive for other countries. Our own National Health Service remains an inspiring organizational model for those who do not want health care to be left to commercial operators. It is an experience we would like to share with our partners in the South to foster solidarity between rich and poor, sick and healthy on a wider scale.

Evaluation of fos health programmes

How can an organization such as fos, with limited resources and activities in several countries in Africa and Latin America, make a difference? Doing what we are good at, this is and remains our focus, so we are talking about social security, labour rights and of course an inclusive health insurance with affordable, accessible and good quality health care for everyone. The added value of fos is that we can share our expertise with partners in the South, and thus realise a relationship of solidarity with other mutual associations.

Do you have a specific message? With the help of modern communication more people around the world are aware of inequality and injustice. The struggles for greater freedom and social rights throughout the world, but particularly in Latin America and recently in the Arab World, are striking and hopeful examples. Our international socialist message of social rights for all is more topical than ever before.

fos in the South 4.1 An ambitious health programme For 15 years fos has been working on the theme „Access to healthâ€&#x;. Nicaragua (Central American region), has the most prolonged and extensive operation in the form of setting up mutual associations. In recent years, fos extended its health operations to the Andean region and Southern Africa and there are ambitions for further growth in these regional programmes. Table 1 gives an overview of the health component of the programme. Within the fos health programme, there are a variety of approaches, ranging from contributing to or controlling the supply of (basic) services, access to drugs, setting up of mutual associations and support of social insurance (same as social protection/ community health insuranceand CHW programmes). Targets have been formulated for each of the three regions in collaboration with partners (local mutual associations, farmers' organizations, trade unions, pressure groups and platforms). Every operation is therefore tailored to local conditions and while there are different approaches within and between regions, social protection is always the common thread. To achieve these goals, fos uses a strategy of organizational development (internal, institutional and service delivery capacity) of the partner organizations. The fos programme is ambitious because, despite limited resources, it seeks to make an impact: locally in the communities, in wider-spread social movements, and where possible at the national policy level. Next in this chapter, we will elaborate a number of case studies that illustrate this work.

Table 1: Overview of the health programmes of fos

Region/ country

Health aspects

Start health programme

Central America Nicaragua






El Salvador















South Africa










Andeqn region

Southern Africa

Middle East Palestine


Evaluation of fos health programmes


4.2 The promotion of social security in Peru The Peruvian government wants to improve access to its country wide network of services these by implementing its „Universal Health Insurance ProgProgram‟. The poorest 40 percent of the population is entitled to a free package of care, provided they join this system. In practice, entire rural communities and villages enrol in the system which is largely decentralized to the regions. With this provision of health insurance, the government budget for health increased, although the funds available have not increased at the rate of the number of new programme members. In the past few years the government focused on increasing the number of users; in the next phase it will seek to improve the quality of service provided.


In addition, employees in Peru may also benefit from health insurance. EsSalud is a semigovernmental organization under the responsibility of the Ministry of Labour. EsSalud operates a primarily urban network of clinics and hospitals, providing better quality health care than the Ministry of health. This results in situations where, for example, one can find in a small town a surgeon in the health centre of the Ministry and an EsSalud centre where an anaesthesiologist works. However, they cannot perform surgery together as a team. Wages are higher in EsSalud and services are better equipped. In addition, there are also private practices used by the wealthier middle class. By and large, the lack of leadership in healthcare is denounced by Peruvian experts.

The support of fos Foro Salud, a civil society network and fos-partner, has developed a roadmap for integration and simplification of the health and social security system. Foro Salud lobbied for and drafted a bill based on this roadmap and, in April 2009, Parliament passed the law of universal social security. Although the final version of the law does not meet the high expectations of civil society, it is a step forward. This law enables the Ministry and EsSalud to engage in agreements at local level, facilitating better care provision. The Junta Nacional del Café (JNC), a professional association of small coffee producers in Peru, encourages cooperatives to play a more active role in the promotion of and access to health care for their members. Evaluation of fos health programmes

In recent years, 200 community workers and leaders from the regions of Junín, Cajamarca and Lima were trained in social health protection. An alliance of the International Labour Organisation and Peruvian institutions made it possible for organized coffee producers to join a common and better health insurance programme. In July 2009, EsSalud and the JNC signed a contract for collective enrolment in the social health insurance programme. To implement this agreement, fos will work with the local chapters of the JNC between 2011 and 2013.

“It is possible to work towards political impact on political actors, whether they're called executive, legislative or regional governments, and on current law and existing health and social security systems in order to obtain medium or long term structural changes, and to simultaneously, carry out activities that alleviate the urgent needs of the families who work in coffee production, through agreements with health care providers in health, and to achieve results in the short term.” A. Vidal, report on health insurance for small coffee producers in Peru, united in the Junta Nacional de Café, December 2008

To promote structural and sustainable changes in the long term, it is essential to apply pressure on public health policy. Entering into strategic alliances and formation of a broad powerbase is vital to propel these changes. fos supports Foro Salud in its efforts to stimulate debate and social mobilization around its proposal for universal health insurance.

fos also supports the strengthening of the national social security system in the coming years in:   

 

Bolivia; Ecuador; South Africa: reforms announced by President Zuma, in 2011 fos began working with the People's Health Movement; El Salvador: reforms announced by the new progressive government in 2011; Nicaragua: Embedding of the health services in the national health Insurance.

Interview with Lieve Daeren, former thematic healthcare coordinator for the Andean region Does a "micro-macro approach" in the field pose specific challenges? Having smaller local projects with immediate results in the short term is preferred in the development market these days and there is a lot of pressure to keep it this way. Nevertheless, the challenge is actually to frame such small and local initiatives within clear and nationally-driven policy that addresses longterm structural changes. The challenge with this approach is that, as a development agent, one needs to interact for a long time and engage in policy, explore political options and hold discussions, to learn about the broader structural story. Therefore you may not have “concrete results” for a long time, but in the meantime you are quite busy working on significant changes with far greater potential impact. It requires a lot of networking and the combination of both a technical and political perspective on things.

Does offering health insurance leads to social change? It depends on the type of health insurance and the direction of social change. Offering private health insurance that is seeking profit for large „insurance multinationals‟ rather than the collective well-being will lead to social change, but namely to more social exclusion and inequality. I do not think this is the kind of social change that fos is looking for. However, what is relevant is promoting social and solidarity insurance systems, based on the principles of social security which are at risk of disappearing: „everyone receives according to his needs and gives according to his capabilities‟. This goes, however, apparently more and more against the actual spirit …. Hence, public systems which strive to represent the public and collective interest (or should at least try to) are so important. We know in advance that a private insurance is not primarily interested in your personal well-being, let alone the collective welfare, though it will try to convince you of the contrary. Accounting for everything, a private insurer wins – always more than those insured - while social insurance is, in principle, not allowed to make a profit.

What are the major trends in social security in the Andean region? You cannot speak of a clear trend in the Andes. There are several trends going on. On the one hand, both

the Bolivian and Ecuadorian governments say they will re-invest in some key sectors for more humane and inclusive development, including education and health. But both are struggling especially with the organization and financing of public health interventions aimed at building greater social security or protection for the population. „Free health for all‟, the slogan of the Ecuadorian government, does not mean that the health system will suddenly cost nothing. The main question is: where will a government find the money if they are not going for a Bismarkian system of social security contributions on wages? The most obvious answer is thorough tax reform with arguments of economic and social redistribution, and also environmental sustainability, but this is obviously not popular with the current power groups that still dominate the economy and politics, even in those countries where a so-called „social revolution‟ took place. On the other hand, you have Colombia and Peru, the „good students‟ of the IMF and World Bank programmes, which increased privatization of health care and a clear push for health insurance under the guise of „reform of social security‟. Colombia shows that - at least in social terms - the initial results are not too positive and that, as happened before in Chile, a radical privatization of the health sector and social protection ultimately leads to a State that channels funds to private companies (hospitals, pharmaceuticals, social services, etc.) without receiving the promised social efficiency. It is not for nothing that in Chile, (the first Latin American country that „reformed‟ its social security towards privatization) a counter-movement is now trying to get as much as possible back into the hands of the State.

What are the biggest obstacles to achieving change in those countries? Political power configurations. However you look at it, the economic interest groups still dominate the political scene. The Andean countries still have very precarious „democracies‟. Rather than promote social change, the political establishment would prefer to maintain the „status quo‟. If something will eventually start to stir, it will be from below. It is ultimately popular movements that will dispose of presidents and demand changes in government. The problem is that when these movements come to power, they have difficulty presenting technically well-grounded and politically feasible policy proposals because they have been too stuck in the resistance, with insufficient attention given to developing their own viable, alternative proposals.

Evaluation of fos health programmes


4.3 Mutual associations: a case study of Nicaragua The health system in Nicaragua is also complex, consisting of three components, summarized in Figure 5.

Figure 5: The current health system in Nicaragua

Current health system in Nicaragua


(Local Integral Health Care System)

Private companies offering medical services

Private clinics and hospitals






(Ministry of Public Health)

(Nicaraguan institute of Social Security)



Private services


Source: Regional evaluation Nicaragua (Michael Forsch, 2009)

The „Local Integral Health Care Systemsâ€&#x; are decentralized centres of the Ministry of Health, responsible for preventive programmes and for supervision of public health centres. These decentralized services provide care to the vast majority of the population and especially to the poor. The government has introduced the principle of free care for the population through the public system, but it lacks the resources to consistently implement this policy. The Nicaraguan Institute of Social Security runs some limited number of health centres and clinics which are accessible to the insured, mainly employees. In addition, the Institute engages in agreements with for profit private companies to provide medical services at the level of primary and secondary care.

Evaluation of fos health programmes

The support of fos fos has reintroduced the concept of mutual associations in Nicaragua (see Figure 6). The first mutual

associations of the 1990s encountered severe difficulties following the collapse of international coffee prices. Currently, 11 Community mutual organisations are in operation. These are grouped under three umbrella federations. The main target groups are informal and uninsured workers. The success of the mutual associations depends on their integration in the community structures and the support given by the National umbrella federations. fos works again with AMUN and the Mutual Urbana which depends on Cooperative Umbrella organisation FENACOOP, next to Fundeser and Corudes , and the Trade Union confederation CTCT-FNT respectively.

Bart Criel, ITM health expert, on mutual associations 1.




5. The mutual associations are a means but not an end (the goal is efficient, equitable and sustainable social protection in health that enables a dynamic of social „transformation‟). Sometimes it is an interesting means, but other times it can be inefficient. One must accept this reality and deal with it consistently. That is, supporting where it is worthwhile and letting go and investing in other strategies 6. where it is not. There is no universal formula that explains what one must do to obtain universal health care coverage: it will always have local solutions, adapted to the context. It is useless to speculate about the 7. duration, which will also depend on the context. If mutual associations are an option they must fit within systems that are characterized by the coexistence of a variety of funding schemes covering different subgroups of the population. The mutual associations (in the South) will never be fully self-financed by contributions from their members, because the population is poor. One must therefore (accept to) subsidize them intelligently. Otherwise, the mutual associations will always remain weak in their coverage, as is the case in most African countries.

The mutual associations have a rather complex structure and at the basic coverage level are inefficient in terms of transaction costs (personnel management, management structures). This inefficiency can only be justified if there is a significant socio-political “return” (empowerment) that other funding arrangements do not generate. The design of mutual associations in the South is often inflexible and not well adapted to the local context: too often they are standardised and work to a template. Questioning this standardised approach can lead to clashes with donors. In the South, mutual associations (as with any other health insurance system) need a government that regulates and provides subsidies. Collaborating with the government is vital from the beginning.


One must simultaneously work both at supply-level (the behaviour of health professionals, quality of care) and demand-level: a holistic approach to the system is needed. This has not been done to date.


At some point it will be necessary to make contributions mandatory (just as there is an obligation to pay taxes): this will only be socially acceptable to the people if the quality of care meets expectations. The role of government is therefore essential to ensure this.

Figure 6: The Mutual Associations in Nicaragua

The Mutual Association in Nicaragua ASOCIACION CIVIL MUTUA DEL CAMPO


(‘Rural Mutual Association’)

(‘Urban Mutual Association’)

1935 en 1950

Nicaragua: León, Granada, Masaya, Chinandega and Managua. Based on existing forms of cooperation called "Sociedades Mutualistas". Common fund for funeral expenses, purchase of raw materials for its members

1995 / 2000

2003 / 2007

Beginning of the MUTUA del CAMPO.

The Frente Nacional de los Trabajadores (FNT - National Front of Workers) and members/labourers set up the Mutua Urbana.

The Asociación de Trabajadores del Campo (ATC - Association of Rural Workers) supported by the Socialist Mutual Association of Belgium/Fund for Development.

The Mutua Urbana is recognized as a legal entity in April 2007.

The Mutua del Campo is a non-profit organization founded in May 2000.


Source: Regional evaluation Nicaragua (Michael Forsch, 2009) Evaluation of fos health programmes


The establishment of a mutual association is an intensive process. The type of services provided depends on the options chosen by each mutual association: 

General and specialized medical care;

Preventive health education;

Social marketing of drugs.

From time to time, a mutual association chooses to organise other services, such as help with funeral expenses or a rotating fund for micro credit. At the end of 2010, 5,200 families were members, accounting for a total of 31,250 people. The benefits of the concept are summarized in Figure 7. After years of lobbying, the mutual associations‟ system has been recognized legally. The mutuas seek to be closely linked with the national health insurance system.

32 Figure 7: Benefits of mutual associations in Nicaragua

Benefits of the mutual association - To medical care PROVIDING ACCESS

- To pharmaceuticals - To information about health - Low prices of drugs


- General and specialized care - Savings in transport - Savings in time

the right of access - with respect and dignity - to resources and information to improve health

- Respectful treatment MORE HUMAN CARE

- Explanation of use of medicines - Immediate treatment

Source: Regional evaluation Nicaragua (Michael Forsch, 2009) Evaluation of fos health programmes


Ariel Montesdeoca, Regional Health Care Coordinator & Helene van Acker, Regional Coordinator in Central America What are the major social security systems trends in Central America? In the various Central American countries only a limited group of workers and employees are included in formal social security systems. Incorporating domestic staff and those who work informally is being considered in Nicaragua and El Salvador. El Salvador has already issued a law providing access to social security for domestic staff, but it is not yet widely enforced. In the three countries healthcare reforms are being proposed. Nicaragua and El Salvador base this on a universal human rights perspective and hence a system of integrated health care. The emphasis is on promotion, prevention and free services in public health, although there is not (yet) sufficient budget and staff. Honduras seeks to privatise further.

   

In countries with a liberal system/privatization, MA should focus on groups with a history of strong internal solidarity, but with a minimal capacity for financial contributions. They should also think through and clarify the consequences of health privatization and establish a clear advocacy role to achieve inclusive public health care systems. They should offer a service that is better than public or private health care provision. They should provide services in geographic areas where the government is unable to do so. They need start-up capital or temporary subsidies to safeguard their operation. They should contribute to a “mutual solidarity” culture through social action. Cohesion among members is an added value, particularly in MA with members from different social strata.

What is the added value of the fos programme?

There is a growing demand from the unions and social movements to bring currently excluded groups and sectors within the social security system. This includes domestic staff, urban and rural workers in informal jobs or working for their own account, and comprises most of the working population in those countries.

In El Salvador, the fos programme supports social auditing and consultations for the reform of the health sector; providing practical answers to immediate needs in the case of drugs and strengthening the MA as instruments of social protection and increasing public awareness at local and municipal levels.

What are the specific challenges for the mutual associations (MA)?

In Honduras, fos works to promote models of mutual solidarity from a management perspective and to strengthen national discussions on proposals of social protection for countries emerging from dictatorship.

Being able to meet several requirements to ensure their survival: 

In countries with a national system of social protection, MA need to be able to adapt, to be complementary to universal health care systems and to lobby for the government to play a regulatory role.

In Nicaragua, fos facilitates the review of the entry points of MA and their integration into a new reality of universal health care provided by the government.

Evaluation of fos health programmes


4.4 Defending the right to health in Ecuador and South Africa Ecuador The current government under Correa aims to provide free health care through public services. The Ministry of Health has a network of services that should currently ensure universal access based on the existing demand for healthcare. The health budget has increased and is sufficient for the current level of demand, but is deemed insufficient to truly generalize high-quality care. Unsurprisingly, the government is concerned about the ongoing financing of this care.


The Instituto de Seguridad Social Ecuadoriano (IESS) is a government-owned agency. IESS funds a portion of the national insurance with farmers contributing 5 percent of the minimum wage and wage-earners 9 percent of their salary. The ILO considers the national insurance, „Seguro Campesino‟, a success. The network of services of IESS is, however, not connected with the services of the Ministry, but there is potential for referral. There is no significant difference between the wages paid by the Ministry and those of the IESS, which could facilitate eventual integration. Wealthier communities, moreover, rely on private doctors and private insurance. There is also a programme of prevention and health promotion with Ecuadorian and Cuban doctors providing home care.

The support of fos The Urban Forum Quito is a network of social organizations, including the women's movement Movimiento Mujeres Por la Vida, which strives to build an inclusive and socially just city based on dignity and human development. fos supports this forum within its objective to organise deprived urban populations around their right to health and to set up a system of civilian control around the universal insurance programme that the government promotes. Following consultation and active participation of civil society, the Constitution was revised to include citizens‟ participation and universal access to health care as a right. Both adjustments are beneficial to the goals of fos‟ partners.

Evaluation of fos health programmes

A project was piloted in five zones and 12 district organizations, enrolling users and creating monitoring committees to promote care „con calidad y calidez‟ (with quality and human warmth). Many fos partner organizations see health not as a discrete theme but as part of a broad social project. For example, this Forum has also submitted proposals to improve the social status of housewives.

South Africa Unemployment, low incomes and poor living conditions have had a major impact on health and the damaging social legacy of apartheid is still evident. South Africa ranks highest in the world in terms of wealth inequality. Dealing with the AIDS epidemic is a huge task for South Africa. Under the previous president Mbeki, now labelled an AIDS denialist, treatment was denied and delayed resulting in hundreds of thousands of unnecessary deaths. Now thanks to lobbying from well organized civil society movements and a more progressive Minister of health, the prevention and treatment of HIV/ AIDS has improved. In August 2011 the government released a paper on the proposed National Health Insurance Plan for discussion. It is a relatively progressive document drawing on the principles of primary health and recommending decentralization and extensive use of CHWs. The implementation of the national health Insurance plan is likely to be hindered by: 

Poor administrative capacity at all levels;

Insufficient medical personnel at all levels and in all categories: doctors, pharmacists, (auxiliary) nurses, technicians and support staff;

Concentration of health services in the cities and lack of provision in rural areas;

A relative reduction in expenditure in the health sector;

Inadequate social protection (social security) for the poorest of society. There is no national insurance system;

The private sector is strong and will fight to maintain its role providing care to the rich.

The existing state services are free and of variable quality, but usually understaffed, poorly equipped and with long queues for treatment. The government has introduced an accreditation scheme to help raise the standards in the state facilities with a view to including them in the NHI and hopes to partially address the chronic staff shortages with extensive use of CHWs.

The support of fos fos has limited resources to dedicate to health and so focuses its resources both geographically and thematically.

During 2005, the HIV/AIDS prevention campaign by the Women on Farms Project (WFP) was selected for the first fos collaboration as well as the focal point for the fos awareness-raising campaign in 2006. The farmers work on the wine, fruit and vegetable farms in the Stellenbosch region. Many of the agricultural workers are unsupported single women/ mothers marginalized in terms of income, education, social status and health. WFP started its operations at the grassroots in 1992, before the 1994 elections. The primary objective was to defend the rights of marginalized female labourers. Central themes identified were land issues, labour rights and health. Separate programmes on domestic violence against women, HIV/AIDS and alcohol and drug abuse were later integrated into one health programme.

The main strategic areas are:    

Building capacity to claim rights; Research (e.g. on pesticides and temporary work); Campaign Work (e.g. around health, temporary work); Networking with like-minded organizations.

Evaluation of fos health programmes


WFP has established about 40 all female health teams who organize a number of promotional activities in the strategic areas mentioned above. Some of the biggest successes, according to WFP, are the presence of organized women's groups on farms, their increased self-esteem, leadership and communication skills and personal transformation. WFP considers itself feminist, a necessary approach to fight the patriarchal society.

4.5 Basic health work with communities in Mozambique and Cuba Mozambique


The challenges for the health system in Mozambique are enormous. Health centres in rural areas are severely understaffed and underfunded and only 50 % of Mozambicans live within 5 kms of a health centre. There is a serious shortage of all health personnel; Mozambique has, for example, only four doctors per 100,000 inhabitants, which is six times less than the minimum recommended by WHO and more than half of them are based in the three largest cities. The National Human Resources plan (2009-2015) for the health sector defines increasing both the quantity and quality of available health personnel as a priority. HIV/AIDS, TB, malaria and malnutrition are among the most serious challenges which Mozambicans face, against a backdrop of poverty and female disempowerment. Accurate information about disease prevention is not easily accessible. The demand for community health workers has also soared because of problems relating to HIV/ AIDS. This has also renewed (inter)national attention to basic health care and the role that community health workers can play. During the 1970s and 1980s, the Ministry of Health trained a large number of community health workers (CHWs) to provide health care for many rural

Evaluation of fos health programmes

communities. Their course lasted six months, and covered both preventive and basic curative care. They were issued with simple first aid kits and had some medicines. However, this system fell apart though due to lack of support. Some individual health workers from this programme are still working mainly on curative tasks. In recent years, driven by international NGOs, a few scattered and uncoordinated efforts were made to reinvigorate the community health worker programme. Those CHWs who participated were given a short course (one to two weeks) and specific tasks, such as the distribution of vitamin A, tuberculosis, malaria prevention (distribution of bed nets), home care, etc. The government recently agreed to revitalise the CHWs and is now piloting the programme in some provinces.


Domingo Zelios, community leader, Chibutu, Mozambique

The support of fos The União de Camponeses de Manica (UCAMA) is a union of subsistence farmers in the Manica province. UCAMA has a longstanding collaboration with fos through the Food Security Programme funded by the Belgian Survival Fund. In September 2008, fos began supporting the health programme, which aims to add value through „social action‟ and institutional development, rather than focusing strictly on „medical interventions‟. The programme is coordinated by an experienced nurse, supported by three assistants, who each support two CHW teams in remote areas. The community health workers, drawn from the communities they serve suggest strategies to prevent and tackle health problems in the absence of health services, which could easily be as far as 12 or even 50 kilometres away. Some of the major successes of UCAMA include: 

Training of 6 teams of community health workers in three districts in Manica province;

Construction of latrines, washrooms, food storage facilities and wells;

Home visits by CHWs to monitor the health of their community members, and offer care to AIDS patients;

Participation in awareness-raising and health promotion campaigns (including vaccination) to increase the number of visits of the population to local health centres;

Dissemination of information, using a variety of methods, including songs and plays which often reach large audiences especially with information about HIV/AIDS, tuberculosis and malaria.


Evaluation of fos health programmes

Cuba: a model country in terms of social policy? Health and health care are highly valued by the Cuban government. This can be seen anywhere in the country, including in the smallest villages. Cuba can also present figures and statistics that stand positively in comparison with Western countries (see annex 2). This was not achieved suddenly but is the result of 50 years of social policy, and is the centrepiece of the „revolution‟. After the revolution, in 1959, the new government took the universal right to health very seriously and made the development of social services and basic public services a priority. The system is public, unique and free and access is universal. There are several notable phases in the development of the Cuban health sector:

Consultations between the government and civil society take place in the National Health Council (Consejo Nacional de Salud) in which the civil society (including FMC) and the academic world are represented. Similar to Western countries, Cuba has seen a transition to non-communicable diseases. Cancer is the second most common cause of death, primarily lung cancer (from smoking) and breast cancer. The above achievements are difficult to understand in light of the obvious poverty of the country and much of its population. Without going into too much detail, here are some factors that seem to have contributed to its success: 

The political leadership;

1959 - 1970: integration of private health care and the public system. Training of new doctors and nurses, decentralization of services.

The focus on the social determinants of health: general education, access to drinking water, housing, employment and subsistence;

1970 - 1980: consolidation of the primary health care system. Each province has its own faculty of medicine.

A culture of dialogue between sectors and disciplines;

1980 - 1990: launch of „family health‟, which relies on prevention and community clinics.

A unique system that serves the entire country;

1990 – 1995: period of economic crisis. Development of new systems for self-reliance, such as production of drugs.

National networks of civil society;

Sufficient qualified and motivated staff;

1995 - 2010: new phase of growth. From 2003, greater emphasis on the international role of health professionals.

Priority focus on prevention and promotion;

Attention to each individual;

The production and availability of essential medicines;

The relative stability of the country.


The Ministry of Health has about 360,000 health professionals, 70,000 of whom are doctors. The information system is well developed and annually a health statistics yearbook is published. Cuba now produces 90 percent of its own medicines. „Alternative‟ medicine (acupuncture, medicinal plants) complements this Western system. The Federation of Cuban Women (Federación de Mujeres Cubanas - FMC) has trained 80,000 „brigadistas de salud‟, volunteers who take on tasks such as health promotion and disease prevention.

Evaluation of fos health programmes

“Our target for the Project‟s success is 100%, because we do not want to lose any lives that we can avoid, we want every woman to participate in the prevention programme.‟” Oneida Broche Valdéz, FMC, Cuba

The support of fos FMC is a recognized membership organisation, with 4 million members and a reach across almost all of the country both geographically and in terms of population. Over 90 percent of its members pay a quarterly fee, and with these revenues the overall operation of the institution is financed. FMC has offices at both provincial and municipal levels. FMC conducts activities in different social domains, including in health. They can count on 80,000 community health workers, each responsible for a group of one hundred inhabitants. These community health workers receive a basic course of several days and are trained for any FMC programmes that require their cooperation, such as vaccination campaigns, the prevention of violence and HIV/AIDS prevention.

Each year the project is implemented in several municipalities of another province. Project activities include the training of supervisors, developing and distributing materials and the provision of materials in meeting halls n some municipalities of the province The project was also used to train trainers for the other municipalities of the province and for activities at national level (TV commercials, radio broadcasts).

In virtually all partner countries fos’ work has a central component to strengthen communities

The programme for 2008-2013 in collaboration with fos includes the „Awareness and training in

timely detection of breast cancer and cervical cancer in women‟. In 2008-10 this programme started

with a focus on breast cancer, a huge problem which has not received much attention. From 2011, cervical cancer was integrated into this campaign.


4.6 Access to medicines in Central America Availability of good medicines remains a major concern for the Central American population and represents a substantial share of health spending. In principle, the services of the Health Ministries have their own pharmacies, mostly stocked with generic drugs, but in practice there are regular supply interruptions and important products are often unavailable. Private pharmacies are booming but they are a problem rather than a solution: they sell any product without prescription and the product is often tailored to the purchasing power of the customer instead of the actual need. To combat this, various social organizations in the region started a system of „social marketing of drugs‟. This appears to work well, because in Nicaragua alone some 300,000 people call on it regularly. They are also united in a federation (COIMA), which, after years of preparation and lobbying, has recently been able to obtain a law regulating the social marketing of drugs.

Evaluation of fos health programmes

Toon Bongaerts, health expert for Central America, ProSalud

The support of fos in Nicaragua The partner for the „Social Marketing of Drugs‟ project is the NGO ProSalud. Social marketing of drugs includes 40 to 100 generic products depending on the size of the villages. Selling of the products is accompanied with exchange of information and education. ProSalud has a large warehouse and a professional distribution system. Many mutual associations combine their activities with setting up a village pharmacy.


As ProSalud we are convinced that we must continue to work on „Social Marketing of Drugs‟ (SMD) as a complementary alternative to the efforts of the public system. It is noteworthy that the Sandinista government in recent years has made positive efforts to extend the health coverage (up to 60 to 65 percent) and to increase the free supply of essential medicines. Nonetheless, there continues to be a large gap (an estimated 30 to 35 percent) between supply and demand. It is not likely that this gap will be filled in the short term (next five years) by the Ministry of Health itself, because they are facing serious budgetary problems in many ways. It pays to keep investing in Social Marketing of Drugs as a complementary programme. The government has ultimately also approved the law of SMD. This does not only mean offering cheaper prices, but implies strengthening education around more rational prescribing by doctors and more rational consumption by the population ... the struggle against the commercial propaganda of pharmaceutical companies … and also the issue of medicine quality, an area where much work remains to be done ...

The network of ProSalud is accessible to a population of over 100,000 people.

fos also supports the social marketing of drugs in El Salvador and Honduras.

Conclusion Defending universal access to health care will be most successful if it is headed by social movements. That is why fos and the socialist movement, already for several decades, support unions, farmer cooperatives, youth and women's movements in their struggle for a just and social society. The right to health and social protection worldwide will only be achieved if there is, alongside the efforts in these countries, also a commitment at international level. fos will continue to advocate for such a “global social contract” and will unite the forces of its partners both in the South and the North. This publication is a working document for fos-associates, sustaining the required networking and alliance building at national and international levels. The external view and recommendations of HERA and the various experts contribute to a renewed outlook of fos’ approach to health and helps to lay the foundation for new choices.

Evaluation of fos health programmes


Evaluation of fos health programmes




Resolution: Primary Health Care, including Health Systems Strengthening


„Three Global Reports, towards a growing consensus?, Editorial Tropical Medicine and International Health, Claudia Hanson, April 2009


Reducing health inequities through action on social determinants for health


See: „Transformative social protection‟, Institute of Development Studies Working Paper, Stephen Devereux and Rachel Sabates-Wheeler, October 2004. 20protection%20Devereux%20Sabates.pdf


Resolution EB 115.R13: Sustainable health financing, universal coverage and social health insurance


See for example: 203.ppt


See for example:


See for example: en index/20071127_459444024_drugsseminarbackgroundpaper.pdf

Evaluation of fos health programmes

Annex 1: Definitions on health and social protection Universal Health Coverage (UHC - WHO and ILO as adapted by Criel and Soors 2009): Access for all to quality health services if need be, with social health protection. Universal coverage is not by itself sufficient to ensure health for all and health equity. The roots of health inequities lie in social conditions outside the health system‟s direct control and need to be tackled through intersectorial collaboration. Universal health coverage however is the necessary foundation within the health sector on the road to health for all and health equity. This complies with the UN‟s initiative, with involvement of WHO and ILO, to set up a Social Protection Floor which includes financial risk protection and the broader aspects of income protection and social support in the event of illness. Social Security (ILO): All measures providing benefits, whether in cash or in kind, to secure protection from 

  

Lack of work-related income (or insufficient income) caused by sickness, disability, maternity, employment injury, unemployment, old age, or death of a family member; Lack of access or unaffordable access to health care; Insufficient family support, particularly for children and adult dependants; General poverty and social exclusion.

Social Health Insurance (WHO): Compulsory health insurance provided to civil servants, people in the formal employment sector, and certain other groups through programmes such as social security funds, national health insurance funds, and other systems. Premiums are often deducted directly from salaries or wages. Social Health Protection comprises protective, preventive and promotional objectives (the socalled ILO framework). Promotional measures aim to stabilise or enhance income (e.g. micro-credits); preventive measures directly seek to avert deprivation (informal and formal insurance mechanisms, and other forms of risk pooling); protective measures in the strict sense aim to provide relief from deprivation (social assistance) to the extent that promotional and preventive measures have failed to do so.

Social determinants of health (Rafaël, 2008): Social determinants of health are the economic and social conditions that shape the health of individuals, communities, and jurisdictions as a whole. Social determinants of health are the primary determinants of whether individuals stay healthy or become ill (a narrow definition of health). Social determinants of health also determine the extent to which a person possesses the physical, social, and personal resources to identify and achieve personal aspirations, satisfy needs, and cope with the environment (a broader definition of health). Social determinants of health are about the quantity and quality of a variety of resources that a society makes available to its members. Primary health Care (WHO & Unicef, 1978): Essential health care; based on practical, scientifically sound, and socially acceptable methods and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and selfdetermination. Essential medicines (WHO): Essential medicines are those that satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative costeffectiveness. Essential medicines are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford. The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations; exactly which medicines are regarded as essential remains a national responsibility. Generic medicines (US Food and Drug Administration): A generic drug is a drug which is produced and distributed without patent protection. The generic drug may still have a patent on the formulation but not on the active ingredient. A generic must contain the same active ingredients as the original formulation. Generic drugs are identical or within an acceptable bioequivalent range to the brand name counterpart with respect to pharmacokinetic and pharmacodynamic properties. By extension, therefore, generics are considered identical in dose, strength, route of administration, safety, efficacy, and intended use.

Evaluation of fos health programmes


Annex 2: Comparative table and some numbers from partner countries Indicators/ Years

Central America



El Salvador

Andean region



Southern Africa



South Africa


Gross National Income per capita, PPP (international dollars) (GNI) 2008(1)






































/ 2005= 0.587(4)







Human Development Index (HDI)(2) 2010












/ 2007= 0.863(3) / 2006= 0.856 / 2005= 0.839

Per capita total expenditure on health (international dollars) (6)
































Private expenditure on health as percentage of total expenditure on health
































Out-of-pocket expenditure as percentage of private expenditure on health (OOP)












































100 (2006) 100 (1995)

73 (2004) 56 (1996)

61 (2003) 59 (1998)

80 (2005) 84 (1995)

92 (2003) 84 (1998)

48 (2003) 44 (1997)

Maternal mortality ratio per 100,000 live births (MMR) 2005(9)









Births attended by skilled health personnel (%) (SBA) Most recent data Previous data

67 (2001) 65 (1998)

67 (2006) 55 (1996)

69 (2003) 58 (1995)


Under-5 mortality rate (probability of dying by age 5 per 1,000 live births) (U5MR) (12) 2009






























Evaluation of fos health programmes

Notes: 1.

“Gross national income per capita, PPP (current international dollars)”, World Development Indicators 2009, World Bank:


Human Development Index Trends 1980-2010, in: Human Development Indices: a statistical update, UNDP: of indicators/49806.html.


Cuba was not included in the 2010 Human Development Report. Only data for 2005, 2006 and 2007 in Human Development Report 2009, annex G „Human Development Index Trends‟, p. 167: http://


No data available for 2000, only for 2005


No data available for 1990 or later


“Per capita total expenditure on health (international dollars)”, WHO Statistical Information System (WHOSIS):


“Private expenditure on health as percentage of total expenditure on health”, WHO Statistical Information System (WHOSIS):


“Out-of-pocket expenditure as percentage of private expenditure on health”, WHO Statistical Information System (WHOSIS):


“Maternal mortality ratio (per 100,000 live births)”, WHO Statistical Information System (WHOSIS): and Maternal Mortality in 2005: estimates developed by WHO, UNICEF and UNFPA.


“Maternal Mortality in 2000”, estimates developed by WHO, UNICEF and UNFPA. http://


“Births attended by skilled health personnel (%)”, WHO Statistical Information System (WHOSIS):


“Under-5 mortality rate (probability per 1,000 that a newborn baby will die before reaching age five, if subject to current age-specific mortality rates)”, World Bank World Development Indicators: http://

Evaluation of fos health programmes


Annex 3: Some reference documents World Reports 

WHO 2008, World Health Report: Primary Health Care, Now More than Ever

WHO 2010, World Health Report: Financing for Universal Coverage (+ 55 background papers http://

ILO 2010, World Social Security 2010/2011, Providing coverage in times of Crisis and beyond

WHO 2008, Commission on Social Determinants of Health: Closing the gap in a generation, health equity through action on the social determinants of health

Recent scientific literature review on universal coverage Stuckler et al. The political economy of universal health coverage. Background paper of the global symposium on health system research and the presentation of Martin McKee dd. 18 Nov 2010, Montreux, Switzerland Recent literature on social protection


Brunori, Paolo and O‟Reilly, Marie, Social Protection for Development: a Review of Definitions, Background paper to the European Report on Development 2010, European University Institute, Florence, Italy

Stephen Devereux and Rachel Sabates-Wheeler, Transformative social protection‟, Institute of Development Studies Working Paper, October 2004. PDF/seminar2009/Transformative%20social%20protection%20Devereux%20Sabates.pdf

Joris J. A. Michielsen, Social protection in health: the need for a transformative dimension, The Lancet, June 2010

Sociale bescherming: een kwestie van sociale verandering, Wereldsolidariteit, 2010

Book Richard Wilkinson and Kate Pickett, The Spirit Level, why equality is better for everyone, 2010

Evaluation of fos health programmes

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Evaluation of fos health programmes


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