**Investing in our health workers: approaches to the scarcity and loss of health personnel in southern Africa
EQUINET briefing November 2004

Antoinette Ntuli, Health systems Trust South Africa, Co-ordinator EQUINET HRH theme network

After decades of neglect, Human Resources for Health (HRH) has in the past few years moved to centre stage of both international and regional debates. Within southern Africa health personnel continue to be scarce in services where they are most needed, are a critical bottleneck to the uptake of new resources from global funds and the region is suffering from escalating out migration of health workers.

Dealing with this impact of the migration of health personnel raises debates about effective and just strategies. Those that restrict health worker rights of movement often don’t work and punish individuals. ‘Ethical human resource’ policies and codes appear to have made little difference to practice on the ground, especially when movement is driven by pull and push factors in both sending and receiving countries. So what comprehensive measures will secure the human resources that southern Africa needs for its health services?

EQUINET is addressing this through a network of institutions from government and non government sectors in southern Africa and working with institutional hubs in Canada, Australia and the UK (given their role as countries absorbing significant numbers of the regions health workers). The network aims to collaborate on research and use the evidence to harmonise policy engagement and advocacy.

At a meeting in April this year the network of researchers developed the analytical framework to guide this work. This framework takes the policy interest of the country planners and authorities in the region as the starting point, and includes four major components:

1. Equitable human resource policies- what will encourage health workers to work in areas of greatest need? This work is looking at what positively and negatively affects the internal distribution of health personnel, including both traditional and allopathic practitioners. In Zimbabwe, Oliver Mudyarabikwa at the UZ Medical School is identifying the factors that cause a maldistribution of public sector health workers. Yoswa Dambisya of the University of the North in South Africa is following up on the distribution of pharmacists who trained at the University of the North, to understand what drives their choices of both sector and location of work. Steve Reid of the University of KwaZulu-Natal in South Africa is exploring what educational factors influence the choice of rural or urban sites of practice of health professionals.

2. Ethical Human Resource Policies- how to respond to international migration of health workers?. Given the work already taking place on codes of practice, and reasons for health workers leaving EQUINET is focusing its work on identifying “what makes health personnel stay”. If the retention factors are known then ethical policies in other countries should reinforce and not undermine these factors and should contribute resources towards their achievement. Scholastika Lipinge of the University of Namibia is exploring how health professionals perceive their conditions of service, and the extent to which this acts as a factor keeping them in the country and the public sector. In Malawi, Adamson Muula from the College of Medicine in the University of Malawi is exploring the coping mechanisms of health workers who stay in the Malawi health sector to identify possible strategies to support these mechanisms and reinforce health worker retention.

3. How are the HIV and AIDS epidemic and the resources for AIDS affecting the distribution of health personnel? The network has built links through its work on HIV and AIDS and its networks with Municipal Services Unions to understand the impact of HIV and AIDS on health workers, and to explore how new resources for treatment are being used in relation to improving (or undermining) the availability, conditions and retention factors of health workers, especially within district health systems.

4. What can we learn as a region and where do we need to act regionally? Country level evidence will be shared regionally, recognising the gain for exchange of experience, policies and interventions across countries in the region. This is also a regional issue, both in terms of the flow of health personnel across national boundaries and the need for a regional policy response to international factors. Common evidence from all countries in the region, and more detailed evidence from Swaziland, Botswana, Namibia, South Africa, Zimbabwe and Malawi will be used to build a more detailed regional picture of the distribution and flows of personnel and the factors affecting this. We will also carry out in early 2005 an analysis of the policy environment, in terms of the priorities, actors and forces in this area and the options this raises for national and regional authorities.

EQUINET and HST are aware of the significant volume of work taking place in different institutions and countries on this issue. We have a database on human resources for health on our website at www.equinetafrica.org through which we hope to share materials and information that we access and encourage people to use and contribute to it.

When the African Ministers of Health raised issues of health personnel migration at the 2004 World Health Assembly they were profiling a situation that calls for policy recognition, such as through protocols and codes, but also for wider strategies and interventions. Those strategies should as first call reinforce the health workers who stay in the system, particularly those who work at primary care and district level, and strengthen the environments that encourage health workers to do this.

* EQUINET briefings are edited by R Loewenson, EQUINET secretariat, Training and Research Support Centre. Please send feedback or queries on the issues raised in this briefing to the secretariat email admin@equinetafrica.org . Reports cited are available as a downloadable pdf file from our website at www.equinetafrica.org

3 by 5 and the momentum towards universal treatment
Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, speaks to a meeting of civil society organizations on the WHO Report on Access to Treatment for AIDS: Nairobi, Kenya, Wednesday, June 29, 2005

The report launched today, by WHO and UNAIDS, as a status update on where the world stands in the provision of treatment for AIDS is a predictably fascinating document.

There will be comments aplenty. I have five.

First, the 3 by 5 initiative seems to me to be entirely vindicated. Mind you, I can even now hear the curmudgeonly bleats of the detractors, whining that we will fall short of the target of three million in treatment by the end of this year. Tell that to the million people who are now on treatment and who would otherwise be dead. The truth is that the 3 by 5 initiative --- which, I predict, will be seen one day as one of the UN’s finest hours --- has unleashed an irreversible momentum for treatment. I see it everywhere as I travel through Africa. Governments are moving heaven and earth to keep their people alive, and nothing will stop that driving impulse. It is surely noteworthy that 3 by 5 has ushered the phrase “universal treatment” into the language of the pandemic, meaning that we’re now all fixated on getting everyone who needs treatment, into treatment, as fast as possible. It is, I readily admit, both painful and horrifying to see the numbers who are dying as they wait for treatment to be rolled out, but at least there is hope amidst the despair.

Second, it becomes irrefutably clear that treatment has been a boon to prevention. I can recall from many quarters all the caterwauling about the neglect of prevention as the world began to focus on treatment. But the detractors were wrong again. Not only do we continue to emphasize prevention and reinforce it at country level, but the provision of treatment significantly accelerates testing and counseling, one of the primary ingredients of prevention. Buried in the report, is the astonishing statistic from a study of a district in Uganda, showing a 27-fold increase in counseling and testing as a result of the introduction of treatment!

Third, the G8 certainly has its work cut out for it. What this report appears to do is to throw many of the financial estimates of resource needs for Africa into a cocked hat. WHO and UNAIDS categorically assert that we will need an additional $18 billion dollars, over present commitments, for the three years 2005-2007. We know from the recent UNAIDS estimates for 2008, that we will require $22 billion annually, minimum, from that year forward. In the face of these resource imperatives, the idea of doubling foreign aid for Africa by 2010, which would represent another $25 billion per year, is clearly inadequate, some might say paltry. The $25 billion is supposed to address all of the Millennium Development Goals; it will barely address the one goal of defeating communicable diseases. Unless the G8 can do a lot better than the present calculus, Gleneagles will be much like all the G7/G8 summits before it: a rhetorical triumph, a pragmatic illusion.

Fourth: the report has one particularly evocative diagram. It’s a world map portraying the twenty countries with the highest unmet treatment needs … twenty countries where the estimated number of people in treatment is pathetically low. Six of those countries --- South Africa, Zimbabwe, Tanzania, Nigeria, Ethiopia and India --- represent fully half of the unmet treatment needs. Five of them are in Africa. South Africa alone has the largest shortfall in the world, some 866,000 people who should at this very moment be in treatment. The country appears to have something slightly in excess of 100,000 people in treatment, but that represents only 10% to 14% of those who are desperately in need. The numbers for the other African countries, while smaller, are proportionately even more grim. This is where the international community must rally urgent support.

Fifth, the report says, without caveat, that treatment should be provided free at the point where it is given. Finally, we’re building a new consensus around the destructive nature of ‘user fees’, particularly as they prejudice the poor. User fees are a sordid relic of the old economic conditionalities: it will be excellent to see the end of them.

It was a good and illuminating report that was released today. It identifies many of the obstacles and bottlenecks, and with spirited intelligence suggests, in each case, a way around them. It’s a first-rate blueprint at this point in time.

* Click on http://www.who.int/3by5/progressreportJune2005/en/ to read the press release about the report and for a link to the full report,

A call for your input! Concerted action for health equity in east and southern Africa
Steering Committee, Regional Network for Equity in Health in east and southern Africa (EQUINET)

How can we attract health workers to stay within our public health services?

How many countries in our region meet the Abuja target of 15% of government spending on health?

What does an African debt burden of $8.6 billion a year mean for health services?

How many countries in our region include the right health in the constitution?

How can the cost of health for the poorest communities be reduced?

What does it mean to have a ‘people centred’ health system?

The EQUINET newsletter is over five years old and has in its lifetime covered a spectrum of issues affecting health equity in our region, and raised some of the questions above. In 2005 our editorials ranged from access to treatment to the outflow of resources from Africa. The spectrum of challenges to health equity are clearly wide, and involve many different people, communities, disciplines and actors. We hope that the newsletter has been informative and useful and will continue to be so. We’d greatly welcome your ideas and information on how to improve it.

In 2006 we are also asking for you to play a more active role! EQUINET will, with your support, be carrying out a regional equity analysis in 2006, to profile the issues, evidence, experiences and options for action to strengthen health equity, through a regional equity analysis. The adoption in 2005 of the SADC Health protocol gives us a policy framework for this. Within this context, we will over the course of 2006 draw together YOUR perspectives, evidence, experiences, and views on how to advance health equity at local, national and regional level.

From the work we have done in EQUINET, including the values and perspectives communicated through the last five years of this newsletter, we have identified some priority areas that we will focus on. People in the region have major health concerns relating to access to incomes, food, employment, healthy living conditions and community environments. These require action from all sectors, and not just the health sector. There is a common concern that to advance health across all sectors and all social groups, we also need to revitalize and build comprehensive, universal and integrated national health systems that address these concerns and that provide access to health care for all. While many features of health systems have been raised, there are some that have been most commonly identified as a priority for health equity that we will give more focus to in 2006.

These are
i. building people-centred health systems that organise, empower, value and entitle communities;
ii. promoting increased fair, sustainable and equitable financing for health at national, regional and global level;
iii. ensuring adequate, well-trained, equitably distributed and motivated health workers; and
iv. backing national policies with fair global policy, including just trade, reversing unfair flows of resources and having the national and regional policy flexibility to exercise policies that improve health.

What policies, programmes and obstacles exist in these areas in our region?

Which have been more successful in overcoming differences in health across social groups and ensuring access to health care for all?

What opportunities and challenges do we face in implementing these policies and programmes?

We invite you to contribute to the dialogue, learning and analysis that we will build in these areas, through your expertise and experience, positive examples and case studies, evidence and data, and photographs. Email us on admin@equinetafrica.org with any information, published papers or pictures of the work you or others are doing in these priority areas. Through the newsletter we will share this information more widely. We will also feed it into the regional equity analysis.

We also invite you to be involved in the research, student grants, training, dialogue forums, exchange visits and other areas of work that we will be carrying out with you in 2006 to inform and strengthen learning and action on health equity. Our website (www.equinetafrica.org) provides up to date information on these activities.

We look forward to working with you in 2006!

A call to keep the promise

With the World Cup football taking place in South Africa absorbing attention, its possible to miss two important meetings taking place at the same time. The first is the 36th G8 and G20 summits taking place in Canada in late June under the theme 'Recovery and New Beginning', and the second the 15th African Union Summit on 19–27 July in Kampala, Uganda, under the theme ‘Maternal, infant and child health and development in Africa’. This newsletter flags concern over these leaders keeping the promise: G8 leaders to their development and aid commitments and African leaders to the Abuja commitments on health, including for 15% of their budgets to go to health. In this issue, a 63rd World Health Assembly resolution points to the need for strengthened health systems to address the relatively slow progress in Africa towards the health MDGs. Geoffrey Njora cautions leaders on taking the advice of finance ministers’ to reverse on the commitments they made at Abuja. Médecins Sans Frontières call the G8 to account over the 'flatlining' of AIDS funding and Oxfam over the inadequate resources allocated for maternal health. African civil society through the Africa Public Health Alliance & 15% Plus Campaign are petitioning AU Heads of States on the grave concerns of African citizens to meet crucial commitments on health and social development in Kampala, in particular the 2001 Abuja pledge on health financing, while the Civil Society Forum on the African Charter on the Rights and Welfare of the Child call for the G8 and African leaders to meet their promises on funding health as we get closer to 2015. What governments deliver at these two summits is worth keeping an eye on- it affects millions of lives.

A call to the 2007 G8 Summit to support African national health plans and comprehensive health workforce strategies
African Council for Sustainable Health Development (ACOSHED), African Medical and Research Foundation (AMREF)

We are African organisations deeply committed to improving the health of the people of our continent. Yet we are deeply concerned about the lack of progress, and in some countries reversal of progress, resulting in millions of preventable deaths that continue to burden our countries each year. It is clear that as long as our health systems remain weak in many dimensions and our countries face a health workforce crisis, the current unacceptable trends will persist.

In spite of this slow progress, we remain optimistic. We have observed progress in some regions and countries, and identify with the deepening commitment to the health of many of our Government and institutions. Our Regional Economic Communities have assumed an important leadership role within the continent in catalyzing actions required to strengthen health systems and achieve health MDGs. We are convinced that the engagement of our partners locally and globally can translate into the political will, resources, and efficiency required to transform health on our continent. With so many lives at stake, our neighbors, our children, and ourselves, we must succeed.

Cognizant of the continuing intolerable burden of disease, African Union ministers of health have developed an Africa Health Strategy 2007-2015 that seeks to “provides a strategic direction to Africa’s efforts in creating better health for all.” At the core of the Africa Health Strategy is the strengthening of health systems based on carefully costed National Health Plans that incorporate the commitments made by African governments, including achieving the Millennium Development Goals and universal access to HIV/AIDS treatment, care, prevention, and support by 2010.

The chief responsibility for the success of these plans lies with our own governments. We will hold our governments accountable. We will insist – and are demanding – that they take the necessary steps to achieve the promises of good health, a foundation of healthy societies. Collectively, we will hold our governments accountable to increasing health sector investments to at least 15% of the national budget, improving the efficiency in allocation and application of these resources, and the implementation of health workforce and systems strengthening strategies capable of providing quality health care to all people. We further commit to work with our governments to identify sustainable financing strategies that can replace point-of-service payments (i.e., user fees) for essential health services and to meet their other commitments and responsibilities including as part of the human right to health.

However, the successful implementation of the National Health Plans requires support from Africa’s development partners, especially from the nations that comprise the G8. Even if African governments significantly increase their own funding for National Health Plans, these plans will have significant financing gaps. Many of the actions required for these plans to succeed will require solutions and expertise that crosses national and even continental boundaries.Building health systems must include building partnerships between health care providers and the communities that use those services. It requires donors to listen to African communities to find out what their needs and concerns are, so that services are tailored to those needs, as opposed to imposing systems that may be effective elsewhere but not in Africa. It is about using the opportunities that exist within communities to advance health care, by harnessing the knowledge, resources, and energy in the community and applying it to work together with the formal health system.
We call upon the upcoming G8 summit in Germany to recognize the Africa Health Strategy developed by our health ministers and to engage in substantive dialogue with communities, civil society, governments, regional economic communities, and the African Union.

This dialogue should be backed by firm commitments about steps that we know will be required of wealthy countries if African National Health Plans are to succeed. We call upon the G8 countries to fulfill existing pledges, including the commitment of 0.7 per cent of their own Gross National Income (GNI) to Official Development Assistance (ODA), the doubling of aid to Africa by 2010, and to adhere to the commitments of the Paris Declaration on Aid Effectiveness, including those that relate to alignment and harmonization of aid investments with country plans and leadership.

We ask that this G8 summit also make the following commitments, which are required for African National Health Plans to succeed:

Fiscal Space
1. Provide long-term, predictable funding to cover financing gaps identified in National Health Plans and plans for universal access to HIV/AIDS treatment, care, prevention, and support, and harmonize health assistance with country-driven National Health Plans.
2. Work with International Financial Institutions and developing country governments and civil society to ensure that fiscal and monetary policies are aligned with the best estimates of the fiscal space required to achieve the MDGs and other human development goals and commitments.
3. Accelerate debt cancellation and ensure that debt cancellation supplements rather than displaces aid.
4. Provide the needed financial and technical support to developing countries to design and implement sustainable financing schemes that can support the elimination of point-of-service payments (user fees) for essential health services and that are designed to enable all people, including the poor, access to quality health services.

Health Systems and Workforce
5. Work with the AU and other continental partners to identify a basic package of health systems interventions, implemented at the community and district levels, that can provide the backbone for the delivery of health service packages required to achieve the MDGs and universal access to the best attainable health care.
6. Support the development and implementation of inter-sectoral and comprehensive health workforce strategies that are integrated with a broader health sector response and public service reforms to address numbers of health workers as well as other variables such as internal distribution, skills mix, work environments, productivity, and management capacity.
7. Engage developing countries to formulate a comprehensive strategy to address health worker migration that emphasizes co-development, including by adopting policies to develop self-sustainable workforces within OECD countries and to follow ethical recruitment practices.
8. Increase support to developing countries to fully utilize TRIPS flexibilities to improve access to medicine, including by helping build capacity to utilize these flexibilities and by avoiding any restrictions to such flexibilities – or any other provisions that may be detrimental to health – in trade agreements.

Mutual Accountability
9. Support initiatives and programs that promote peer and independent mechanisms to track the progress of our governments and their partners to the commitments and declarations made at global, continental, and regional fora.
10. Through diplomatic levers, technical assistance, and other strategies, support African civil society efforts to hold our own governments accountable to their commitments and responsibilities.

Signed by 82 organisations and individuals.

The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET. Please send feedback or queries on the issues raised to the EQUINET secretariat admin@equinetafrica.org.

A commentary on the WSSD from South Africa
Mohau Pheko, Gender and Trade in Africa

International Trade and Gender Network Bulletin, Volume 2, No. 7, July 2002

There are many opportunities and challenges facing women in the upcoming World Summit on Sustainable Development. Perhaps it is worth reflecting on the whole notion of what our forefathers and foremothers meant when they conceptualised what freedom and emancipation for the African people would mean to future generations in Africa.

The most common word we heard in terms of development during the independence explosion, and the fight to decolonise and kill apartheid in South Africa, was self-determination. Where has this discourse gone? What is the difference between sustainable development and self-determination? It is critical to reflect on this in order to locate the gender perspectives in the upcoming summit.

Self-determination is the right to determine our future, to shape it, nurture it in ways that reflect our desires, goals and aspirations as African people. Self-determination opens the space for us to innovate, experiment with new ideas, to fail and from these failures reconceptualise our destiny until it fulfils the vision we have as a people. The vision and hope of preserving the sky, the land, and placing adequate food for everybody to consume not just a few, security of body, mind and soul above everything a peaceful stable environment where everybody can earn a living. Some people call this idealism and are skeptical about attaining this equilibrium.

Sustainable development is a new term. It takes on different nuances depending on who happens to be articulating this concept. How do women fit into this agenda? What sort of development are we sustaining? Is this notion of sustainable development an environment that can promote gender equality?

In reading through the Chairperson’s text towards the summit on sustainable development a number of concerns arise. I want to flag just a few issues that need to be interrogated by gender activists in general and feminists specifically.

1. The concept of sustainable development as framed in for WSSD repositions development perspectives within economic globalisation. This is extremely problematic for women because research is emerging that women have experienced globalisation more negatively than other sectors of society. There is increased feminisation of poverty. Increased flexible labour among women and more women have entered the informal sector. The privatisation of services like water, electricity, healthcare and education has increased rather than decreased women’s work as more people fall through the social safety net. Repositioning development within globalisation introduces a new form of sustainability - sustaining poverty, not eradicating it, and sustaining debt relief, not debt cancellation.

2. The Chairperson’s text reinterprets sustainable development within the neoliberal trade paradigm and the liberalised trade system. This is happening with the background of Africa experiencing the worst terms of trade. For example, industrialised countries control 68.4% of global trade with 15% of the world population.

3. Developing countries control 27.5% of global trade with a world population of 75%. Africa’s share of this is 1.6% with 11% of world population. Africa produces the bulk of raw materials in the world. Women produce sugar, corn, coffee, cotton, tea and many other products yet, the prices of these products has declined steadily in terms of the way they are traded. It is not the producers who set the prices, but the stock exchange in London and New York. There is no access for women farmers to these institutions. Women have no power to negotiate the price of these products. The returns on their products in monetary terms are not sufficient to sustain livelihoods nor bring about development in the true sense.

It is critical to note that the repositioning of development in the WSSD also creates a relocation of development issues from the United Nations to other institutions. This is an important shift for gender activists to study. The World Bank and the World Trade Organisation specifically are the two institutions that are in explicit and implicit ways taking over the development agenda as we once knew it. Under the new term of global governance the World Trade Organisation in particular is attempting to take on issues of environment, labour, and agriculture to name a few. In the meantime, the World Bank is whittling away the power of the state through its’ policy advise. It is advising countries to privatise basic social services through, for example, introducing user fees to healthcare services and education. It is advising countries to sell water, electricity and telecommunications to the private sector. Using the efficiency argument it is convincing governments that the state has no capacity to provide basic services and that this function should be taken over by the private sector. After all, the World Bank claims the private sector has a tradition of running business more efficiently than governments and governments, it says, are corrupt. This dysfunctional ideology of placing profit before people’s development, and gender equality particularly reinforces the exclusionary manner in which the state treats women.

Linked to NEPAD, the New Partnership for Africa’s Development, the new development framework offers the same market-oriented economies that are not compatible with the protection of women’s rights, nor do they promote gender equality in Africa. Framed with a neoliberal stance, this plan strengthens the principle of private property. African women have never had any entitlements under this paradigm. NEPAD, like the new development framework being put forth at the upcoming World Summit on Sustainable Development, does not address the social relations within the market in terms of women’s access to and control of resources in this space. The World Summit on Sustainable Development must be a space that allows for the self-determination of peoples and nation states and promotes sustainable development that incorporates human development and gender equality into its definition and implementation. However, as it currently stands the WSSD further pushes the Northern trade agenda and role of the International Financial Institutions while marginalizing the role of the United Nations. This process will further threaten national sovereignty and further marginalize women.

A crisis to learn and change from
Editor, EQUINET newsletter

In the past two months, drawing on a diversity of inputs, EQUINET has produced a series of information sheets on different aspects of COVID-19 in ESA countries. For 1st June we take a pause on these information briefs to send out our regular quarterly newsletter, with thanks to the newsletter team for meeting the challenges of co-production from various corners of a lockdown. Given the context, there are many articles and resources in the newsletter relating to COVID-19, but there are also those relating to other health challenges and health system developments that continue to be present, to offer learning and to demand attention in our region.

Yet we are in a crisis, not understood as an event to recover from, but in the way the Chinese word for crisis brings together two characters – “wei ji”, with wei standing for danger and ji standing for opportunity. A crisis to learn and change from.

Different dangers and risks in the COVID-19 pandemic are emerging and are the subject of an explosion of information and exchanges across countries, institutions and disciplines. The information exchanges range from stories of lived experience, responses and ideas to evidence from trials, information systems, global case tracking, reviews and analyses. Constrained by size, the newsletter only points to some of these in the region and many many more are reported daily in different platforms.
The pandemic tells us a lot about the status of our societies. COVID-19 has shown us how globalisation has opened up multiple digital channels for information to flow, how scientific collaboration can rapidly advance and share knowledge and how communities show solidarity, initiative and empathy.

It also shows where there are gaps. We talk about the poorest but the voices of the poorest communities and poorest countries are often overshadowed or absent, sometimes even silenced by the very responses to COVID-19. We see the limits in global solidarity as many African countries struggle with the diversion of critical resources to debt repayment and fail to access key diagnostics and medicines. We talk about causes, but treat each outbreak, including COVID-19, as disconnected emergencies, delinked from their deeper, sustained and common drivers in the nature of production and commercial systems, in the destruction of habitats and biodiversity and in the lack of investment in basic standards of water, sanitation, housing, clean energy and other public health inputs, drivers that converge to expose significant concentrations of people to new and old pathogens and to repeated pandemics. The 2008 Commission on the Social Determinants of Health used to say of the health sector “we cannot keep treating people to send them back to the same conditions that made them ill”. It seems we need to expand this to “we cannot keep responding to public health and climate emergencies and sending ourselves as a global community back to the same conditions that led to them.”

There are also signs of opportunities for recalibrating this pathway that is externalising and distributing pollution, climate change, precarious employment, different forms of malnutrition, pandemics, violence and other harms that threaten us as a society and as a species. The online conversations often flag responses to COVID-19 that work with and support communities and local health workers as more successful, especially when built on prior investments in distributed primary health care and socio-economic well-being. There are items in the newsletter that raise similar themes around responses to HIV, health workforce management or gender based violence.

But recalibration also needs to take place at global level. The recent World Health Assembly (WHA) resolution on COVID-19 (included in the newsletter) refers to vaccines as a global public good (implying free from intellectual property protection). There is also a link to a call from leaderships from across all regions that COVID-19 vaccines, diagnostics, tests and treatments be provided free of charge to everyone, everywhere. At the opening of the WHA, the UN Secretary General Antonio Guterres stated that “the recovery from the COVID-19 crisis must lead to more equal, inclusive and sustainable economies and societies” , as “an opportunity to address the climate crisis and inequality of all kinds”… and “to rebuild differently and better”.

The pandemic has provoked a sense that it cannot be ‘business as usual’ . For example, the Africa Group, Zambia and other country inputs to the WHA, and an ECSA HC and EQUINET brief included in this issue, raise some immediate, practical issues, including debt relief or cancellation for African countries to invest in the response and rebuild, and the removal of barriers to innovation and technology transfer for local manufacturing of diagnostics, medicines, vaccines for COVID-19 in Africa. How such issues are now treated in global forums, such as the forthcoming World Trade Organisation Ministerial and beyond, and how far our international, national and local responses reflect ‘more equal, inclusive and sustainable economies and societies’ will signal how far and for whom this crisis has been an opportunity for change, or a continuity of danger.

A few words on changes in the newsletter
Editor, EQUINET newsletter

From July 2019 the EQUINET newsletter will be coming out quarterly in March, June, September and December of every year. The next issue will thus be in September 2019. After discussion in the EQUINET steering committee we will try where feasible to have a stronger thematic focus on issues, while still keeping a wide range of coverage of resources, announcements and updates and publications. As a reminder we are keen to share information on and about the region and invite you to share news, information, papers, reports, briefs, announcements and resources of different types and are happy to receive editorials from or on the region. Please submit by visiting the newsletter on the EQUINET site and selecting "submit news" on the online menu. We are also keen to get your feedback on how to improve the newsletter as a resource for you so please do submit your feedback!

A focus on parliamentary roles in health in the region
Editor, EQUINET newsletter

In 2008 parliamentarians from Parliamentary Committees on Health in East and Southern Africa committed to raising the profile of health in all parliaments in the region, to strengthen their leadership, roles, capacities in and evidence for promoting, monitoring and advancing equity in health and health care. In this issue we have given attention to the role and work of African parliaments in health, both in the editorial and in various recently published items. Parliaments play a critical role in health, promoting public information and dialogue, scrutinising and reviewing laws, reviewing budget proposals and overseeing the implementation of policy and the functioning of the executive. There are numerous documents on the EQUINET site that report this parliamentary work in health since 2008, including on raising accountability on the Abuja commitment on domestic financing for health. This issue gives a glimpse into the more recent work and debates on health underway in African parliaments.

A framework convention on global health: Good for health equity?
Leslie London, University of Cape Town Department of Family and Public Health

For the health sector, finding new ways of thinking about strategies to address health inequities is critical if achievement of the Millennium Development Goals is to be remotely possible. Over the past few years, the notion that a Framework Convention on Global Health could help to address some of the most fundamental inequities in health at global level, has been gaining ground. First proposed by Larry Gostin, a leading scholar in the field of health and human rights in 2007, the idea that a new model of global health governance could succeed where ethical exhortations and/or appeals to international legal norms have failed, is very attractive. Indeed, it is not only in health that increasing attention is being turned to these 'Framework Conventions'. The Internet Governance Project (IGP), an alliance of academics that focuses on Internet policy and how information and communication technology affects the interests of civil society, also proposed in 2004 the idea of a Framework Convention as an institutional option for internet governance globally.

Is a Framework Convention on Global Health the missing spark in our efforts to address the yawning and seemingly growing health inequalities around the world? Is it possible that such a Framework Convention will provide answers hitherto lacking in the debates and strategies to strengthen equitable people-oriented health systems? To do so, it is first necessary to understand what is meant by a Framework Convention.

To date, there are approximately four existing framework conventions, two better known conventions under the UN machinery, namely, the UN Framework Convention on Climate Change and the WHO Framework Convention on Tobacco Control, and a convention on the Protection of the Ozone Layer, as well as a Council of Europe Framework Convention for the Protection of National Minorities. A framework convention provides a mechanism for international consensus that avoids focus on details that may be contentious and contested and which may bog down negotiations. It rather establishes principles and norms for international action, setting up a procedure for later negotiation of more detailed arrangements. This was evident in the early agreements needed to set up the Global Convention on Climate Change, which is now overseen by the Conference of States Parties to the convention, with subsequent rounds to establish targets globally.

Gostin argued in 2008 that a Framework Convention on Global Health could significantly improve global health governance and would, amongst other goals, “...commit States to a set of targets, both economic and logistic, ...set achievable goals for global health spending as a proportion of Gross National Product,...build sustainable health systems; and create incentives for scientific innovation for affordable vaccines and essential medicines.” However, central to the purported benefits of the Framework Convention is the notion that “governments should care about serious health threats outside their borders” in that such threats pose direct health, economic and security risks.

Is this likely to offer us more leverage than other forms of policy engagement, particularly those using existing international human rights mechanisms related to the right to health, such as, for example, holding governments accountable for core obligations regarding the right to health? The experience in relation to other Framework Agreements is perhaps salutary. Firstly, negotiations to provide teeth to the Framework Convention on Climate Change through the Kyoto protocol remain locked in dispute, despite the agreement on the basic principles in the Framework Convention. Indeed, the huge quantum of effort invested in lobbying, advocacy, research and policy work since adoption of the Convention to support stricter controls of greenhouse gas emissions has remarkably little to show for the years of investment. Secondly, the ability to strike a deal within the UN system relies on careful diplomacy usually guided by the lowest common denominator acceptable to a wide range of national players and networks, usually dominated by rich and powerful nations. The likelihood of the outcome of such a set of circumstances generating a Framework Convention that fundamentally challenges global power relations therefore seems low. Thirdly, whereas the Climate Change and Tobacco Control Framework Conventions challenged interests that were fundamentally corporate-driven, a Framework Convention on Global Health would be essentially directed at nation states. Such states may either be those actors who need to be convinced that their own interests lie in improving the health of populations outside their border, or states whose weak economies and subservient trade relationships undermine the extent of their sovereignty and ability to regulate independently to realise the right to health of their own peoples. In the latter case, the value of such a Framework Convention, which is likely to be replete with general provisions and non-binding targets, appears singularly weak.

However, the most important consideration is really the extent to which a Framework Convention on Global Health is able to strengthen opportunities for civil society engagement and building agency on the part of those most adversely affected by global health inequalities. Inasmuch as Gostin suggests that a Framework Convention on Global Health “would stimulate creative public/private partnerships and actively engage civil society stakeholders,” it is the extent to which such engagement offers meaningful mechanisms for preferentially strengthening the collective agency of the most marginalised groups, within and between countries that will be the test of whether the Framework Convention on Global Health really promotes equity and the right to health, or whether, like much other international policy-making, it proves a nice-sounding but ineffectual sump into which health equity activists invest endless amounts of energy, with not much to show for it.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit the EQUINET website- www.equinetafrica.org.