The poorest countries in the world have been unable to reach agreement at the World Trade Organisation (WTO) on relief from global rules that would allow access to much needed medicines for their citizens. The 16 October 2015 meeting to resolve the impasse has been suspended indefinitely according to reports by IP-Watch in Geneva.
At the forefront of resistance to this application from least developed countries (LDCs) were the United States, Canada and Australia, in positions raised in June and again on 16 October. The LDCs have a two-fold demand that amounts to a request for a waiver from the application of WTO rules on intellectual property (IP) rights, such as patents (which protect owners of new medicines), data and marketing rights. Firstly, they have requested an extension of the 2013 waiver related to pharmaceutical products, currently expiring on 1 January 2016. Secondly, they have petitioned through Uganda, as LDC representative, for a general exemption from applying the WTO intellectual property rights agreement (TRIPS), granted until 2021. Their position is that it ought to be granted for as long as countries remain designated as least developed according to the United Nations. Most LDCs are in Africa.
Over 140 non-governmental organisations have come out in support of the LDC petition. Médecins Sans Frontières accused the US, Australia and Canada of seeking to worsen access to medicines in LDCs by weakening the exceptions granted to them.
Some reports imply that LDCs were ‘collateral damage’ for other IP interests for the US. The US Trade Representative failed to reach the high standards of protection sought in the mega-regional trade and regulatory agreement called the Trans-Pacific Partnership (TPP). Commercial US stakeholders were reported in an October 2015 paper by Knowledge Ecology International (KEI) to be upset with the concessions made in this flagship trade deal, with an informed but unnamed source stating, "the TPP did not deliver as expected on IP [Intellectual Property] and so we are under a lot of pressure not to give in more on IP."
In contrast, the LDCs’ proposals were supported by developing countries, including Cambodia, Cuba, Brazil, China, Uruguay and by the Africa Group. Norway and the European Commission also supported the LDCs request, as did the World Health Organization (WHO), the United Nations Development Programme and UNAIDS.
The costly nature of pharmaceutical drug production and the complex rules on production for export to countries with public health needs requires the certainty of a permanent waiver. According to James Love of KEI, "A permanent waiver of drug patent obligations is needed. No country will amend its patent laws if the waiver is limited in time, like the previous extensions...”
The public health basis for the LDC application is also evident. In a statement in June 2015, Uganda’s representative put the case to WTO members that 63% of people living with HIV in LDC countries still had no access to appropriate treatments. The United Nations Office of the High Representative for the Least Developed Countries, Landlocked Developing Countries and Small Island Developing States in its 2014 report indicated that most LDCs had not yet met the Millennium Development Goals on health, stating that LDCs “also need financial and technological support to derive maximum development benefits from the waivers granted under the WTO TRIPS agreement.”
LDCs, as the poorest countries in the world, serve as some measure of the level of civilisation of the global economic order. These countries are in effect asked to repeatedly expend scarce domestic resources and diplomatic capital supplicating rich countries at the WTO for exemptions from international rules that clearly do not take their interests into account. It is refreshing that the WHO is taking the side of the LDCs and access to medicines in this instance as the position has been less clear in the past. For example, Third World Network raised in 2010 that the WHO initiatives on “counterfeit” drugs threatened medicines access by conflating legitimately produced generic drugs with drugs that were illegally produced or traded, given that the term ‘counterfeit’ is used to denote trademark infringements in intellectual property rules.
The LDCs request for a waiver signals that the access to medicines activism that secured the 2001 WTO Doha Declaration on Public Health was just the start of a battle against vested interests pursuing profits at the expense of human life. The 2001 Declaration was in fact a statement of legal rights that all countries enjoyed already, but over which poor countries had to ensure legal certainty at global level as they were under threat. For example, the US Special 301 list designated countries deemed to violate intellectual property rights, as unilaterally imposed sanctions with negative economic and reputational effects. Given that the WTO disciplines unilateral action by states that affects multilateral trade, the US undertook to not use Special 301 in violation of the WTO, according to Chakravarthi Raghavan in 2000. However the US repeatedly breached this undertaking, such as in its placement of Thailand on the 2007 watch list for issuing compulsory licenses for patented pharmaceutical products.
The industry has significant lobbying power and the preponderantly US-based branded products pharmaceutical industry is one of the most profitable in the world. According to a 2014 BBC report, the sector made a 42% margin of profit in 2013 in the US, compared to about 29% for the banks. Many US pharmaceutical companies held tens of billions of dollars offshore to avoid US taxes, according to Bloomberg’s Richard Rubin on 4 March 2014.The cost of such concentrated corporate power is evident in the fact that US medicines prices are almost twice that compared to other developed countries. US policies are rationalised with ideas of free trade, competition and the full functioning of markets. The super-profits being made by branded pharmaceutical companies should lead even free trade proponents to be concerned about the enormous rents they extract from the market. The suspension of discussions on the LDC waiver on Friday coincided with the US and developed countries stating they would also not make binding commitments for special treatment of LDCs on other issues at the next WTO Ministerial meeting scheduled for 15 to 18 December in Nairobi.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
Editorial
Challenges of high costs, out of pocket spending, regulation and quality affect the contribution the for-profit private sector makes in healthcare, according to presenters in a session on ‘Private sector and Universal Health Coverage: Examining evidence and deconstructing rhetoric’ hosted by Oxfam and Dr. Anuj Kapilashrami, of the Global Public Health Unit, University of Edinburgh, in the July 2015 International Conference on Public Policy.
The session aimed to look at new and existing evidence on the role of the private for-profit sector in health, and to critically evaluate this in the context of achieving UHC in low- and middle-income countries. The five papers on experiences in Asia and Africa presented at the session looked at a wide range of private sector actors in health care delivery but raised a number of common themes and challenges.
One common feature was high levels of out-of-pocket spending (OOPS), or cash payments by households for services, medicines and other charges. This was found for example where state insurers pay for services from private providers. Asha Kilaru presented study findings that people covered by state insurance schemes in Karnataka, India still had out of pocket spending for services, even for schemes where all costs should be covered. The study found that 93% of those insured by at least one government scheme sought care from a private hospital, and that only 8% reported receiving completely free care. Even where healthcare was provided for free, additional costs, such as multiple hospital referrals for different tests and treatment, meant OOPS still occurred. One of the respondents’ interviewed in the study stated:
‘Only the operation [C-section] was free. At the government hospital, a C-section would be only Rs3-4000, but we went to a private hospital since we had insurance and wound up spending so much. It seems like government are agents that send us to a private hospital. In this yojana [Yeshasvini insurance scheme] the government spends and we also spend’.
As the respondent indicated, high costs of care can be a burden to both households and the state. While this particular scheme (Yeshasvini) claimed to be self-funded, Kilaru found that it received Rs. 40 crore (equivalent to more than US$6 million) as a government grant in 2012-13 and Rs. 45 (or almost US$7 million) crore in the 2013-14 budget.
Jane Doherty, from University of the Witwatersrand, South Africa presented evidence in the session on the for-profit private healthcare sector in east and southern Africa. She noted that out of sixteen countries, ‘no country places a ceiling on the prices that its private hospitals may charge’ (although there may be some limitations to reimbursement payments made by insurers in two of the countries). Her study found ‘little control of the fees charged by health professionals or limits placed on their total incomes, except in Kenya’.
These challenges in controlling out of pocket spending and the overall costs of private healthcare present significant obstacles to achieving universal health coverage, and especially to ensuring access to healthcare for the poorest. Another recurring barrier to equitable access that was highlighted is the location of private services. Indranil Mukhopadhyay of the Public Health Foundation of India reported from a mapping of India’s private healthcare provision that urban, metropolitan areas have the majority of private hospitals. In rural areas, where more poor people live, the private sector is largely comprised of individual practitioners. Moreover, almost half of India’s private hospitals were located in cities with a population of more than 5 million. Mumbai alone has 16% of all India’s private hospitals. The same bias towards urban provision was reported by Jane Doherty in east and southern Africa.
Iornumbe Usar, of Queen Margeret University, Edinburgh, investigated perceptions of shops selling medicines in Nigeria. His paper for the session highlighted major concerns around ‘pervasive regulatory infringements’ by these shops, especially in selling medicines beyond the scope of their licenses, as well as the lack of training of their staff. The paper raised the challenges of regulating medicine vendors in Nigeria in order to improve their quality, highlighting how this has been constrained by inadequate funding, weak institutional capacity, the often-remote location of the shops, and conflicts between the different agencies responsible for regulation.
The same problem of poor regulation was reported by Jane Doherty in relation to for-profit private providers in east and southern Africa. Both an absence of regulation, and poor enforcement of regulation where it exists, were found to contribute to distortions in the wider health system, such as in treatment decisions or in the brain drain of health personnel from the public sector. She observed that ‘there is little monitoring by governments of quality and health outcomes, or attention to how the private health sector supports national health objectives’. She observed that there is also little regulation to guard against anti-competitive behaviour, such as when insurers, providers and pharmacies are all owned by the same company. She flagged in her presentation the challenges to regulation in the region, including patchy regulatory frameworks, the high cost of introducing new regulation, limited available information on the private sector, and the resistance of key stakeholders to regulation, or their “capture” of regulation to safeguard their own interests. In South Africa, for example, attempts to regulate dispensing fees for pharmacists have been resisted heavily.
As Doherty concluded, these ‘legislative gaps and enforcement problems, together with the fact that prices are not contained in any meaningful way, either through price controls or active reimbursement mechanisms, mean that for-profit private care in the region is likely to become increasingly unaffordable for any but the wealthiest’. Yet, Doherty also concluded that the for-profit private sector is growing, so that these impacts need to be addressed.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information see the full papers from the meeting at http://tinyurl.com/psma5ov; Oxfam’s 2009 paper “Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries,” www.oxfam.org/en/research/blind-optimism and the EQUINET discussion papers 87 http://tinyurl.com/3gky5k2 and 99 http://tinyurl.com/ou2dh4n on the growth and legislation of the private health sector in east and southern Africa. Oxfam will be hosting additional discussion on its Global Health Check blog on the issues raised in the coming months.
At Rio+20 in 2012, country leaderships promised to strive for a world that is just, equitable and inclusive, and committed to work together to promote sustained and inclusive economic growth, social development and environmental protection for the benefit of all. They set a mandate to develop a set of sustainable development goals (SDGs) for consideration by the UN General Assembly at its 68th session in 2013. These SDGs should be coherent with and integrated into the UN development agenda beyond 2015.
The 17 Sustainable Development Goals are:
• Goal 1 End poverty in all its forms everywhere
• Goal 2 End hunger, achieve food security and improved nutrition and promote sustainable agriculture
• Goal 3 Ensure healthy lives and promote well-being for all at all ages
• Goal 4 Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all
• Goal 5 Achieve gender equality and empower all women and girls
• Goal 6 Ensure availability and sustainable management of water and sanitation for all
• Goal 7 Ensure access to affordable, reliable, sustainable and modern energy for all
• Goal 8 Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all
• Goal 9 Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation
• Goal 10 Reduce inequality within and among countries
• Goal 11 Make cities and human settlements inclusive, safe, resilient and sustainable
• Goal 12 Ensure sustainable consumption and production patterns
• Goal 13 Take urgent action to combat climate change and its impacts
• Goal 14 Conserve and sustainably use the oceans, seas and marine resources for sustainable development
• Goal 15 Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss
• Goal 16 Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels
• Goal 17 Strengthen the means of implementation and revitalize the global partnership for sustainable development
They are simple statements with great intent. They respond to a harsh reality of spectacular progress and spectacular inequality.
How widely are these goals known by those most affected by the situations they seek to address? The SDGs add to many other current global commitments: the Universal Declaration of Human Rights, the Programme of Action for the Least Developed Countries for the Decade 2011-2020 (the Istanbul Programme of Action), the political declaration on Africa’s development needs, the Doha Declaration on Financing for Development, the United Nations Framework Convention on Climate Change and the Millennium Development Goals, amongst others. Over the years these statements of international cooperation have built a growing vocabulary of aspiration. No doubt the 17 goal statements will also attract many words and terms, targets and data, discussions, interpretations and explanations.
If words and targets begin to mystify intent and to obscure reality, particularly for those most directly affected, we may need other tools. Cartoonists from sixteen countries globally in the Cartooning for Peace network have, for example, portrayed their lens on the 17 SDGs in a book published in June 2015, and found at http://fr.calameo.com/read/002524839b003362c3438 . They present images of the goals for sustainable development as “work that is still precarious”. Visit the link and you will see some that are aspirational, and many that are picture codes, communicating without a word the contradictions that exist in the face of the SDGs.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For information on the SDGs see https://sustainabledevelopment.un.org/focussdgs.html . Cartooning for Peace is an initiative born in 2006 that now brings together 125 cartoonists globally. For more information see http://www.cartooningforpeace.org/?lang=en.
In a 2015 report on the Representation and Participation of Key Populations on Country Coordinating Mechanisms (CCMs) in Swaziland, Lesotho, South Africa, Botswana, Zimbabwe and Zambia, (http://tinyurl.com/obuudjv) Aidspan noted that key population representatives (KPRs) “have often in the past been seen as somewhat token CCM members” and that “their ability to contribute, and the quality of their participation in the processes of these bodies [is] unclear”.
We believe indeed that building the capacity of KPRs to contribute their indispensable share to the governance of Global Fund-supported programs is a central condition for achieving the vision of ending HIV, tuberculosis and malaria as public health threats by 2030.
Women and girls, men who have sex with men, people who inject drugs, transgender people, sex workers, prisoners, refugees and migrants, people living with HIV, adolescents and young people, orphans and vulnerable children… Giving those groups a voice by opening the doors of CCMs to their representatives is a major step in the right direction. But to unleash their potential to be heard and become a trusted force for change, they need support to build essential skills and competencies.
The Global Fund and its success against AIDS, TB and malaria owe a lot to the extraordinary contributions of civil society representatives worldwide. With the new rules of engagement in the Global Fund governance systems, activists with high levels of formal education are now making room for a new generation of civil society representatives, whose level of preparedness varies considerably, as highlighted in the Aidspan report. These new arrivals must absorb a tremendous volume of information and data that is made available, at an increasing speed, about the Fund, its partners and health-related issues.
A variety of toolkits, manuals, guidelines, tutorials and training workshops has already been produced around Global Fund policies and processes. But these good initiatives are scattered, developed separately, written primarily in English, sometimes in French and Spanish, and generally not designed with a focus on the specific needs of less-educated or extremely marginalized groups. Let’s face it: how many KPRs have been efficiently trained through sporadic two or three-day workshops? How many have excelled basing their knowledge and understanding of program implementation through Global Fund orientation sessions? Self-education and workshops cannot by themselves be substitutes for a better structured and adapted training curriculum for KPRs.
In a 2014 study on the engagement in the funding model of key populations from 11 countries (at http://tinyurl.com/qxwuzd7), the Global Fund Board’s communities delegation observed: “In cases where community representatives had received capacity building over the longer term, KPs were empowered to engage, raise concerns, challenge existing power structures and decision making processes and influence final outcomes. In cases where capacity building was lacking, KP representatives were engaged only in a tokenistic way and faced stigma during the process, labelled as incompetent and seemingly reinforcing negative preconceptions about key affected communities”.
KPRs have access to extended networks and an intimate knowledge of the needs and priorities of some of the most hard-to-reach communities. They bring a unique expertise that other CCM members, be they doctors, academics, government representatives or other high-level officials don’t have. But to make the most of it, to enter CCM discussions confidently and influence public health decision-making in a credible way, they must learn to speak the language spoken at CCM meetings and in public health circles. They need to master the technical complexities of Global Fund procedures and be fully at ease with using the language of decision makers to represent the interests of their groups. This needs long-term capacity building.
We see four main components for such a curriculum, which could be conceived as a training-of-trainers program to reach out to members of marginalized communities in their own languages. Program management, from design to evaluation, is an area where KPRs and communities can bring true innovation, especially in monitoring and qualitative program evaluation. Good governance of their own community organizations is another essential component of their credibility. Advocacy is a third area that requires special skills, especially in the context of a complex international multistakeholder partnership. To develop and implement effective strategies that attract attention to their cause or to play constructive watchdog functions, KPRs must be able to conduct needs assessments and evaluations of service delivery systems, notably public ones.
Underlying those three areas, the importance of information literacy cannot be overstated. To keep learning, KPRs must develop essential skills to navigate their way through a vast and expanding array of information resources (websites, social media channels, mailing lists, databases, etc.). This is critical to building their networks, understanding where their priorities fit in the bigger picture, and keeping a strategic watch over the most relevant developments in their field of interest while avoiding information overload.
This may seem like a formidable challenge. The good news is that today’s internet offers cheap and reliable channels to deliver certified courses in multiple languages at no cost to participants, to connect to a global and diverse audience, reaching out to distant individuals at their own pace and offering a space for networking with their peers around the world. Although face to face training will remain indispensable to provide more targeted support, open online courses can offer an extraordinary channel to deliver training to very large groups, to monitor its results and to address concerns over fake, ineffective and costly training. The KPRs’ skills and knowledge gaps, as well as the technology to deliver a program that addresses them, can quite easily be figured out. For the Global Fund and its partners, it is mostly a matter of making this a priority and investing in the design and development of a curriculum for maximum impact, in a coordinated way.
Community leaders and KPRs represent the untapped ‘human resources’ of current and future public health efforts. By pooling together different capacity building initiatives and internet possibilities, public health training for KPRs is at our grasp. Let’s support their capacity to be heard, if we really hope to win the fight against disease.
A longer version of this post was published in Aidspan’s Global Fund Observer newsletter Issue 266 28 May 2015 http://tinyurl.com/pd7bhz3 and in R. Bourgoing’s Aid Transparency blog at http://tinyurl.com/owr4qb2 and it has been used with the authors permission. Hélène Rossert is a US-based Global Fund advocate and former Vice Chair of the Global Fund Board. Robert Bourgoing is an aid transparency advocate and trainer, and former Manager of Global Fund Online Communications.
The way a healthcare system is designed, financed and performs has consequences for inequality. User fees, for example, prevent people from accessing healthcare and push over 100 million people each year into poverty. The 2001 Abuja Declaration committing at least 15% of their budgets to health was signed by African governments with a goal that every member of society have access to healthcare when they need it, without risk of financial ruin. Thirteen years later, less than ten countries in the Africa region have increased their national or provincial budget to at least 15%, as stipulated in the declaration. Less than 10% of African people are reported to be protected from financial risks associated with using health care, even though health care plays an important role in the still unfinished business of achieving the Millennium Development Goals. Unless health budgets are adequate to meet priority health needs, inequalities in access to health services will remain high and these goals will not be achieved for all.
The concept of universal health coverage (UHC) offers an opportunity to address these challenges. UHC is seen as a means to deliver on the principle of Health for All that was set out more than 30 years ago in the Alma-Ata declaration. In 2005, there were calls to revitalize primary health care (PHC). The principle of universal coverage was reaffirmed in the 2008 world health report on PHC and various subsequent World Health Assembly resolutions. In May 2012 in the World Health Assembly, WHO Director General Margaret Chan’s asserted that UHC is “the single most powerful concept that public health has to offer” to reduce the financial impoverishment caused by people spending on health care and to increase access to key health services. In December of that year, the United Nations General Assembly adopted a resolution on UHC, urging governments to move towards providing all people with access to affordable, quality health-care services, given the important role that health care plays in achieving international development goals.
Achieving these goals is, however, first and foremost a political process. It involves a political negotiation between different interest groups in society over what services are provided, how services are allocated and who should fund them.
On this understanding civil society organisations have come together to form a network - the African Platform for Universal Health Coverage (AFP- UHC) - to remind African leaders of their duty to shape health policies so that everyone can enjoy their right to health. Civil society organisations have already contributed to increased community roles in decision-making in health; have acted as watchdogs of service delivery and demanded accountability on policy commitments. Civil society has represented and defended the rights of poor and vulnerable people. In doing so they are vital for building more equitable health systems. The organisations involved bring existing civil society organisations together in national coalitions, engaging the public and governments through a variety of tools, including stakeholder engagement, policy briefs, strategic meetings and press briefings. Member organisations have held radio talk shows in Ethiopia, workshops in Egypt, public marches in Ghana, meetings targeted at policy makers in Kenya, campaigns challenging inequalities and user fees in Malawi, television programmes and lobbying of the Prime Minister in Mali, a public march in Kampala and a UHC Day commemoration in Zimbabwe.
The AFP-UHC thus brings civil society organisations together to contribute to, support and implement policies promoting UHC, on the basis that health is a human right. The organisations seek to bring UHC to the political agenda of African countries. The network thus seeks to support national non state organisations to advocate that UHC be achieved through people-centered, right based approaches, in a manner that guarantees people’s right to health services. The network measures its value by the extent to which it is able advocate for and achieve an increase in public sector health budgets and in the political commitment towards health. These changes are seen as key to improving the lives and wellbeing of the most vulnerable people in the society, whose rights to health are usually infringed though their sustained neglect by governments.
The network expects to see governments abolish user fees, raise and spend budgets for health more equitably, increase public sector health financing, ensure that UHC is included in global and national goals post 2015 and that governments set targets and deliver on those goals.
The author is the Zimbabwe coordinator of the African Platform for Universal Health Coverage (AFP- UHC), a network of African non government organisations with a long experience working together to demand a set of measures from governments to move towards Universal Health Coverage. Further information on the network can be found at http://www.africaforuhc.org/. Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
We remember you in Maputo, in the 1980s, from that time you spent as a political refugee in Mozambique. Often our paths crossed on Julius Nyerere Avenue and we would greet each other with the casual friendliness of neighbours. Often I imagined the fears that you must have felt, as a person persecuted by the apartheid regime. I imagined the nightmares you must have experienced at night when you thought of the ambushes plotted against you and against your comrades in the struggle. But I don’t remember ever seeing you with a bodyguard. In fact it was we Mozambicans who acted as your bodyguards. For years we gave you more than a refuge. We offered you a house and we gave you security at the cost of our security. You cannot possibly have forgotten this generosity.
We haven’t forgotten it. Perhaps more than any other neighboring country, Mozambique paid a high price for the support we gave to the liberation of South Africa. The fragile Mozambican economy was wrecked. Our territory was invaded and bombed. Mozambicans died in defence of their brothers on the other side of the border. For us, Mr President, there was no border, there was no nationality. We were all brothers in the same cause, and when apartheid fell, our festivities were the same, on either side of the border.
For centuries Mozambican migrants, miners and peasants, worked in neighbouring South Africa under conditions that were not far short of slavery. These workers helped build the South African economy. There is no wealth in your country that does not carry the contribution of those who today are coming under attack.
For all these reasons, it is not possible to imagine what is going on in your country. It is not possible to imagine that these same South African brothers have chosen us as a target for hatred and persecution. It is not possible that Mozambicans are persecuted in the streets of South Africa with the same cruelty that the apartheid police persecuted freedom fighters, inside and outside the country. The nightmare we are living is more serious than that visited upon you when you were politically persecuted. For you were the victim of a choice, of an ideal that you had embraced. But those who are persecuted in your country today are guilty merely of having a different nationality. Their only crime is that they are Mozambicans. Their only offence is that they are not South Africans.
Mr President, the xenophobia expressed today in South Africa is not merely a barbaric and cowardly attack against “the others”. It is also aggression against South Africa itself. It is an attack against the “Rainbow Nation” which South Africans proudly proclaimed a decade or more ago. Some South Africans are staining the name of their motherland. They are attacking the feelings of gratitude and solidarity between nations and peoples. It is sad that your country today is in the news across the world for such inhuman reasons.
Certainly measures are being taken. But they are proving inadequate, and above all they have come late. The rulers of South Africa can argue everything except that they were taken by surprise. History was allowed to repeat itself. Voices were heard spreading hatred with impunity. That is why we are joining our indignation to that of our fellow Mozambicans and urging you: put an immediate end to this situation, which is a fire that can spread across the entire region, with feelings of revenge being created beyond South Africa’s borders. Tough, immediate and total measures are needed which may include the mobilization of the armed forces. For, at the end of the day, it is South Africa itself which is under attack.
Mr President, you know, better than we do, that police actions can contain this crime but, in the current context, other preventive measures must be taken. So that these criminal events are never again repeated.
For this, it is necessary to take measures on another scale, measures that work over the long term. Measures of civic education, and of exalting the recent past in which we were so close, are urgently needed. It is necessary to recreate the feelings of solidarity between our peoples and to rescue the memory of a time of shared struggles. As artists, as makers of culture and of social values, we are available so that, together with South African artists, we can face this new challenge, in unity with the countless expressions of revulsion born within South African society. We can still transform this pain and this shame into something which expresses the nobility and dignity of our peoples and our nations. As artists and writers, we want to declare our willingness to support a spirit of neighbourliness which is born, not from geography, but from a kinship of our common soul and shared history.
This editorial is reproduced from Brittle Paper and is an open letter addressed to President Zuma, written by award-winning Mozambican novelist Mia Couto.
The attacks against foreigners in KwaZulu Natal, Johannesburg and other parts of our country are shameful. If we close our eyes, or turn away, we bring shame on ourselves. The attacks present South Africans to the world as a barbaric, violent and murderous nation. We are not. Our march will show another South Africa to ourselves and the world. We are the country of Nelson Mandela, Oliver Tambo and all people who gave their lives for freedom. In our freedom struggle we had vital help from our sisters, brothers and comrades throughout Africa and the World. In 1994 we voted for peace, not war. We have the fairest Constitution in the world - that protects ALL who live here.
We link arms with our sisters and brothers from other countries who live with us here in South Africa. We are proud our extended family transcends national borders, languages, cultures and religions - because we need each other, because we are one! We will march to celebrate our solidarity with everyone from other countries living amongst us - particularly the poor, people seeking refuge, and political and economic migrants who have come to our country to try and survive. We will march to show our deep concern and solidarity to all poor communities where chronic unemployment, inadequate housing, rising crime and bad schools have become the norm. We will march to appeal to people who live in poor communities not to resort to violence. Do not to be distracted by blaming people from other countries who are also poor. The poor of the world must unite!
We will march to expose employers who play one group of workers off against another in order to maximize their profit. They are part of the problem right across our Africa. Workers, do not to be fooled: recognize that it is only by uniting workers and communities within and across national borders that a real challenge to poverty, pay and conditions can be fought and won.
International solidarity helped end apartheid. Likewise, we must build unity within and across our national boundaries. Our struggle against all forms of oppression continues. Authorities must listen to our pleas, and improve and protect our communities and respond positively.
We are all human beings. We must be treat one another with respect, and live our lives in dignity. It is time for all good people to come together. We are the majority. We reject division, and it is time for real change! Don't turn away. Don't make excuses. Join us! Come from your school, workplace, union, your church, your university, your business, your community. Take three hours to march for life, dignity and equality. Together, let us show the world and our countrymen and women that another South Africa exists - where solidarity defeats xenophobia!
This call was made by South Africans for a march on 23 April that involved about 30,000 people through Johannesburg, to demand an end to a recent wave of xenophobic attacks.
One question being asked in relation to the recently adopted Sustainable Development Goals (SDGs) is how they relate to human rights based approaches. In the health sector for instance, SDG 3 aims to ensure healthy lives and the promotion of well-being for all ages. This includes a target of reducing the global ratio of women dying in childbirth to less than 70 in every 100 000 live births. While maternal mortality has fallen by almost 50 per cent since 1990, fourteen times more mothers do not survive childbirth in developing countries than in developed countries.
By 2014, Uganda’s maternal mortality rate was amongst the highest, with 360 mothers dying in every 100 000 live births, according to Uganda’s 2014/5 Annual Health Sector Performance Report. The country has failed by a large margin to realise the target set for maternal mortality in the Millennium Development Goals (MDGS), and what should be a healthy reproductive event continues to claim women’s lives in the country. The 2014 figures indicate that 6 000 Ugandan mothers die in childbirth annually, which is an average of sixteen daily, or one death every 90 minutes.
There have been a number of promising policy statements and interventions suggested by government to address this unacceptable level of mortality. Bottlenecks in the financing, delivery and uptake of maternal health services have however led to a shortfall in the delivery of these interventions. We view this situation as a complete failure by the state to deliver its constitutionally mandated obligations under Article 33 of the Constitution to provide the facilities and opportunities needed for women to realise their full potential; and to protect women and their rights, including their reproductive rights and functions in society.
The shortfall in maternal health services has been a focus of civil society advocacy in Uganda for some time. Civil society has consistently argued for the state to resolve the poor conditions in which mothers have to give birth in Uganda. It has used a human rights based approach in this, framing the demands in the language of legal rights and constitutional obligations. There is evidence of some success in this. A group of civil society organisations, led by the Center for Health, Human Rights and Development (CEHURD), acting together with two aggrieved families brought before the courts the deaths of two mothers. This was led as a constitutional challenge, arguing that the deaths occurred as a result of failures in the health system to provide basic commodities for safe deliveries. In this case, the Supreme Court directed the Constitutional Court to hear the case, on the basis that the failure by the government of Uganda to provide women with basic essential care was being challenged as a contravention of Uganda’s Constitution and the women’s rights.
The legal battle did not go without challenges. There were constant delays, with frequent adjournments due to non-appearances by the state or the failure to assemble a full panel of judges to hear the case. The state objected to the case, claiming that the judiciary had no authority to question the political decisions of the state. Initially the Constitutional court agreed with the state and dismissed the case. This was, however, reversed on appeal to the Supreme Court. In his judgment at the Supreme Court, Chief Justice Bart Katureebe stated that “….if a citizen alleges that a health policy or actions and omissions made under that policy are inconsistent with the constitution…., then the constitutional court has a duty to come in…”. The case is thus now before the Constitutional Court, as directed by the Supreme Court. The process to date raises an important point of law for the SDGs, and particularly Goal 16. This goal focuses on promoting peaceful and inclusive societies for sustainable development. It emphasizes access to justice for all and building effective, accountable and inclusive institutions at all levels. For the health sector, traditionally a reserve of public health and medical actors, the SDGs and human rights approaches indicate that other actors will now have a significant role to play.
The experience in Uganda already raises learning on this: The court process motivated civil society to advocate for health issues with one voice. It created awareness that social and economic rights are justiciable in Uganda, and that citizens can seek justice in the courts if other arms of government do not deliver on their obligations. The Ministry of Health has since pushed for increased funding for maternal health and parliament has made resolutions to support increased health financing and asked government to recruit more health workers to strengthen health services. The Ministry of Health has also now developed guidance on the mainstreaming of human rights in the provision of health care in Uganda.
The judiciary has also increased its understanding of health rights. Subsequent court judgments have, for instance, pronounced that access to emergency obstetric care is a human right, which was not the case previously. The courts have also held a local government authority accountable for a mother’s death where it failed to properly supervise the health professionals falling within its mandate.
While there is still a lot to be done, and while the constitutional case is still pending, the experience indicates that framing health demands in the language of legal rights and constitutional obligations, including through litigation and other legal processes, can assist to place health rights as a more central issue for the court of judges and the court of public opinion. Our experience indicates that such human rights based approaches have a role to play in taking action to implement global goals to ensure healthy lives and the promotion of well-being for all ages.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
This month's editorial presents one of the many experiences of the mechanisms that exist at primary care level for community participation in health services and for communication between services and communities. A series of case study briefs have been produced on these experiences, highlighting their contribution to people centred health systems, but also their challenges. As noted by those working with health centre committees in the region, if the intention is to build PHC-oriented, people-centred health systems then these mechanisms need skills for activism and transformation to help build social participation and power and a range of capacities, tools and processes that support this. The case study brief on experiences in South Africa is included in this newsletter and we will include further case study briefs in forthcoming newsletters.
South Africa is in a process of transforming its health system from a centralised and largely curative model to a district health system implementing primary health care and addressing the social determinants of health. The strategies for this depend on an effective district health system, and this in turn depends in part on the role given to communities in health. But who shapes this role?
Public participation in health is covered in the country’s law and policy. South Africa’s 1996 Constitution provides for the right to health, health care, participation and association, and for public participation in policy-making. The 2003 National Health Act provides for participation at community level in clinic and community health centre committees. The 1988 Municipal Structures Act and the 2000 Municipal Systems Act create mechanisms within local government for communities to participate in decisions on local community developments through ward committees and local government councillors. These frameworks for participatory democracy need follow up to realise them in practice.
In September 2014 a National Colloquium found that while many provinces have established committees, there is a lack of clarity on their roles, affecting their functioning. The Department of Health at national level issued draft guidelines for HCCs in 2014 to address this gap. In the Eastern Cape, a policy was published in 2010 on the establishment and functioning of clinic and community health centre committees. It describes the roles, linkages, reporting and accountability of those in the committees. The policy seeks to involve communities in the planning and provision of health services, as a link between the community, health facility, and district health council and to foster co-operative governance. It sets out the community representation in the committees, drawn from women, the religious community, youth, non-government and community based organisations, traditional health practitioners and disabled people, with flexibility to include social groups relevant to the local context. This structure, while set in policy, is only slowly being operationalized in the districts. While in some districts the HCCs may be less functional, in the Nelson Mandela Bay Health District, where additional support has been provided by the university to the fifty clinics, all the committees except one are functional. Forums are held at sub-district and district level, as required by the policy, to monitor and support the committees and their members.
Communities in the Eastern Cape have played a role in formulating and implementing the guidance on their roles and functioning in the committees. In the Nelson Mandela Bay Health District, for example, health committees had been operating since 1996 but in a haphazard and variable manner, without guidelines for their functioning and erratic staff and management support. This frustrated members. In 2006 a team from the Eastern Cape Provincial Department of Health invited health committee members, health service, local government, community and other local stakeholders to a meeting to contribute and to provide substance to the policy on health committees. This workshop served to frame the draft policy, which was later sent to all districts for discussion before further review and feedback by HCC representatives. The amendments made in this process were integrated into the final policy that was adopted in 2009by the legislature in the province and published in 2010.
The policy provides for three-yearly review. In 2014 a review was initiated with HCC members, in consultation with the province. Workshops were held with the committees, facilitated by University of Cape Town. These reviews helped to make the policy more accessible, to support understanding of roles amongst HCC members, to raise roles that had been overlooked, challenges in implementation of functions and suggestions on improvements. It demonstrated tangibly to HCC members that their voices can be heard in amending and adapting policy to improve it. Reviewing the policy also made the HCC members clearer on how to monitor its implementation and the duties of service providers.
Some issues were raised during the policy review: Greater support was urged from facility managers and local government councillors who were seen to be critical members for the functioning of committees, but inadequately involved. Communication between communities and services was observed to be weaker than set in the policy. Community members were found to distrust the complaint box process where HCCs monitor the opening of complaints boxes, recording and resolution of complaints. The committees noted that very limited resources are made available to support their work, including for transport, communication or capacity development. The HCCs made various proposals in the review, to ensure include processes for establishing committees and re-election every three years; to formally recognise HCC members; to make the reporting obligations of facility managers clearer; to include ongoing capacity building and skills development in the policy and to proactively support opportunities to discuss and engage with local communities and give feedback on issues to communities to build confidence in the system.
The process taught lessons about how people can shape and use their policies for participation on health. HCC members feel empowered when they know policies, not only to understand their own roles and responsibilities, but to ensure that they are enforced and that service and local government personnel are accountable for their roles.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised please visit www.equinetafrica.org.