Dear Mr. Jim Yong Kim,
We have the honor to address you in our capacities as special procedures mandate-holders of the United Nations Human Rights Council. We are writing to you with regard to the World Bank’s draft Environmental and Social Framework (“ESF”), which was released for consultation on July 30, 2014. We would like to share with you a number of concerns relating to the approach to ‘Safeguards’ reflected in the current draft ESF.
At the outset, we wish to underscore the significance of the Bank’s first adoption of such standards some thirty years ago. And we commend the Bank for its continued recognition of the central importance of a carefully calibrated framework of standards to ensure that its programs to promote sustainable development, poverty elimination, environmental protection and social standards do not have a negative impact on a diverse range of important values. Most of those values represent important components of international human rights law, to which the Bank’s Member States have subscribed within the framework of the United Nations. It is because the Safeguards implicate human rights so directly that we have chosen to write to you as independent human rights experts appointed by United Nations Member States to provide our inputs to the Bank’s consultation process.
As the Bank seeks to revise and adapt its Safeguards approach to the challenges of the twenty-first century, we believe that it is imperative that the standards should be premised on a recognition of the central importance of respecting and promoting human rights. But there is no such provision in the current draft. Instead, by contemporary standards, the document seems to go out of its way to avoid any meaningful references to human rights and international human rights law, except for passing references in the Vision statement and Environmental and Social Standard (ESS). The Bank restricts itself to noting that its operations are, in ways that are not explained or elaborated, ‘supportive’ of human rights and that it will ‘encourage respect for them in a manner consistent with the Bank’s Articles of Agreement’. As noted below, however, the convoluted and anachronistic interpretation of the Articles that has so far prevailed ensures that this is a largely empty undertaking.
While the Bank is clearly committed to ending extreme poverty and improving the quality of life of people in developing countries, the pursuit of these worthy goals does not automatically ensure that the resulting programs and projects will promote and respect human rights. We acknowledge that it is not the Bank’s role to act as an enforcer of human rights, but there are a great many other ways in which it can assist governments in meeting their own international obligations, provide support and advice on how programs and projects might be made more human rights compliant, and build knowledge and understanding of human rights into its own work. By opting not to take these steps, the Bank is setting itself apart from other international organizations and agencies which have long since recognized the importance of human rights in the context of carrying out their specialized mandates, and have also rejected the notion that human rights are somehow problematically ‘political’ in ways that the many other accepted goals of development policy are not.
In many contexts, the international community has accepted that development and human rights are interdependent and mutually reinforcing. This has been recognized, for example, in the 1993 Vienna World Conference on Human Rights, the 2000 Millennium Summit and the 2005 and 2010 World Summits. Reference might also be made to a document that is cited on the Bank’s own website which is the 2003 UN Common Understanding adopted by the United Nations Development Group. The Common Understanding requires that human rights guide all development cooperation and that development cooperation “contributes to the development of the capacities of ‘duty-bearers’ to meet their obligations and/or of ‘rights-holders’ to claim their rights”. It is fair to say that the vast majority of development actors, from the European Investment Bank to the United Nations Development Programme, have expressed a clear commitment to human rights in their policies, thus making the Bank an increasingly isolated outlier in this regard.
The Bank’s official reluctance to engage operationally with human rights also stands in marked contrast to the lessons that its formal statements suggest it has drawn from its own experience, including through the work of the Nordic Trust Fund (“NTF”). The Bank acknowledges on its website and in many of its non-operational policy analyses that a focus on human rights can improve development outcomes. This is consistent with the seminal insight provided in the work of Amartya Sen, undertaken in his capacity as a Presidential Fellow at the Bank, who argued that freedoms are essential means for achieving development. There are many examples of analyses and reports by the Bank that highlight the potential or actual importance of human rights in promoting the achievement of the Bank’s proclaimed goals, such as those relating to gender equality and the role of women in society.
Rather than seeing human rights as a means by which to facilitate the participation and empowerment of the beneficiaries of development, the Bank’s proposed new Safeguards seem to view human rights in largely negative terms, as considerations that, if taken seriously, will only drive up the cost of lending rather than contributing to ensuring a positive outcome. While a 2010 report by the Bank’s Independent Evaluation Group (“IEG”) concluded that the benefits of Safeguards outweigh their costs, the approach in the draft Safeguards seems to be driven by the desire to privilege rapid approval of loans over all else, an orientation which has long been identified as a problem for the Bank. A sense of being increasingly in competition with other lenders to secure the ‘business’ of developing country borrowers seems to be at the root of this approach. The Bank has defended its increased reluctance to engage with human rights on the basis that alternative sources of development financing are emerging, which do not require meaningful Safeguards, thus providing the latter with a significant advantage over the Bank. In our view, the failure of other lenders to require that projects they fund should respect human rights standards is not a valid reason for the World Bank to follow suit. We believe that the problems that will flow from such a race to the bottom are already becoming apparent, and it will be for us, in different contexts, to make this clear to the relevant lenders.
Human rights are not merely a matter of sound policy, but of legal obligation. As an international organization with international legal personality, and as a UN specialized agency, the Bank is bound by obligations stemming not only from its Articles of Agreement, but also from human rights obligations arising under ‘general rules of international law’ and the UN Charter. Moreover, each of the 188 Member States of the World Bank has ratified at least one (and, in almost all cases, several) of the core international human rights treaties.16 Those States are also bound by human rights obligations stemming from other sources of international law. It is widely recognized that Member States should take their international human rights obligations into account when acting through an international organization such as the World Bank. States that borrow from the Bank also continue to be bound by their own international human rights obligations in the context of Bank-financed development projects and the Bank has a due diligence responsibility not to facilitate the violations of their human rights obligations, or to otherwise become complicit in such violations.
In the past, the Bank has often pointed to its ‘non-political mandate’ to argue that it is prohibited from, or at least restricted in, its ability to deal with human rights more directly. But the Bank’s Articles of Agreement should be interpreted in the context of today’s international legal order, rather than that of the mid-1940s. The Bank and its Member States are bound by both the Articles of Agreement, and by international human rights law. The provisions of the Articles can clearly be interpreted in a way that underlines their consistency with international human rights law. Since all States have long ago accepted human rights as a “legitimate concern of the international community” the suggestion that these remain little more than political considerations is not sustainable.
Our call for the Bank to include HR within its overall program objectives does not amount to suggesting that the Bank should ‘sanction’ countries with a poor human rights record. Consistent with international law, with its own obligations and with those of its Member States, the Bank should acknowledge the relevance of human rights in its overall program objectives, as well as incorporate human rights due diligence into its risk management policies. The Bank should also avoid funding projects that would contravene the international human rights obligations of its borrowers.
In the annex, we have highlighted our particular concerns with elements of the proposed ESF. Our aim is to indicate specific means by which a human rights dimension would strengthen the Bank’s new Framework and ensure its compliance with international law. As Bank President, you have repeatedly undertaken that this revision process will not result in a dilution of the human rights components of the Safeguards. We believe that honoring this promise requires a significantly different approach from that which is now being pursued and there are strong legal, policy and instrumental reasons why human rights should be given a central role in the work of the Bank. The current Safeguard Review process provides a critical opportunity for the Bank to fully integrate human rights in its policies and standards. We will be submitting this letter together with its annex to the World Bank’s public consultation process and plan to issue a press release in due course. We stand available to engage further with the Bank in this process and can be reached for any comments and views on our letter. Your response will be made available in a report to be presented to the Human Rights Council for its consideration.
For further information on this open letter see www.ohchr.org/Documents/Issues/EPoverty/WorldBank.pdf
Editorial
The steering committee of the Regional Network for Equity in Health in East and Southern Africa wish all a healthy new year and renewed energy in our efforts to advance equity and social justice in health. The editorial this month shows how wide is the deficit, but also how vigorous the struggle!
This year, as we look back upon 26 years of World Aids Days, we honour the millions of heroes and heroines who fought the good fight against AIDS but are no longer with us. We need to make sure that this day and the year that follows is about what we do to ensure that people continue living positive, productive lives, with great decency and dignity.
As a young person, I grew up hearing statistics like more than 4 young people are infected with HIV every minute and over 6 000 are newly infected every day. Over half of all new HIV infections were amongst young people in my age group. We had even been called the doomed generation, because many of us had never known a world without HIV and AIDS. AIDS had become our disease and it was feared that within a decade, we would be reduced to mere statistics.
Stigma and exclusion had hindered the efforts of many young people seeking the counselling, testing, treatment and support they required to ensure that those who were not infected remained uninfected, and the infected and affected were well cared for. Many carried the virus for years without knowing.
HIV changed our communities and civilizations, hacking away more than twenty years of hard gains in education, food security and socio- economic development; making our families poorer, and driving us into poverty.
While the scale of devastation caused by the epidemic was unmatched, we also knew that we could beat it - with quality treatment and effective prevention. So we began to fight back, to reclaim our spaces through advocacy, education and awareness. We changed and reclaimed our lives, forcing the epidemic into retreat in many places.
We were not always supported. To save lives we had to successfully confront the monopolies that endorsed skewed TRIPS+ trade agreements, greatly limiting the flexibilities that were won within TRIPs in the Doha Declaration to protect public health and increase access to essential medicines. We had to confront transnational corporations that had tried to challenge Indian law in an attempt to shut down 'the pharmacy of the developing world' - one of the largest producers of affordable generic medication. We had to claim our right to affordable and accessible quality medication.
But we are not done yet.
According to the UNAIDS GAP Report 2014, less than 50% of the 35 million people living with HIV globally know they are HIV positive. Adolescent girls and young women in Sub-Saharan Africa account for a quarter of the new infections. Gender based discrimination, poverty, and the denial of their economic, social and cultural rights continues to drive the epidemic. We are also facing high rates of antibiotic resistance and a reduction in the effectiveness of other medicines we have struggled to access. As a result people with drug resistant diseases like MDR TB need more expensive drugs. This has put a great burden on health services that are already underfunded.
World AIDS Day 2014 and every day after presents the opportunity for us to harness the power of social change to put people first and to close the gap. Ending the AIDS epidemic by 2030 is possible, but only if we leave no-one behind.
Closing the gap means enabling all people, everywhere, to access the services they need,
• By closing the HIV testing gap, so that the 19 million people who are unaware of their HIV-positive status can begin to get support.
• By closing the treatment gap, so that all 35 million people living with HIV have access to life-saving medicine.
• By closing the gap in access to medicines and care for all children living with HIV, and not just the 24% who have access today.
• By closing the gap in power so that young women, children, people of all ages, income and cultures can be included as part of the solution.
We are not done yet. Let’s close the Gap!
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
The Health Systems Research Symposium in Cape Town was an experience to savour. It was particularly refreshing in shifting away from the rather restricted vision of the earlier symposia in Montreux and Beijing. Opening it to debates on ‘people centered health systems’ raised the opportunity to move from the confines of the restricting, dominant neoliberal concept of Universal Health Coverage (UHC) that has circumscribed the discourse in the earlier symposia, with its focus on a narrow and preconceived template of issues, largely informed by the language of health financing and insurance. In contrast, this year’s symposium promoted a public health language of care (not just coverage) and of solidarity, equity, gender justice and rights.
Several speakers, especially in the plenaries, articulated the profound impact different dimensions of power and power relations are having on health systems. In the Peoples Health Movement, we see this as an important and extremely positive sign of our collective intent to confront and challenge these power relations. Several presentations talked about the role of social movements in building, safeguarding, nurturing and expanding health systems that are truly people centered.
There is, however, a gap between our rhetoric and our praxis. We need to integrate concerns about power and an articulation of the role of popular mobilization and of social movements in challenging power relations that undermine health into the priorities and practice of the research community. Here we have a gap, with too little practical translation of these concerns into research priorities and practice. Existing power structures play a hegemonic role in influencing research –using their financial clout and exercising dominance in the domain of ideas. Unless we are able to change this, our work will continue to be informed by a hegemonic discourse that legitimates injustice and inequity. This is a challenge for young researchers, to be bold and innovative in questioning the dominant paradigm of the current research system.
We need to build on the deliberations of the symposium to change our current practice, in all stages of the research cycle. Health research should name and interrogate the practices of those who perpetuate inequity at a grand scale by their cynical use of power. There is robust evidence on this that is waiting to be mined. It was heartening to see evidence in the symposium that there is now a growing interest in participatory research that places people at the center of research systems and not just as passive ‘beneficiaries’ of the outcomes of research. A research community that views research as a tool for change must give attention to the role of civil society and of social movements in catalyzing and driving sustainable change. Civil society is often seen as an afterthought in the research cycle. It is brought in late to legitimize often deceptive or limited evidence that maintains the status quo. Civil society in general and social movements in particular should, in contrast, have a meaningful and decisive counter-hegemonic role to drive an alternative research practice that can propel change, including research that is conceived of and driven by civil society. We need, for example, to develop work that examines the role social movements play in shaping, nurturing and advancing health systems that are solidarity based and sustained by the public.
In the symposium, there was talk of bringing to the foreground the ‘shadow reports’ that are produced by civil society at key forums. Surely we should walk the extra mile and view such shadow reports as the real reports? They present the popular concerns and aspirations and mainstream the voices of the unheard majority. Civil society thus has a task to produce evidence in such reports that is people driven, robust and that challenges the conventional wisdom replicated in the often glossier versions produced by multilateral organisations and well-heeled private foundations. The Peoples Health Movements’ Global Health Watch is one effort at taking up this challenge.
The long shadow of the current Ebola epidemic reminded all of us at the symposium about all that we have failed to do. It has directed our attention to the collective failure of public health and health research to harness evidence and action to promote public services - publicly owned, nurtured and conceived by the people. Health systems that are in the public domain are failing in many regions of the world, in spite of evidence that they are the main life-line for poor, marginalized and voiceless people. They are failing because of deliberate acts of commission that are bringing down, brick by brick, the edifice of public systems. They are failing because evidence that favours nurturing solidarity based public systems has been disregarded. Instead evidence has been used in a selective fashion to promote the notion that market based systems in healthcare delivery are superior. The Ebola epidemic was preventable, in part if overwhelming evidence on building public health systems had not been brushed aside. As a health research community we need to accept part responsibility for the current failure, in our not being vocal enough in the pursuit and use of good evidence.
As we look towards the next symposium due to take place in 2016, can we at least make partial amends for what we have failed to do? Can we collectively raise our evidence and voice to call for public health systems, built around solidarity and justice, rather than the current dominant model of spliced and diced healthcare delivery, designed for trade in the market?
These reflections are drawn from remarks made by the author at the closing session of the 2014 Global Symposium in Health Systems Research 30 September – 3 October 2014. For further information on the issues raised see the PHM website at http://www.phmovement.org/
The final session of what was without a doubt one of the best symposiums in health lent itself to reflection on four days of sessions that sparked debate and hopefully action on people centred health systems. As a funder of health systems research in low and middle income countries for over a decade, International Development Research Centre has supported the Health Systems Research Symposium from its birth, with an aspiration that be one of the processes that contribute to access to health and health care for all.
So what were the key messages that I heard and have taken home.
Professor Thandika Mkandawire began by articulating that we need health systems to be democratic, social, inclusive and to contribute to development. At the same time Prof Irene Agyepong reminded us of a Nigerian proverb that a “goat that belongs to the whole village belongs to nobody - this is how health systems can be described, but we must not let it go that way.”
So as a funder I ask myself whether I will stick to, as one panelist said “the politics of the achievable”? My answer is no, as it would not do justice to the energy, excellence and commitment that I witnessed from participants over the course of the last three days and more importantly it would not do justice to the people who have no access to health or do not have a voice.
I’ve organised what I have heard into: the “not to dos”, the “must dos”, and the “how to do”.
As a ‘not to do’ Rene Loewenson reminded us that by simply putting people in the middle does not make it a people centred health system.
So what must we do? In terms of how we do people centred health system research, the knowledge that matters is the knowledge that facilitates change, as we were reminded by Kumanan Rasanathan. As Nancy Edwards suggested we must move from gold standards to platinum standards of methods. In practice this means, quoting several people from the conference:
• Firstly, that people’s knowledge and role in the production, analysis and interpretation is a critical driver of people centred health systems. It means that people are in control and researchers are the facilitators of the process.
• Secondly, making data work for people rather than have people work for data. In one session someone spoke about “chasing data to fit with multiple donors’ agendas”. We need to incorporate multiple types of evidence and to bring in other practices and methods.
• Thirdly, while strengthening capacities are key, we cannot assume that none exist. We should recognise that capacity strengthening goes beyond training to actually shifting power, as noted by Aku Kwamie.
As a further ‘not to do’ Gita Sen reminded us that we cannot confuse the PC of People Centred with the PC of Political Correctness. We must break divides of race, gender, class, caste, culture or language and come together. This was illustrated eloquently despite the English language barrier by Lina Roso Polomo, a researcher from Mexico, as she explained how international guidelines do not always recognise the cultural diversity of our countries.
So if accountability is brought in by people, then as Kausar Khan eloquently relayed, the ‘must do’s’ include duties for us to reduce ethnic and racial divides as we facilitate, mobilise, fund, engage and catalyse people-centred health systems. It cannot be ‘us’ and ‘them’ as Martin McKee reminded us. At the conference I saw reflected in the program the silos being reduced as ‘systems’ sessions starting to integrate with ‘disease’ sessions, and discussions moved to bridge social movements with think tanks. Inclusion and integration are key. After all, as Lucy Gilson said on the first day of the symposium, the challenge that we must squarely address is governance.
Throughout the conference there was concern about the double-edged sword of Ebola, that has served this community with deep and significant challenges. The West African Health Organisation is demonstrating commitment to work with all of us to address Ebola and the system failures that it has starkly uncovered. WHO, UNICEF and European funders are advancing initiatives that address both basic science and health systems but as a global community we must do more and USAID and the World Bank called a number of meetings throughout the symposium to discuss this.
Moving from the ‘not to dos’ and the ‘must dos’ to the ‘how to do’, the wisdom of the Emerging Leaders (young researchers) is the take home lesson for all of us here. They said that to change mindsets we need to see, talk about and deal with the gorilla in the room. To make an impact we need to take the time to stop and reflect, with others that are like minded and also with those who are not. Lastly they told us that in each of us we have the capacity to lead as we bridge divides to build collective ownership of health systems that - quoting Sheik, Ranson and Gilson from the Health Policy and Planning Supplement on the Science and Practice of People-Centred Health Systems - truly “serve people and society”.
These reflections are drawn from remarks made by the author at the closing session of the 2014 Global Symposium in Health Systems Research 30 September – 3 October 2014. For further information on the global symposium visit http://hsr2014.healthsystemsresearch.org/
Seven out of ten Tanzanians think that have no say in what Government does. Yet seven out of ten Tanzanians also think that voting is their only means of influence over Government. This may sound contradictory, but at core, they both reflect the same sentiment. Aside from the choices they make during elections, citizens do not feel that they influence government decision-making or activity. They appear to have little trust that formal institutions or local government officials will address their issues, and formal political institutions seem to play minimal roles in people’s lives. Nine out of ten people report that they have not interacted with their member of parliament in the last year, half have not interacted with their street or village chairman to raise issues and only one in seven citizens are members of any political party.
These findings were released by Twaweza in a research brief titled Citizens making things happen: are citizens active and can they hold government to account? The brief is based on data from Twaweza’s Sauti za Wananchi, Africa’s first nationally representative mobile phone survey that interviews households across Mainland Tanzania.
Sauti za Wananchi, (http://www.twaweza.org/uploads/files/Sauti-za-Wananchi-English.pdf) was initiated by Twaweza as a response to the concern that policy makers make decisions for the whole country, but with poor information on the experiences and realities of a large majority of citizens and on whether their policies are working on the ground across different places. It provides timely, low cost and reliable data and is a nationally representative barometer of the reality reported by Tanzanians. In 2014, together with our partners, we expect to conduct 20 survey rounds, and use widespread dissemination and intensive media outreach to share the findings, especially with policy actors, to shine a light on citizens’ experiences and views.
So how are people taking up their concerns? Despite the apparently low levels of interaction with formal channels uncovered by Sauti za Wananchi, 6 out of 10 citizens report that they made joint or collective complaints to officials in their community in the last 12 months, sometimes repeating the same complaint. Common complaints ranged from seeking improvements in local public services, to teacher absenteeism and access to clean and safe water. Just over a quarter of people reported raising complaints about the absence of drugs at local facilities, generally complaining several times in the past year.
When it comes to raising issues within the community, Sauti za Wananchi found that people are fairly vocal about problems they face. Eight out of ten citizens raise their issues in the groups they belong to, and three out of ten have called in to a radio station or complained to a friend. In contrast, people are much less likely to walk out of a discussion, attend a demonstration or protest or to refuse to pay tax, and far less report that they would or use force to achieve a political cause.
Community groups thus play a more significant role in people’s lives. Seven out of ten Tanzanians belong to one, often religious groups, but also savings and loans groups. Community solidarity appears to be high: almost all citizens believe that if an unforeseen incident, such as house fire, occurred, their community would get together to help. The same confidence doesn’t extend beyond immediate communities, and when asked whether they trust people generally, nine out of ten people felt that you had to be very careful with others. Citizens also strongly feel that they can rely on themselves to get things done. Seven out of ten citizens respond positively to statements about their own ability to overcome challenges, find solutions to their problems and accomplish their own goals.
People also contribute collectively to their services: Seven out of ten citizens directly contribute to constructing or maintaining public facilities, most giving money and the rest contributing time. While the level of tax collection is low, people are in one way or another contributing to the running of government. However these collections are not well regulated. The lack of transparency and checks and balances mean that contributions may not be collected fairly or used productively. In fact, four out of ten of those who contributed to local facilities say they were forced to do so, eroding public trust.
Sauti za Wananchi paints an interesting picture of the experience of Tanzanians. Rakesh Rajani, Head of Twaweza at the time, summed it up: “Tanzanians are active members of community groups and undertake collective action to complain to officials in their community. They also feel that they are able to tackle obstacles and make things happen in their own lives but express feelings of powerlessness when it comes to their influence over government. Thus far citizens have shied away from the more emphatic and vocal forms of citizen agency such as tax refusal, protests or walk outs. However significant service delivery challenges remain in all major sectors. If the Government does not become more responsive to this softer engagement, we may see citizens become more aggressive in the future.”
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the evidence, issues and processes raised in this op-ed please visit Twaweza at www.twaweza.org and read the full report at http://www.twaweza.org/uploads/files/CitizenAgency-EN-FINAL.pdf
Thomas Deve, a member of the EQUINET steering committee, passed away on Sunday 7th September. The diversity of people who have written tributes show how widely he connected from local to global level. He brought a personal connect to people and struggles across the continent and critical analysis and debate to our network. He was a researcher, a policy analyst, a band manager, a teacher, a thinker, an activist and much more. We bid him a reluctant farewell and Thomas, our struggle to reclaim the resources for health will continue.
At the recent 2014 International AIDS Conference we heard that 35 million people are living with HIV, but 55% haven’t been tested. Under the 2013 WHO guidelines, UNAIDS reported in 2013 that the HIV treatment coverage in low and middle-income countries represented only 34% of the 28.6 million people eligible in 2013. Medicines for malaria, pneumonia and other common conditions don’t reach many low income communities and there are new challenges in ensuring the long term treatment for chronic conditions.
Access to medicines continues to be a major preoccupation in African health systems. Beyond the unequal distribution of access to essential medicines globally and within countries, resistance to anti-malarials, antibiotics, and treatments for TB and other conditions can worsen the problem. The new medicines developed are frequently more expensive and may also require more stringent supervision to ensure they are properly used. For example in the 2014 AIDS Conference it was noted that there is a 10 fold price increase from first to second line treatment, and the World Health Organization (WHO) reported in 2012 that the 450 000 new cases of multidrug-resistant tuberculosis (MDR-TB) longer and more expensive treatment. These medicines are often imported, at a cost that consume a large share of health budgets. Countries in east and southern Africa (ESA) often draw on support from external funders to meet these costs.
This rising challenge, coupled with high levels of dependency on external producers and funders makes ESA countries very externally dependent when it comes to medicines. This, and the potential contribution that pharmaceutical manufacture could make to economies and trade within the continent, especially given the rich natural resources for medicines, prompted the African Union and its sub regions in east and southern Africa to come up with plans to enhance local pharmaceutical production. African Ministers of Finance, Planning and Economic Development in Nigeria in March 2014 noted: “There is growing consensus that strengthening the local production of essential medicines is a priority, along with advancing industrial development and moving the continent towards sustainability of treatment programmes for HIV, tuberculosis and malaria, and improving access to safe and effective medicines to treat a broad range of communicable and non-communicable diseases.”
The Pharmaceutical Manufacturing Plan for Africa (PMPA), the Southern Africa Development Community (SADC) Pharmaceutical Business Plan 2007-2013 and the East African Community (EAC) Regional Pharmaceutical Manufacturing Plan of Action 2012-2016 all propose policy measures to create the conditions for and support local production, as one, albeit not the only way to strengthen access to medicines.
The same plans are also rather clear about the obstacles that have to be overcome to achieve this, including in terms of ensuring adequate legal provisions, improved and reliable energy, transport and other infrastructure, technology, skills and research and development capacities to enable and sustain production and finance capital. The same 2014 conference of African Ministers of Finance, Planning and Economic Development cited above noted in its statement: “The challenges the pharmaceutical industry faces in upgrading facilities and production practices in Africa include the requirement for large capital investments and the need for experts, specially trained workers, increased regulatory oversight and regulatory harmonisation at the regional and continental levels in order to create bigger markets.”
In research that we carried out in 2013 and 2014, we found signs of progress in overcoming these obstacles, but also many challenges. Kenya, Uganda and Zimbabwe, for example, produce medicines that are not only consumed in their own countries, but are exported to other countries in the region. Some of the factors that appear to support this include the presence of a sound regulatory framework for the pharmaceutical sector, partnerships with other countries bringing investments in manufacturing and in capacities for it (such as in Uganda), local skills and research and development institutions that can support the technology for local production. Further, existing practice points to the critical importance of regional trade as a way of ensuring adequately sized markets to provide a return on investments. These are examples in practice of measures that are articulated in the regional plans.
However, we also found that while many countries have national pharmaceutical policies that articulate such goals, they also depend on policy in other areas, such as energy and infrastructure, and that there is a gap between policies and their implementation.
The implementation gap is evident in a number of areas. One is in the extent to which governments are supporting local production with tax and other incentives to create a conducive investment, business and trade environment. For example there could be stronger measures to exempt duty and value added tax (VAT) on imported pharmaceutical raw materials and packaging materials to stimulate local production and reduced corporate tax rates, investment tax credits and other incentives for companies to set up production. Yet sometimes we find that the opposite is in place. For example in Zimbabwe imported drugs were in 2000 exempted from duty and VAT, while the raw materials and packaging needed for local manufacturing attracted duties of up to 40% and VAT of 15%. This increases the cost of locally produced drugs, especially when other countries are not placing these high charges on their producers, making imports cheaper than locally produced medicines. This doesn’t make sense given the policy intentions and we should at least level the playing field and avoid tariff structures that promote de-industrialisation!
There is also a gap in the dialogue that should be going on between governments, pharmaceutical companies and training institutions on what capacities, skills and personnel are needed for the pharmaceutical industry and how these can be attracted and developed, including through schemes to attract and retain appropriate personnel in the public service and in countries.
While there is an emerging interest in south-south partnership agreements on some of these areas, it is equally important that attention be given to implementing the regional plans, to use memberships of Common Market for Eastern and Southern Africa, the Southern African Development and the East African Community to negotiate for a tripartite Free Trade Area between the three blocs to widen markets for medicines and to strengthen regional interactions on the technology, infrastructure, capacities, research and development and capital needed for pharmaceutical production.
In a continent with such high health need and demand for treatment, surely we need to not only be asking when we will get better access to medicines, but when we will get better control over access to medicines?
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 in this op-ed please visit www.equinetafrica.org
Our health systems are sites of constant change and struggle. In east and southern Africa national health services centred on comprehensive primary health care (PHC) have been ‘reorganised’ through waves of liberalisation, privatisation, disease focused verticalisation, performance based financing and many other reforms. People have come to services to find new rules for what is free and what is charged, for what medicines and supplies are present and what is not, and community health activities and workers have appeared, disappeared and appeared again.
The drive for a universal national health service was embedded in national liberation struggles. The PHC approach was a global concept that resonated strongly with popular expectations of what post independent health systems should look like. Many of the subsequent changes have emerged as waves of international reform, increasingly influenced by global level actors. When we ask people in participatory sessions to form a human sculpture of how their health systems are organised around a patient visiting for care, the sculpture most commonly has health workers, managers and others looking upwards to the next level to get the resources and attention they need to solve problems, (most looking away from the patient), usually with the person representing a powerful but distant global funder elevated in both power and stature on a chair in a far corner of the room.
While these may be caricatures, they raise the question- when it comes to changes in health systems, who counts? Whose views, expectations, ideas, evidence, numbers, analysis and knowledge is used to generate change?
This matters because health is ‘a state of mental, physical and social wellbeing and not just the absence of disease’, because health outcomes reflect conditions that are socially created, and health systems are thus social institutions, built out of and influencing society. The explosion of knowledge on the biomedical basis of disease and on risk factors in public health has informed massive advances in survival. It has, however, weakly addressed and often ignored the social context and determinants of health and the social nature of health systems. As a consequence we face persistent and sometimes widening inequality in health and in access to services, rising levels of multiple morbidity and chronic conditions, epidemic resurgence and antibiotic resistance, amongst other challenges.
The problem does not lie in the extraordinary scientific innovation and creativity that lay behind these medical advances. The problem lies in one form of knowledge subjugating others, excluding and disempowering others from the creative processes that transform society, a mistake akin to suggesting that the trunk of the elephant is the whole elephant.
That knowledge as socially constructed is not a new concept. This understanding has been central to social sciences and to cultural, anticolonial, gender and indigenous struggles. With the failure to implement what is known, in health sciences it has led to increased attention to fields such as health systems and policy research, where rather than absolute prescriptions, there is a quest to better understand ‘what works where and for whom’.
This wider lens will generate a better understanding of context in health sciences. Will it also overcome a tendency for ordinary people to be the last to know the waves of reforms transforming their health systems? Freire argued decades ago that meaningful social transformation, including of health systems, can only occur with the deep involvement of the people affected. The incubation of the PHC approach, the efforts to build national health services across diverse countries, the refusal to allow health care to be commodified, the gains in access to improved living and working conditions have all been a product of social and political action.
This type of action does not grow out of knowledge and perspective built in distant corridors. In the last century activist scientists such as Orlando Fals Borda in Latin America pointed to a different understanding of science, one that seeks to not only understand the world but to transform it, and, as importantly, one in which knowledge is built from lived experience and from the learning and self-awareness that grows from action. Participatory action research (PAR) has developed in different forms as a method for such science. It overcomes the separation between subject and object. Those affected by the problem are the primary source of information and the primary actors in generating, validating and using the knowledge for action, and using action and change as a means to new knowledge. A new methods reader on ‘Participatory action research in health systems’ produced by EQUINET and TARSC with Alliance for Health Policy and Systems Research and IDRC Canada that can be obtained on the EQUINET website in end September details the principles and methods of PAR, its challenges and the many ways and levels at which it is being used.
In different parts of the world, PAR has built a more direct link between theory building and practice in health systems. Workers and unions have used PAR to expose and organise for change in working conditions that are harmful to their health. Young people in high and low income countries have used it to raise visibility of and engage with authorities on harmful community environments. Indigenous communities have used it to negotiate the organisation of their health care. It has been used in continuous processes in local authorities in shaping PHC, learning from cycles of transformation.
The practice of PAR flags that change is not itself a problem in health systems in east and southern Africa. It is rather a problem when the knowledge used to guide this change does not draw on the experience, knowledge and wisdom of those directly involved, through methods that build their power to inform, learn from and shape that change.
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 in this op-ed please read Participatory action research in health systems: a methods reader, available on the EQUINET website www.equinetafrica.org from end September 2014
The roll out of Performance-based financing (PBF) in east and southern Africa is now widespread. Yet a recent study found cause for concern with this often ‘taken-for granted’ financing mechanism. As a result, there is a need to better understand and debate how PBF reinforces or contradicts other measures being used to build and strengthen universal health systems.
Performance-based financing has become increasingly popular in global health financing. It involves the transfer of money or goods based on implementation of a measurable action or achievement of a predetermined performance target. It is seen to increase accountability to both external funders and national stakeholders, by tracking of how money is spent. Having clear targets is argued to strengthen health systems by providing a way of assessing what programs are efficiently delivering ‘value for money’ and by rewarding good practice. Its proponents argue that external funders, generally large contributors to African heath systems, should transfer funds based on performance to achieve these gains.
In the past year we carried out research examining PBF in South Africa, Tanzania and Zambia, and with regional and global institutions (more fully reported in EQUINET discussion paper 102 at http://tinyurl.com/nudgky3). This work raised questions about how PBF affects the strength and equity of health systems, and what latitude African actors have to ‘reframe’ PBF mechanisms to address their concerns.
Certainly a majority of the African actors had a positive perception of PBF and its ability to strengthen health systems, a perception also evident in the general literature pertaining to PBF. In particular, evidence suggests that Africa actors believe that PBF is useful in curbing corruption, in incentivizing targeted health outputs, and in increasing accountability mechanisms. These benefits, where they have occurred, have generated support for and ownership of the approach.
Nevertheless, at the same time there were many concerns regarding the practice of PBF. Questions were raised about how performance criteria are selected and how far national input was factored into the design of PBF, a key principle in the Paris Declaration. We found that the space for genuine participation in the design of PBF was narrow, usually limited to high level personnel in national systems, and that it was affected by factors such as how much of the public budget is externally funded. Lower dependency on external funding appeared to give countries greater possibilities of setting their own targets and resisting funding conditions that potentially conflict with national strategic plans. We found, for example, that South Africa, with less than 10% of its health budget externally funded, had greater latitude to negotiate and resist unfavourable conditions. We also found that this ability to ‘push-back’ was less available in Tanzania and Zambia, where external funding contributes up to half of the health budget. Some African actors in health ministries and in service provision expressed weariness about the external conditions demanded by funders, and called for a more decisive national voice. As one senior African health official suggested, ‘when PBF is the result of national ownership then it has excellent potential to be a mechanism for change… however, if it is not, then it will certainly be doomed to…not deliver on its promises.’
We found that while there is great enthusiasm for monitoring and rewarding outcomes, in practice this needs substantive investment in health information systems. We found, as others have, that information systems lack the reliability, capacities and support to analyse and use evidence to evaluate performance. Unless this is recognized and addressed, use of performance indicators can cause weaker services (with poorer capacities to manage information) to do worse, reducing their PBF ‘score’ rating and thus restricting their funding. This causes considerable concern, since these services are usually the ones that are in more marginalized areas of highest need. In addition, many of the African actors we interviewed complained that the reporting systems required by funders are cumbersome, time-consuming and add considerable overhead costs. External funders, particularly the Global Fund, were reported to change reporting requirements and ‘goal posts’ mid-stream, without sufficient notification or technical assistance, leading to confusion and delays in programme reporting and roll out.
Furthermore, external auditing mechanisms were often found to be ‘not fit-for-purpose’, implemented by auditors with little health knowledge or understanding of the recipient country, with inadequate communication between auditors and recipients.. Audit processes were found to be inflexible on target satisfaction. For example, Local Fund Agents (LFA) of the Global Fund were reported to often refuse to answer recipient’s questions during report writing, to refuse to discuss reporting problems during the audit, or to allow the final LFA evaluations to be seen by recipients. This was argued to damage partnership and national input to PBF conditionalities.
Moreover, many African actors that we interviewed assumed the merits of PBF, without being able to refer to strong evidence to support this view. There is also a growing weariness about PBFs ability to ‘be all things to all people’ and an urge to have a more realistic national assessment of PBF as being one of many financing measures available.
Where PBF is seemingly most successful is in cases where there is a strong sense of national ownership and multi-sectoral partnership. PBF has had positive impacts where robust information systems exist, so that future targets can be based on valid data, where performance monitoring is possible, and where evaluations can be made reliably. It is seemingly most successful when targeted on tightly focused health interventions, like payment per patient seen, and not on broad whole-of-system targets, where it is difficult to isolate and track individual variables. A better understanding of the positive features can contribute to health system strengthening.
However our study also found evidence of negative consequences that can weaken national health systems. Reaching PBF targets can sometimes compromise quality of care, vertical PBF schemes can create ‘health silos’ that are not always fully integrated into comprehensive primary health care, and PBF schemes are often not well embedded into a sustainable long-term health strategy.
These are issues that partners can identify, negotiate on and attempt to resolve. So our findings on the weaknesses of partnerships and genuine national leadership of the PBF agenda – as raised in this editorial and detailed in the full report- are crucial issues to be discussed and debated; to build better partnerships between global and African institutions and to design better systems for strengthening African health systems. As one senior health official commented, ‘we should be accountable for the money we receive and we should try to get as much value for money as possible... this is the non-debated part of PBF and a reason why it is so popular… but exactly how to best generate value for money is still open for discussion and for PBF to work effectively it will be important to get its processes right and to then generate agreement by all those who have to deliver these processes.’
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 in this op-ed please read the full report on the EQUINET website and visit www.equinetafrica.org