Editorial

The World Health Organization (WHO) recently released the first set of comprehensive data comparing the prevalence of HIV/AIDS in poor countries with the rates of antiretroviral (anti-HIV) drug access in those nations. The data are striking and disheartening, yet have received little press coverage. Indeed, at the time of their release, some American newspapers ran editorials indicating that antiretroviral access has received "too much attention".

Two problems are implicit in such a contention. The first is political. AIDS is very much a symptom - albeit the most extreme symptom - of the large diseases of inequality and poverty that result not only in HIV, but also in hunger, hemorrhagic fever and housing problems. The same credit and political obstacles that have led to gender discrimination in housing and employment have led women into prostitution and relationships based on sexual dominance [1, 2]. The same structural adjustment programs and neoliberal economic policies that have crashed farming sectors and forced thousands into migration are the same policies that have led migrants to the barracks of minefields to live with depression, alcoholism and the subsequent solicitation of prostitutes [3-5]. And so to address AIDS appropriately would be to appreciate that it does not simply receive "too much attention", but that the attention it receives should be drawn towards its base - and this includes the inequalities in healthcare access that are symbolized by antiretroviral access disputes.

The second problem with the new popular line of thought on antiretrovirals is a statistical problem. The recently-released WHO data are striking but perhaps not surprising. If "too much attention" has been focused on drug access, then why are only six-tenths of a percent of the 1.6 million infected people in Tanzania able to access antiretroviral medications? Why are only 1.5% of the 2.4 million in Mozambique and the Congo able to gain such access? In a country like Zimbabwe, where one of every four adults is infected, only one of every fifth can access an antiretroviral medication. As one scrolls through the WHO's data, the numbers of infected persons continue to be expressed in seven digits, while the percent of those gaining access to antiretrovirals continues into smaller and smaller decimal ranges.

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The SADC Health Protocol came into force at the 2004 SADC Mauritius Summit and now applies across the region. It outlines the priorities and mechanisms for regional co-operation in health. We look forward to the protocol being raised and discussed within the parliaments of the region to see how far we are making progress in the regional priorities and approaches signed on to by the heads of state in Mauritius.

Why should parliaments be important to struggles for equity in health? Parliaments are a watchdog of public policy and consolidate this policy in law. In their legislative role they are able to transform social norms and values into binding legal entitlements. Their oversight role on the budget and on the actions of the executive provides an important opportunity to ensure that these legal entitlements are realized in practice. For example parliaments are an important watchdog of the government Abuja summit commitment that at least 15% of government budgets are invested in the public health sector. They can give voice through various processes of debate, inquiry, public hearings and consultation to public views, including the views of those areas and groups where such voice may be weaker or less articulate.

In an EQUINET, GEGA and SADC Parliamentary Forum regional meeting in South Africa in August 2003, it was recognized that parliaments are uniquely placed to build alliances with the Executive branch of government, across political parties, between different portfolio committees and with civil society, health sector and other agencies at national and regional level in support of health equity. (The report of this meeting is found at www.equinetafrica.org) The parliamentary reforms taking place in the region provide an enabling environment for this. At the August 2003 regional conference, delegates agreed that the establishment of parliamentary committees on health provided a forum for deeper review, policy monitoring and analysis, and noted that a range of health related activities were already taking place. These committees have held public hearings on laws and policies, visited and investigated conditions in the health system, held systematic hearings on the national budget and its consistency with national health policies and promoted public awareness on key areas of social norms and action in health, such as HIV and AIDS. In Zambia, South Africa and Zimbabwe, for example, with support from institutions in EQUINET and GEGA, parliamentary committees on health have analysed and made input on equity issues in the health budget and have visited districts to follow up on the equity issues raised. In Tanzania the parliament has established a parliamentary forum on AIDS at which key issues such as equity in access to Antiretroviral treatment have been debated. In Malawi parliaments have raised and promoted debate on issues of migration of health personnel and on the quality of health services at the district level.

In June 2004, during the EQUINET regional conference on equity in health, parliamentary committees and organisations working on health equity agreed that these critical areas of work needed more consistent regional exchange of information and good practice, support and activity. They would also benefit from longer term co-operation with state, academic and civil society institutions working on health equity. How can this be achieved? Is a more regular forum of health committees needed, within the SADC framework? How can the current work and institutional partnerships with parliaments be better networked and more consistently supported to ensure greater exchange of information, learning and good practice? These issues were raised as matters of concern to organisations like EQUINET working with parliaments and we invite readers and institutions working with parliaments to give feedback to these queries. What experiences exist in the region of work with parliamentarians on equity in health? How can we better strengthen and support such parliamentary roles, particularly if we are to achieve our goals of equity and social justice in health, and the policy commitments expressed in the SADC Health Protocol?

This briefing is produced by the EQUINET secretariat at TARSC. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat email admin@equinetafrica.org . Reports cited are available as a downloadable pdf file from our website at www.equinetafrica.org

The debt relief movement is poised for a historic day this October 1st when G-7 finance ministers discuss 100% multilateral debt cancellation for impoverished countries. Debt cancellation would free up significant funds for development, including fighting AIDS and strengthening health systems. You can help make this happen.

If you are a health professional, please lend your name to an international health professional sign on letter that will reach all G-7 finance ministers and presidents/prime ministers before this important meeting. This letter is copied below. If you would like to add your name, please respond by September 20th to aidsact@phrusa.org with your full name, degree, affiliation, and state/country.

International Health Professional Sign-on Letter

September, 2004

Dear G-7 Presidents and Prime Ministers:

We write to you as health professionals from diverse countries in Africa, Asia, Latin America and the Caribbean, North America, Europe, and Australia who strongly support debt cancellation for poor countries. Debt cancellation is a prescription urgently needed to help heal seriously ailing health systems – some of which cannot even provide minimal care – in many of the countries in which we live and work.

Debt cancellation would free large sums of money, funds that should be used to build stronger and more equitable health systems, which are desperately needed if the fight against AIDS and other killer diseases is ever to be won. Right now we are losing that fight. AIDS alone kills about 3 million people per year, as another 5 million people becoming infected with HIV annually. At the end of June 2004, fewer than 10% of people in developing countries in urgent need of AIDS treatment were receiving it. In light of the health crises that many of our countries face, debt cancellation is necessary on human rights and humanitarian grounds. We therefore urge you to endorse 100% multilateral debt cancellation for impoverished countries when the issue is discussed at the meeting of G-7 finance ministers this October 1.

We know that poor countries need this debt relief urgently. African countries alone are collectively spending about $15 billion per year servicing their debts to wealthy creditors, including multilateral institutions. The fifteen focus countries of the U.S. President’s Emergency Plan for AIDS Relief spent $10.3 billion servicing their debts in 2001; this is more than the $9 billion these countries are scheduled to receive over the Emergency Plan’s entire five years. The World Bank, IMF, and regional development banks are typically the largest creditors of the most impoverished nations.

Relief from debt could be instrumental in enabling countries to meet AIDS treatment targets, as well as other health goals. Your governments all support the World Health Organization’s (WHO’s) 3 by 5 initiative, which aims to get 3 million people in developing and middle-income countries on AIDS treatment by the end of 2005. Yet treatment goals cannot be achieved without health workers. And as so many of us know through our own experiences, many countries, particularly in Africa, have nowhere near the necessary numbers of health personnel. For example, WHO and the World Bank have reported that Tanzania and Chad, both countries that would benefit greatly from debt cancellation, require their health workforces to triple and quadruple in size, respectively, to achieve the Millennium Development Goals.

The connection between suffering health systems and the debt payments that limit funds available to them is palpable. To a significant degree, the severe shortage of health workers in Africa is a symptom of acute underinvestment in health systems, many of which suffer from too few staff, too few supplies, and too few drugs. This underinvestment is a central cause of the migration of health professionals to wealthy nations, where health systems are stronger and pay is better. Creating the conditions that will enable health professionals to remain in their home countries and allow them to provide the best care possible for their patients will cost money. Health care workers will continue to leave if they are unable to meet the charge of our professions: serving our patients. Our colleagues will continue to emigrate so long as they do not have medicines for their patients, or functioning equipment, or proper supervision. And they will continue to leave so long as they cannot support their families or be confident of their own safety. They need fair salaries, equipment to protect themselves from occupational infections of HIV and other diseases, and psychosocial support to help cope with the constant death and stressors they face.

Full multilateral debt cancellation for impoverished nations could go a long way towards meeting people’s right to the highest attainable standard of health. Indeed, debt relief that countries have received under the Heavily Indebted Poor Countries (HIPC) initiative has already begun to do so. In Malawi, savings from debt relief have paid for extra staff and support in primary health centres, nurse training, and improving the supply of essential drugs in health facilities. In Mozambique, debt relief funds helped increase the number of children receiving immunizations for tetanus, whooping cough, and diphtheria. Debt relief savings have also helped fund primary health care in Uganda, including salaries of health care workers, while countries including Uganda and Cameroon have used debt relief savings to help finance HIV/AIDS programs.

Debt cancellation is an excellent investment not only in people’s health, but also in countries’ economic well-being. Increased spending by impoverished countries in health, education, and other fields that promote human development, which will result from debt cancellation, goes hand-in-hand with economic growth. As WHO’s Commission on Macroeconomics and Health has highlighted, investments in health will increase worker productivity, creating economic gains that would far exceed the initial cost to creditors of debt relief. Debt cancellation will help put countries that are economically marginalized and heavily dependent on foreign aid onto paths towards economic autonomy and integration in the world economy. By contrast, without debt cancellation and other investments to reverse the spread of and treat people with HIV/AIDS, decreased worker productivity will make countries increasingly dependent on foreign assistance and unable to participate in the global economy.

We therefore urge you to support 100% multilateral debt cancellation for impoverished countries, including HIPC countries and as well as non-HIPC countries that are in need of this relief. We hope that your finance ministers will announce your governments’ support for such an initiative at their October 1 meeting. And we encourage you to work with countries whose debts are cancelled to ensure that their savings from debt payments are used on poverty reduction and human development. Countries can establish mechanisms to ensure that savings from debt services payments are used to reduce poverty and to promote human development. Uganda has established a Poverty Action Fund into which savings from debt relief are channelled, and which includes a series of procedures to ensure that the debt relief savings are well spent. Other countries, including Tanzania and Malawi, have established similar mechanisms.

We also encourage you to work towards a permanent solution to the debt of impoverished countries – including for countries that do not receive 100% multilateral debt cancellation and for any new debt assumed by those countries whose debts are cancelled – by creating a new understanding of what level of debt countries are expected to repay. In particular, we urge you to announce that from this time forward, countries will be neither obliged nor expected to make debt payments that would compromise their ability to meet their people’s basic needs or otherwise fulfill their people’s human rights.

We are health professionals. Our job is to heal. So it pains us to see debt payments siphoning away funds that could go far towards enabling our colleagues and ourselves do our jobs and meet the needs of the patients we serve. We fervently hope that you will help enable us to be the healers that we were trained to be.

Sincerely,
[If you would like to add your name, please respond by September 20th to aidsact@phrusa.org with your full name, degree, affiliation, and state/country.]

Cereal production in Southern Africa has remained stagnant for over a decade since 1990 at 22 million MT, despite a growth in population of 60 million in the period. This fact highlighted at the SADC Heads of state summit on food security brought sharp attention to unacceptable and mounting shortfalls in food security in the region. Rates of childhood stunting in Africa are predicted to increase to above 25 percent by 2015, more than double the Millennium Development Goal (MDG) for that year. Only 3 out 10 African countries have experienced an improved maternal nutritional status in the last decade.

The EQUINET steering committee highlighted at the June 2004 regional conference its agreement with SADC heads of state that food security and food sovereignty are now an important focus to achieve wider goals of health equity and social justice in the region. The gross statistics were further debated as they mask the fact that it is the lowest income rural and urban communities, women and children who are most at risk of food insecurity and its consequences.

Mary Materu, from the Centre for Counselling, Nutrition and Health Care (COUNSENUTH), Tanzania highlighted the massive inequity of the fact that “when the world is producing enough food to feed everybody, more than 800 million people, most in developing countries, do not have enough food to cover their nutritional needs.”

Mickey Chopra, from the University of the Western Cape School of Public Health, highlighted the wider fallout from this deprivation of the right to food: “Adequate food and nutrition is a basic right. The deprivation of this right has immense consequences for addressing inequities across the region. Poor nutritional status stunts educational development as well as increasing the risk of acquiring, and the severity of, infectious diseases (including HIV/AIDS). The lack of household food security has led to increased vulnerability, especially of women, to diseases such as HIV. If the huge cost of burden of disease suffered by the poorest is to be tackled addressing lack of household food security and malnutrition is essential.”

This deprivation arises from a combination of increasing food prices and falling food production. These immediate causes are driven by macro level factors such as trade relations, domestic food and agricultural polices and micro level factors such as intrahousehold food distribution, gender roles and caring practices.

The EQUINET steering committee noted that the current food insecurity cannot be traced purely to drought or to AIDS. “The 2002/3 food crisis in Southern Africa was more widespread and impacted much more severely on households than could be predicted from rainfall patterns. The destructive effect of AIDS on household labour and incomes clearly compounded other threats to food security, such as inequities in access to productive resources and to market access, particularly for women.”

Current trade policies were identified as having a profound and negative impact on food security in Africa. Chopra highlighted how OECD subsidies to agriculture between 2000 and 2002 of about US$250billion placed protectionist barriers against food imports from Africa, undermining returns from production and thus effectively suppressing production. Kenya, for example, more than doubled production of processed milk between 1980 and 1990. When subsidised milk powder imports could be sold more cheaply than Kenyan processed milk, imports soared, increasing from 48 tonnes in 1990 to 2 500 tonnes in 1998 and domestic production of processed milk plummeted by almost 70 percent. Kenya's ability as a nation to diversify into processing was undermined. More importantly small producers bore the brunt of this decline in demand for local milk. At national level production for export has led to decreasing land areas planted with food crops for domestic consumption. Domestic food production has also been weakened by falling investment in agricultural research.

These trade and economic barriers, harming small producers and thus women farmers, worsen the impacts of HIV/AIDS on household-level labour, assets and skills, on burdens of care and household productive capacities that have set up a vicious interaction between malnutrition and HIV. Mary Materu of COUNSENUTH further highlighted the need for improved nutrition to be supported by access to education, water and sanitation.

This understanding of the immediate and underlying factors driving food insecurity and malnutrition underlined the view at the EQUINET conference that addressing food security and nutrition called for action across a wide range of sectors. At global level it was clear that Millennium Development Goals that call for improved nutrition cannot co-exist with trade policies that undermine the production basis for achieving the goals in the most vulnerable regions of the world. At regional and national level Chopra presented evidence to show that improved food security calls for more equitable access to land, improved investment in small holder farming, and increased access by women farmers to production inputs.

Dr Erika Malekia of the Southern African Development Community (SADC) echoed this call for “an integrated plan of action, focused on addressing inequalities in areas such as land distribution, gender equity.”

The conference delegates resolved to advocate for trade and agricultural policies that ensure food sovereignty and household food security through land redistribution and investment in small holder farming in ways that promote gender equity and sustainable food production. EQUINET will be following up on this resolution in a more focused future programme of work on food security and health equity. The conference suggested that EQUINET support for SADC regional strategies for food security should include two critical components, particularly if equity issues are to be addressed. The first is to strengthen and inform from a health perspective the challenges to trade policies that undermine national food production. The second is to inform and strengthen the health dimensions of policies and programmes that support land redistribution, smallholder production and increased access by women smallholder farmers to production inputs.

The EQUINET Conference abstract book and resolutions are available on the EQUINET website at www.equinetafrica.org and the conference report will be posted on this site in the coming month. EQUINET welcomes feedback to its editorials, suggestions, information and follow up enquiries to the EQUINET secretariat at TARSC, email admin@equinetafrica.org