Dr LEE Jong-wook, Director-General of the World Health Organization, died on 22 May 2006 following a short illness. EQUINET joins the many who have paid tribute to Dr Lee for his contribution to global public health, and send deep condolences to his family and colleagues.
Dr Lee was a national of the Republic of Korea and a world leader in public health. His contribution to global health has been commended from a wide spectrum of the global community: Treatment and health activists have recognized his decisive and bold leadership in declaring AIDS a global emergency in 2003 and in mobilising WHO organizational resources to deliver on the global commitment to provide 3 million people with Ante-retroviral treatment by 2005. While many challenges remain in this, the over 700% increase in the number of people in Sub-Saharan Africa on treatment between 2003 and 2005 is testimony to this leadership.
According to the WHO website (http://www.who.int/dg/lee/tribute/en/), Dr Lee, in explaining his vision of "universal access" to staff a few days before his death, indicated that there could be no 'comfort level' in the fight against HIV, and that the commitment to universal access to treatment by 2010 would be measured by an outcome in 2010 that no-one dies because they can't get drugs. In another editorial in this issue we explore some of the issues this poses globally, and for the region.
The United Nations Secretary-General Kofi Annan declared " The world has lost a great man today. LEE Jong-wook was a man of conviction and passion. He was a strong voice for the right of every man, woman and child to health prevention and care, and advocated on behalf of the very poorest people."
In his very first speech to WHO staff as Director-General, Dr Lee vowed that WHO would do the right things, in the right places. The WHO tribute makes clear that to him, the right places were the countries that most needed WHO's support. He considered WHO's job as one of huge responsibility to its 192 Member States, and the health needs of their people. This country focus sharply raised a glaring issue: that of equity and the inequalities within and across countries in health and health care. In his address to the Fifty Seventh World Health Assembly in 2004 Dr Lee noted “We have yet to get to grips with the links between health, equity and development. The underlying theme of my first year as Director-General is equity and social justice”.
To support work in this area, WHO set up a Commission on the Social Determinants of Health to gather evidence on the social and environmental causes of health inequities, and how to overcome them. EQUINET values the focus that Dr Lee gave to these inequities in health and health care, and the wider responsibility he articulated for action on the conditions and policies causing them within the whole global community. As he noted in 2004: “Hopes of peace and security in the world fade where these inequities prevail”. We pay tribute to Dr Lee for his championing, at the helm of the WHO, these values and goals of equity and social justice. They are deeply shared by EQUINET.
Under the Rules of Procedure of the World Health Assembly, and in accordance with the decision of the Director-General, WHO has indicated that Dr Anders Nordström - currently Assistant Director-General for General Management - will serve as Acting Director-General.
For information on the institutions in the EQUINET Steering Committee see www.equinetafrica.org or contact EQUINET through admin@equinetafrica.org
Editorial
When the United Nations General Assembly meets in June to review progress in tackling the AIDS epidemic it will be reminded by civil society globally of the commitment made to ensure universal access to treatment for AIDS by 2010. This commitment has greatest resonance in sub-Saharan Africa where AIDS related mortality is highest. Two years ago, in June 2004 the regional EQUINET conference of civil society, state, academic and parliamentary delegates resolved that the health challenges in east and southern Africa demanded health systems that are universal, comprehensive, equitable, participatory and publicly funded. This also has urgency in a region where poverty is undermining progress in meeting the most basic Millennium Development Goals.
How do these two sets of imperatives relate to each other? Do they reinforce each other or are they competing for policy attention and resources? Does giving urgency to addressing the right to treatment for AIDS boost or weaken efforts to rebuild fragile health systems? This was the focus of debate at a meeting in Cape Town in early May this year that gathered international AIDS activists, people living with HIV and AIDS (PLWHA) and health activists. The meeting was organised by Gay Men’s Health Crisis with support from the Rockefeller Foundation, and focused on “Identifying public policies for scaling up antiretroviral therapy (ART) and strengthening health systems in developing countries”
The gathering of AIDS and health systems activists itself signals a widening social debate on health and health systems, raising the social, economic and political profile of health after decades of market reforms that have undermined equity and solidarity in health and that have weakened public health systems. It builds on new and increased resources that AIDS brings to health systems, and a growth in social movements for health that can strengthen relationships between health services and communities.
Delegates recognised that access to treatment for AIDS is a right, and so too is access to essential health care. An advocacy and public policy agenda that recognises both of these rights of necessity calls for health-systems friendly, people (especially PLWHA) driven approaches to the establishment, scale-up and long-term sustainability of AIDS treatment programs. There has been past debate on whether the speed of responding to treatment rights compromises this goal of building sustainable systems. The AIDS epidemic is an emergency, and the level of avoidable infection and death calls for measures to bring HIV prevention and AIDS treatment services rapidly to community levels. At the same time it is a chronic long term issue that calls for sustainable systems and measures beyond emergency responses.
How can this be achieved? The meeting reinforced the more general call within the region for people centred health systems. The role people play in decision making in the health sector is important, and often weakly recognised. Specific measures were called for to remedy this.
For example it was proposed that decision making structures and processes include the active participation of PLWHAs, their communities, health care workers and other stakeholders from civil society. However, the governance of the health sector is weak in many countries and the acceptance of the role of civil society is contentious for many governments, thus making real participation a challenge in most settings. In order to pave the way for greater involvement, this participation needs to be backed by regulatory frameworks, guidelines, clear policy messages from governments and effective mechanisms and processes to manage this engagement, including for transparently managing conflicts in the interests and priorities of different groups.
Delegates agreed that involvement in decision making and delivery raises a corresponding obligation of PLWHAs and communities to be literate on both HIV prevention and AIDS treatment and on how health systems work. Building on community-based AIDS treatment literacy, health systems literacy is needed to build community knowledge on public health, and the health systems through which prevention and treatment are delivered. Just as AIDS treatment literacy has become a vehicle for mobilising communities around rights of access to ART, so health systems literacy should be a tool to mobilise communities around their collective rights to health and health care.
The desire to move at ‘AIDS speed’ has led to vertical programming to meet short term demands and delegates at the meeting agreed that some verticality is needed in the short term in response to the epidemic. However vertical programmes can only sustain the long term, lifetime delivery of ART if they are integrated within the wider health system. The issue of vertical programming and the integration in health systems is not unique to AIDS, and affects many other disease based programmes. The resources flowing to AIDS programmes gives it specific prominence, however, as the positive and negative systems effects can be pronounced. This issue naturally arose in the dialogue: delegates at the meeting recommended that plans for AIDS treatment programs need to assess which components can be immediately integrated into general health systems and which require vertical implementation in the short- to medium-term. Delegates also raised the need for plans to be set up front for how all vertical components will be integrated into the health system in the medium- and long-term. Whether initial decisions are made to vertically implement certain components of AIDS treatment programmes or to immediately integrate these components into general health systems, delegates raised the need to recognise, monitor and address problems that might arise from whatever approach is adopted. As the meeting noted, this calls for national information systems and research that is able to identify these effects. It also calls for policy processes that are responsive to this information and flexible enough to rapidly correct problems.
EQUINET has raised that fair financing and valuing of health workers is central to rebuilding national health systems in the region. These issues were also central in the dialogue at the meeting.
The absolute shortage of trained health care workers, at crisis levels in some African countries, is now a major impediment to treatment access, and needs short-term action linked to long-term measures. Health systems and AIDS activists agreed on this. Efforts by some governments in east and southern Africa to tackle this issue were noted, and need to be supported, spread, and backed by consultation with health workers. This calls for targets for training and employing health workers, new resources to employ and pay incentives to retain health workers and removal of any international finance institution conditions or fiscal restraints that undermine the application of these measures. The meeting delegates expressed frustration at the slow pace of global discussions and measures to cancel debt, mobilise aid and lift fiscal restraints to support these health system measures, relative to the speed with which these resources are needed.
The meeting agreed that a point of synthesis of all these points is that of support for bottom-up district level planning as this brings communities and health service providers together around priority health needs, including AIDS treatment. A number of key features were raised, for example:
• bottom-up level district planning that involves communities in a substantive way;
• respect for district planning by governments, international agencies, non government organisations and donors;
• ensuring free access to AIDS treatment (and primary health care services) at point of service and addressing other barriers to accessing care, such as transport to health services;
• resource allocation systems that are responsive to district planning.
To this we may add ensuring that health workers at district and primary health care levels are adequate, valued and retained, including ensuring their own access to AIDS treatment, strengthening district level health information and planning systems and revitalising and resourcing the community health worker and primary health care approaches that strengthened the interface between communities and health services.
Finally, the stewardship of global public health, AIDS programs and health systems, needs independent and rigorous external monitoring. The promises made at the 2001 UNGASS were largely promises broken and the new promises made at the 2006 UNGASS in New York need to be held open to greater scrutiny in the years ahead. Stronger mechanisms for monitoring of good practices and stewardship in health at global, regional and country level must be established and led by institutions from developing countries.
The dialogue at the meeting in Cape Town in May provided a useful opportunity to identify shared goals and paths to strengthening health systems and ensuring universal access to AIDS treatment. It now provides a useful ‘watching brief’ for health systems activists and AIDS activists to see how far the dialogue at UNGASS addresses our shared expectations.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org . EQUINET work on equity and health systems strengthening in health sector responses to AIDS is available at the EQUINET website at www.equinetafrica.org . Information on Gay Men’s Health Crisis can be found at http://www.gmhc.org/
The issue of appropriate health care financing mechanisms is once again high on the policy agenda of African governments. Not only have a number of governments (including South Africa, Uganda and Zambia) abolished some or all fees at public health facilities, which looks set to have ripple effects around the continent, but international organisations are placing considerable importance on health care financing in their engagements with African governments.
This is occurring in a context where:
• funding of health services from government tax revenue is very low, with about 60% of African countries devoting less than 10% of government expenditure to health care, despite the commitment by African Heads of State in Abuja in 2001 to commit 15% of their funds to the health sector;
• there is a heavy reliance on donor funding, with donors accounting for over a quarter of total health care financing in about 35% of African countries;
• there is very limited health insurance coverage; and
• the single largest source of health care finance is in most cases out-of-pocket payments – more than half of all health care expenditure is financed in this way in 40% of African countries.
It is critical that African governments are empowered to make their own decisions on appropriate ways of financing health services in their specific context. This is necessary to avoid the devastating consequences of financing policies imposed on Africa by international organisations over the past two decades. The most striking example is the World Bank and IMF requirement that governments reduce their funding of health services and increasingly rely on user fees as part of their Structural Adjustment Programs. This has not only contributed to the systematic devastation of public health systems but has impoverished households through the costs of illness. International organisations are already fighting for the hearts and minds of African policy makers. Some like Save the Children and the British agency DfID are pushing for rapid removal of user fees but with insufficient consideration of the need for wider action to develop the locally sustainable financing systems necessary to reconstruct national health systems. Others, specifically the World Bank, are pushing for private insurance for those working in the formal sector, with no acknowledgement of the equity problems of such financing mechanisms. The 2005 World Health Assembly adopted a resolution encouraging member states to pursue social and other forms of health insurance. WHO-AFRO is currently preparing a resolution on health care financing for review by African Ministers of Health. There is thus an urgent need for greater awareness of health care financing issues to promote locally relevant and equitable financing options.
It is particularly important that a set of equity principles are adopted at an early stage, against which alternative financing mechanisms can be evaluated within individual country contexts and which can be used to counter the arguments of international organisations and others attempting to impose inappropriate mechanisms. These include:
• The mechanism(s) should provide financial protection. No one who needs health services should be denied access due to inability to pay and payment for health care should happen before rather than at the time of use of services, such as through tax and/or health insurance.
• Contributions to health care should be based on ability-to-pay. Those with greater ability-to-pay should contribute a higher proportion of their income than those with lower incomes.
• Cross-subsidies (from the healthy to the ill and from the wealthy to the poor) in the overall health system should be promoted. This implies that there should be cross-subsidies across different financing mechanisms.
• Financial resources should translate into universal access to health services. All individuals should be entitled to benefit from health services via one of the funding mechanisms in place, and the package of benefits to which they are entitled should be clear, known and accessible. There should not be substantial differences in the range and quality of health services that different groups have access to.
On the basis of these principles, and an extensive review of health care financing options (outlined in EQUINET discussion paper 27) we recommend that in Africa:
• Governments make explicit commitments to move away from out-of-pocket funding of public sector health services and pursue alternative financing approaches.
• We increase tax revenue for health through improved tax collection and more appropriate corporate and wealth taxation strategies.
• We increase the health sector’s share of government resources in line with the existing commitment of African Heads of States, made in Abuja in 2001, to a 15% share for health.
• There be unconditional cancellation of African governments’ external debt, so that debt servicing can be redirected to health care.
• We introduce or expand health insurance schemes as part of an overall financing system that allows for cross-subsidy and closely monitor their equity impacts.
• We exercise caution in relation to private insurance for formal sector workers, which has undermined system-wide cross-subsidies in countries such as South Africa and Zimbabwe.
• Ministries of Health lead and control decisions on the use of donor funds to ensure that they contribute to achieving national health priorities.
• We implement effective mechanisms for identifying and protecting the poor and other vulnerable groups, such as by ensuring that they are subsidised as members of health insurance and do access decent health services.
• We equitably allocate the funds for health to ensure universal access to services
• We carefully plan any new financing policy developments, to take into account the views of beneficiaries, gain support from the health staff responsible for their implementation and identify any other strategic action required to generate adequate political and popular support to sustain policy change. It is particularly important to recognise that health workers are often caught in the middle of these policy changes, managing patients without the resources to meet their needs and expectations.
• We monitor progress and build ‘early learning’ mechanisms to review and adapt policies as implementation proceeds.
These principles and recommendations are a signal of our recognition of a bottom line: no matter what our policy aspirations, the way we finance our health systems will fundamentally determine the way our health systems reflect our social goals and meet our social needs.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org. EQUINET work on fair financing is available at the EQUINET website at www.equinetafrica.org. Discussion paper 27 on health care financing in Africa can be found at http://www.equinetafrica.org/bibl/equinetpub.php
The forthcoming June (volume 16 (1)) issue of the Malawi Medical Journal is a special issue focussing on equity. This special edition of the Malawi Medical Journal attempts to capture, synthesise and present debates and action around ‘how to’ deliver on equitable health service delivery in Malawi. The papers are organised into four sections.
The journal isssue explores the research and advocacy partnerships needed to promote equity in health in Malawi. It presents various equity studies on how the health sector can reach poor women, men, girls and boys. These studies were commissioned by the Equity and Access Sub Group to inform the equity monitoring of the Essential Health Package (EHP). Although each paper deals with a different health issue, cross-comparison of the papers allows system-wide analysis. The studies point to the need to bring essential services much closer to the poor– not only in terms of geographical proximity, but also in terms of affordability, cultural acceptability, and epidemiological relevance. This recommendation is closely in line with Government policy to implement the EHP of basic services. Thus, the recommendation is not to change policy, but rather to ensure its’ more energetic and effective implementation The EHP – free basic services at the point of delivery – lays a strong foundation for equitable health service provision. More energetic delivery then means improving access, strengthening human resources in Malawi at community level (including investing in Health Surveillance Assistants) and addressing stock outs of essential drugs.
The journal captures different viewpoints and perspectives on equity. The
six articles in this section highlight the importance of viewing equity with a holistic lens. The articles clearly illustrate the need for insights on equity drawn through various methods that capture the perspectives of different players - health workers as well as community members for example. They also demonstrate that many disciplines and approaches need to collaborate to understand, document and take action on the different factors that shape equity or inequity in health services.
The journal gives information on staying up to date and presenting information on equity in different ways. This section contains policy briefings, themed abstracts and details of useful websites on equity and health, which readers can use to stay current with equity and health debates and priorities at a regional and global level. The policy briefings and abstracts produced by REACH Trust are included in this journal for dissemination purposes. They cover issues such as linking research policy and practice to improve equity in health care in Malawi and promoting poor women and men’s access to health services through developing partnerships with community groups in Lilongwe. The abstracts provide snapshots of research findings across a number of thematic sub-headings, including equity and gender perspectives on TB and HIV in Malawi, equity monitoring, equity perspectives on TB diagnosis and an equity lens on pathways to care for TB and HIV care and treatment.
For more information on this journal issue contract REACH trust Malawi directly or through admin@equinetafrica.org
At this year’s World Health Day the WHO will be launching its annual report which focuses on human resources for health. In Africa, as we have raised in previous editorials in this newsletter, we are experiencing a ‘global conveyor belt’ of health workers flowing from rural, primary health care level in the public sector to urban, private care; from poor to rich areas and countries in the region and from the continent, with its high health needs and under-resourced health services to developed, high income countries such as USA, Canada, UK and Australia. The loss of public investment and social resources in this outflow is significant and outweighs any returns in remittances or aid for education.
However health workers will certainly continue to go to where they can work in adequately resourced health services, in decent jobs and where they can secure their own family needs. This draws attention to the much wider question of how in Africa we secure the resources to retain and value our health workers, and more widely to meet our population health needs. The latest EQUINET discussion paper, written by Patrick Bond and produced jointly by EQUINET with the Centre for Economic Justice in southern Africa points to a South-North drain of African wealth that undermines the resources for health and development, and that increases our dependency on the global North, and our loss of health workers.
The 2005 Commission for Africa report leaves the impression of a continent receiving a vast inflow of aid, with rising foreign investment, sustainable debt payments and adequate remittances from the African diaspora to fund development. Our discussion paper tells a different story: of significant and dramatically rising flows of resources out of Africa northwards, draining the continent of the important resources needed to address its own development, including in health. The paper synthesizes data about the outflow of Africa’s wealth, to reveal factors behind the continent’s ongoing underdevelopment, as the basis for proposing policy measures to reverse these flows.
The statistics speak loudly of a continent being progressively dispossessed of its wealth, and thus the resources it needs to improve health and human development:
* A debt crisis with repayments in the 1980s and 1990s that were 4.2 times the original 1980 debt levels, and annual debt repayments equivalent to three times the inflow in loans and, in most African countries, far exceeding export earnings, leaving a net flow deficit of by 2000 of $6.2 billion.
* Unequal exchange in trade and trade liberalisation policies that have lowered rather than increased Africa’s industrial potential and exacted an estimated toll in sub-Saharan Africa of $272 billion over the past 20 years.
* Flows of private African finance that have shifted from a net inflow during the 1970s, to gradual outflows during the 1980s, to substantial outflows during the 1990s.
* Falling foreign direct investment (FDI) from roughly one third of FDI to third world countries in the 1970s to less than 5% by the 1990s, and a shift to highly risky speculative investment in stock and currency markets – with erratic and overall negative effects on African currencies and economies.
Africa is commonly and mistakenly represented as the (unworthy) recipient of a vast aid inflow. Aid flows in fact dropped 40% during the 1990s, and the phantom aid that flows back to the source countries in technical and administrative costs was estimated in one study to be $42 billion of the 2003 total official aid of $69 billion, leaving just $27 billion in ‘real’ aid to poor people.
There is also a perverse subsidy in the extent to which industrialised countries exploit the global stock of non renewable natural resources . This takes place through the extraction of minerals and natural resources from Africa by Northern investors with little investment in return and few royalties provided. It also takes place through use of global goods like the earth’s clean air. Forests in the South absorbing carbon from the atmosphere are estimated for example to provide Northern polluters an annual subsidy of $75 billion. A method for measuring resource depletion used by the World Bank suggests that a country’s potential GDP falls by 9% for every percentage point increase in a country’s dependency on resource extraction. This implies, for example, that Gabon’s people lost $2,241 each in 2000, based on oil company extraction of oil resources,
These outflows deplete the resources available for productive and human development. They are felt most heavily by women and poor communities, and undermine progress towards the achievement of human security for the majority of African people.
They imply that the first step to effect genuine growth and to deliver welfare and basic infrastructure is for African societies and policymakers to identify and prevent the vast and ongoing outflows of the continent’s existing and potential wealth.
Current global reform agendas do not address these outflows. While they point to debt and unfair trade, they do not seek to reverse the outflow of African wealth.
Campaigns to reverse resource flows and challenge perverse subsidies are emerging from grassroots struggles and progressive social movements, such as those in Africa that are resisting privatisation and commodification of basic services, pressuring for rights to generic anti-retroviral medicines and resisting encroachments on human development through trade and macroeconomic policies that intensify inequities.
These grassroots struggles can be consolidated by national governments and regional co-operation to improve disclosure of financial flows and apply policies within Africa to prevent the outflows and encourage the ‘stay’ of domestic investment resources. The paper points to some options - systemic default on debt repayments, strategies to enforce domestic reinvestment of pension, insurance and other institutional funds; national-scale regulation of financial transfers from offshore tax havens; clearer identification and renegotiation of tied or phantom aid; and improved calculation and negotiation around of the costs of FDI (not simply the benefits), including natural resource depletion, transfer pricing and profit/dividend outflows.
EQUINET welcomes the focus on this year’s World Health Day on one area through which Africa is bleeding- its loss of human resources. We would however urge that to deal with this effectively in the continent, and address the inequity globally in the resources needed for health and human development goals, we need to deepen the debate. In 1998 EQUINET highlighted that a critical dimension of equity is the power and ability people have to make choices over health inputs and their capacity to use these choices towards health. For Africa this must surely include bringing control over the resources for health and development back within the continent.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org . EQUINET work on economic policy and health is available at the EQUINET website at www.equinetafrica.org
Research has consistently shown that gender inequalities and gender stereotypes restrict people’s access to health services. The same is true of treatment for HIV and related problems. Testimonies from women gathered by the International Community of Women Living with HIV/AIDS (ICW) shows the many ways in which this continues to take place, even as access to treatment expands.
HIV-related stigma and discrimination and gender inequalities are rife and when, for example, a woman has to ask relatives for permission to access services her safety and confidentiality are jeopardised. Violence and sexual coercion in the first place put women at risk from HIV infection. An HIV positive diagnosis can lead to increased levels of abuse, violence and abandonment and also lead to a further lack of self-confidence all of which undermine women’s ability to look after their health and assert their rights. When services are centrally located in major urban areas or when they charge fees for service, women are even less likely to access them. In fact even when ART is free women have found that costs associated with travel and treatment for related health problems puts the chance of leading a healthy life with HIV out of their reach.
A further concern arises when women access ARVs and their families do not. This may happen either due to a lack of ART provision for families or a reluctance on the part of family members to be tested. This puts the women who are being treated under severe pressure, through coercion or guilt, to share their treatment. "Most of us as women living with HIV and who are using ARVs we face a common problem that our husbands or partners tend to force us to give them our ARVs dose while he has not tested for HIV and doesn’t know his CD4 counts. They do not want to go for testing while they show all HIV symptoms. Even if you refuse he will find where you keep your medicine and steal them." (ICW members, Tanzania, 2005). Further, if family members are not accessing treatment then the burden to care for them as their health worsens generally falls on women.
Gender and HIV-related stigma and discrimination are also reflected in the health services. Our members have reported that health care workers:
• are often indiscreet and disrespectful;
• put conditionalties on treatment access, for example, making women go on contraceptives;
• fail to understand the context within which women have to put into action advice and treatments given, for example, advice against breast-feeding maybe ignored because of the associated stigma;
• lack specialist knowledge and services about treatment issues for women; and
• do not provide suitable monitoring and follow-up care of treatment and side-effects.
These latter two conditions are worsened in resource poor settings. Women report that they feel better able to deal with a positive diagnosis when health care workers are respectful of women and their rights, refer them to sources of care and support and understand the specific problems they face in terms health; and how they can act on the advice and treatment given them.
"We have been having some changes and interruptions in our treatment regimes because many times when we go for ARVs clinic we are being asked for some money so we tend to miss the dose even for a week or month till we get some money to pay for that service. Another regime is lack of enough food especially to us women who are under treatment. The consequences were; not finishing my dose which caused infections, staying without a dose till the clinic day and lie to the service provider that I have finished my dose, fighting with my husband or even chasing me out of the house when I refuse giving him my dose."
(ICW members, Tanzania, 2005)
Too often information is not tailored to cover the range of concerns that HIV positive have regarding care, treatment and support. Information given may be pushing a government or company line, be written in English and not local languages or may use medical language and dense text. The information may only be available in health centres and not distributed to places where women can access it during their daily routines. It may only be available in written form causing problems for women that are not literacte. The scarcity of relevant information is made worse by the lack of research on the gender-related impact of treatment for AIDS, or on related issues like its interaction with social and clinical factors such as hormonal contraceptives and violence in the family.
That is why ICW calls for knowledge and information tailored to the specific needs of women, delivered in a way that understands that women may not chance upon it on a table in a waiting room at the hospital. Support groups are already doing a wonderful job in this regard. We also call for women-specific clinical and social research that does not just treat participants as research subjects from which information can be extracted, but empowers them to participate in research in ways that enable them to gain skills and to use the information to advocate for change in their communities and countries.
Finally, there are a growing number of HIV positive women who are treatment activists. We feel frustrated when we constantly hear policy-makers tell us that we, as women treatment activists, we do not have the skills to engage with them. We would rather ask whether those in policy positions have the skills to engage with us in a way that is respectful and meaningful. With the challenges we face in reaching universal access, surely it is time that we all challenged our notions of where true expertise lies?
The International Community of Women Living with HIV/AIDS (ICW), set up in 1992, is an international network with over 5000 HIV positive women members worldwide. This article is based on their testimonies. “ACTS” refers to HIV positive women's ability to gain consistent access to all available care, treatment and support services.
Please send feedback or queries on the issues raised in this briefing to ICW http://www.icw.org/tiki-view_articles.php or to the EQUINET secretariat at TARSC, email admin@equinetafrica.org . EQUINET work on access to treatment is available at the EQUINET website at www.equinetafrica.org
Sally Theobald, Ireen Makwiza REACH Trust, Malawi; Erik Schouten, Ministry of Health, Malawi and Management Sciences for Health; Andrew Agabu, Andrina Mwansambo, National AIDS Commission, Malawi.
Why the move to universal access when we haven’t yet met the 3 by 5 target? What does universal access actually mean? Does this new focus on universal access offer an opportunity for advocacy for equity?
The focus on universal access has its roots in the Special Session of the UN General Assembly (UNGASS) declaration in 2001 and was further reinforced by discussion at the International AIDS Conference in Bangkok in 2004 and the G8 Summit in Gleneagles, Scotland, 2005. The onus is for countries to define – through consultative processes – what ‘universal’ access means rather than working to global targets and put together plans and processes to meet universal access. These country consultative processes should in theory feed into regional consultation processes. For southern and east Africa, these will be held in Zimbabwe from 7-10 March, 2006 and will, in turn, shape the Africa Wide consultation 4-6 May, 2006 and the Global Steering Committee.
While there are sceptics, this may be seen as an opportunity to raise the profile of equity concerns. EQUINET’s work on antiretroviral therapy (ART) in the context of health systems reported on the EQUINET website (www.equinetafrica.org) raises two overarching and inter-related equity challenges:
1. How can we address barriers to access to quality treatment and care – by gender, age, socio-economic status and geographical coverage?
2. How can we ensure that ART delivery strengthens rather than undermines the broader public health system?
Countries have been asked to consider main barriers to scaling up which will be fed to the Global Steering Committee for action. In Malawi, for example, initial barriers highlighted include:
* Constraints to ensuring adequate sustained financing, and therefore to planning ahead, for scaled up AIDS responses:
This calls for sustainable and responsive funding for the provision of ART and for the strengthening of public health systems. This is critical to ensure that we continue to be able to provide ART to those in need. The current Global Fund for AIDS TB and Malaria process of proposal writing for 5 year programmes and resubmitting after 2 years is problematic, as it can result in decision making delays and risks of interrupted supplies of ART, HIV test kits and other supplies.
* Too few trained human resources, and health and social systems constraints:
We need to build and sustain a healthy and motivated workforce to provide ART and to meet the broader health needs of our citizens. This means investing in training and developing supportive working environments to retain our workers and address the brain drain. However, despite our best efforts the numbers of professional cadres will not be adequate by 2010. We also need to think creatively about who constitutes ‘human resources for health’, and how to deliver services through building partnerships with lay health workers, NGOs, private sector providers and community based organisations. Such partnerships and decentralisation of health provision will enhance the access of poor women and men to HIV and AIDS Treatment and Care.
* Barriers to reliable access to commodities and low-cost technologies (e.g. condoms, injecting equipment, medicines and diagnostics):
There is need for use of TRIPs flexibilities, and for pharmaceutical companies to not only reduce the cost of drugs but also ensure long-term fair access to patient-friendly ART regimens for adults and children. Diagnosis and treatment of paediatric AIDS is made difficult due to the unavailability of simple and affordable technology for diagnosing HIV in children, and the lack of paediatric formula. The current first line regimen for adults is based on fixed dose combinations (FDCs) and with the advantage that patients only have to take 2 tablets a day. Scaling up programmes in resource poor environments relies heavily on these simplified regimens which ease the supply chain and instructions to patients on adherence. If the next generation of regimens is not available as FDCs (our current second line regimen consists of 7 tablets per day) the scale up of ART will be heavily compromised.
* Stigma and discrimination, inequity, gender discrimination and insufficient promotion of HIV-related human rights:
We need to be active in addressing stigma and ensuring that gender equity and rights based approaches underpin action. In Malawi we have a policy on equity and ART. The focus on universal access provides an opportunity to advocate to implement this and monitor progress.
These challenges to universal access resonate clearly with EQUINET’s equity focus and work. Make sure your voice is heard in these consultation processes at country, regional and global level. You can also join an e-mail based consultation with civil society organisations and networks to provide direct input into a Global Steering Committee on Universal Access which is currently being hosted by ICASO. Send your feedback to: universalaccess@icaso.org The ICASO press release for more information on the consultation process is available at:
http://www.healthdev.org/eforums/cms/showMessage.asp?msgid=9701
Please send feedback or queries on the issues raised in this editorial or requests for further information on EQUINET and REACH Trust’s work on equity and health systems strengthening in ART outreach to admin@equinetafrica.org
How can we attract health workers to stay within our public health services?
How many countries in our region meet the Abuja target of 15% of government spending on health?
What does an African debt burden of $8.6 billion a year mean for health services?
How many countries in our region include the right health in the constitution?
How can the cost of health for the poorest communities be reduced?
What does it mean to have a ‘people centred’ health system?
The EQUINET newsletter is over five years old and has in its lifetime covered a spectrum of issues affecting health equity in our region, and raised some of the questions above. In 2005 our editorials ranged from access to treatment to the outflow of resources from Africa. The spectrum of challenges to health equity are clearly wide, and involve many different people, communities, disciplines and actors. We hope that the newsletter has been informative and useful and will continue to be so. We’d greatly welcome your ideas and information on how to improve it.
In 2006 we are also asking for you to play a more active role! EQUINET will, with your support, be carrying out a regional equity analysis in 2006, to profile the issues, evidence, experiences and options for action to strengthen health equity, through a regional equity analysis. The adoption in 2005 of the SADC Health protocol gives us a policy framework for this. Within this context, we will over the course of 2006 draw together YOUR perspectives, evidence, experiences, and views on how to advance health equity at local, national and regional level.
From the work we have done in EQUINET, including the values and perspectives communicated through the last five years of this newsletter, we have identified some priority areas that we will focus on. People in the region have major health concerns relating to access to incomes, food, employment, healthy living conditions and community environments. These require action from all sectors, and not just the health sector. There is a common concern that to advance health across all sectors and all social groups, we also need to revitalize and build comprehensive, universal and integrated national health systems that address these concerns and that provide access to health care for all. While many features of health systems have been raised, there are some that have been most commonly identified as a priority for health equity that we will give more focus to in 2006.
These are
i. building people-centred health systems that organise, empower, value and entitle communities;
ii. promoting increased fair, sustainable and equitable financing for health at national, regional and global level;
iii. ensuring adequate, well-trained, equitably distributed and motivated health workers; and
iv. backing national policies with fair global policy, including just trade, reversing unfair flows of resources and having the national and regional policy flexibility to exercise policies that improve health.
What policies, programmes and obstacles exist in these areas in our region?
Which have been more successful in overcoming differences in health across social groups and ensuring access to health care for all?
What opportunities and challenges do we face in implementing these policies and programmes?
We invite you to contribute to the dialogue, learning and analysis that we will build in these areas, through your expertise and experience, positive examples and case studies, evidence and data, and photographs. Email us on admin@equinetafrica.org with any information, published papers or pictures of the work you or others are doing in these priority areas. Through the newsletter we will share this information more widely. We will also feed it into the regional equity analysis.
We also invite you to be involved in the research, student grants, training, dialogue forums, exchange visits and other areas of work that we will be carrying out with you in 2006 to inform and strengthen learning and action on health equity. Our website (www.equinetafrica.org) provides up to date information on these activities.
We look forward to working with you in 2006!
The current WTO negotiations, headed for the next trade ministers meeting in Hong Kong in December, look set for more protection of corporate rights and a further erosion of health rights in the General Agreement on Trade in Services (GATS) and the Trade Related Intellectual Property Rights Agreement (TRIPs). Outcomes in these discussions depend on a breakthrough in the agricultural negotiations.
While health is a basic human right, the protection of this right still has little recognition in the global trade agenda. The formal recognition of public health interests is in fact subjugated to the interests of corporate profit, with the protection of these corporate interests by rich countries.
While the TRIPs agreement allows violations of patent rights for public non-commercial use, compulsory licensing and parallel importation, these rights are not exercised because political pressure is brought to bear on countries that try to use them. TRIPs are creating a false scarcity of access to pharmaceutical drugs. Developing country governments and civil society campaigned at the 2001 Doha, Qatar World Trade Organisation (WTO) Ministerial Conference to improve access to drugs. This ended with a statement of ministers (restating the rights contained in the 1995 agreement) allowing countries to use flexibilities in the agreement to legally bypass patent rights.
Since achieving this confirmation of rights, global public health has suffered a series of defeats. Flexibilities are still not being used because unseen threats are made against countries that try to use their rights. The practical import of these deceptively generous rights in TRIPS is nullified, while rich countries are still able to exercise them (such as when the US accessed patented drugs to cope with the threat of a terrorist anthrax attack).
Even when flexibilities are exercised, African countries still have a problem that compulsory licensing under TRIPs can be used to produce mainly for local consumption. Countries with low or no local production capacity, cannot access branded drugs because of price. They cannot import generic drugs produced under compulsory licenses in other countries because other countries must comply with the local consumption regulations where up to 49% of production can be exported. Before the 2003 Cancun Ministerial, a settlement was reached allowing countries with limited local production capacity a waiver to import these drugs, but the waiver agreement is so onerous as to be useless. It has not been used once since coming into effect – not even by developed countries who can also take advantage of this flexibility to export drugs to poorer parts of the world.
The WTO Secretariat - supposedly merely international civil servants - also changed the signed text of the waiver, by including a footnote and asterisk after the signature. (The footnote refers to a document that was not part of the agreement, called the Chairman's text, which carries language about sustainable development and the fundamental rights to food, productive assets, development, health, education, economic, social and cultural autonomy, and self-determination but insists that signatories must resort to market mechanisms to claim these rights.) The US insists this footnote should guide the interpretation of the waiver, while developing countries regard it as irrelevant. The WTO Secretariat has refused to remove the asterisk and the footnote, despite the millions of lives affected by its addition.
Africa is pushing for a useable settlement in current negotiations, seeking to amend the TRIPs agreement and remove the onerous conditions in the waiver – so they can access low cost drugs. This has been summarily rejected by the US which wishes to retain current arrangements to protect profits and divert cheaper drugs into their markets. The EU is playing a brokering role, with the same ends as the US, but minimising the ambitions of the Africans in a more diplomatic way.
And with no progress on TRIPs, rich countries are making more demands on developing countries. The draft text on services for the Hong Kong Ministerial negotiations disregards developing countries submissions on domestic regulation and reflects the rich country proposals. It promotes the “list it or lose it” approach to regulations, requiring countries to list restrictive regulations or face losing them if challenged at the WTO. Developing countries have opposed the deception that the draft text reflects a possible consensus position: these objections have been “noted”, but not reflected in the text.
Regulatory measures are major impediments to international services trade. The GATS agreement – which regulates professional health services, health care services and health insurance – places disciplines on the state’s ability to regulate the service sector. Only “necessary” regulations can be validly imposed, with GATS demanding that ‘necessity’ be determined by the WTO and not by nations themselves – effectively outsourcing government regulatory power to the WTO's Dispute Settlement Body in Geneva. Therefore, GATS will seriously limit the ability of states to manage destructive competition and create adequate economies of scale. They will undermine the flexibility to use subsidies to the poor and cross-subsidisation. For poor countries, these commitments are effectively permanent because reversing commitments requires the payment of compensation that poor countries can ill-afford.
To add insult to injury, the EU demands countries in the south liberalise service sectors while giving European civil society “assurance” that their public services will not be put on the table. The EU says there is a crisis in the services talks with too few offers of liberalisation on the table from developing countries. Developing countries contend that offers from the rich countries do not match their export interests, so they cannot take the blame for the lack of progress in negotiations. To improve the liberalisation offers on the table, the EU proposes changes in the GATS negotiations process. Instead of countries volunteering a list of sectors the EU is demanding that target benchmarks be set for liberalisation of sub-sectors. Qualitatively, the EU wants: limits removed with respect to consumption of services abroad; increased access to cross border trade and commercial presence; removal of foreign equity ownership; and the reduction of discriminatory economic needs tests. Developing countries have rejected this aggressive pursuit of GATS.
The most important matter in the WTO remains agriculture, which could unblock all the other negotiations. Rich country subsidies allow produce to be sold at prices below the cost of production. These subsidies (to the tune of US$ 1 billion per day) play havoc with international commodity prices and undermine the export market interests of developing countries. Compounding this are demands for reduced import tariffs in developing countries. The subsidy cuts offered by the EU and US will have little or no impact and leave us far from an international trading system that promotes the type of food sovereignty needed for improved food security and nutrition outlined in earlier EQUINET newsletters.
The current WTO negotiations expose the extent to which proposals from the rich countries will seriously undermine advances in public health. The trade, political and other pressures brought to bear indicate that below a veneer of ‘democratic functioning’ the discussion on global trade continues to be held within institutional arrangements and processes that protect excesses of wealth and hide the exploitation of the poorest nations in the world.
* Riaz Tayob is from SEATINI and represents EQUINET's theme work on trade and health.
* Please send feedback or queries on the issues raised in this briefing to SEATINI at www.seatini.org or to the EQUINET secretariat at TARSC, email admin@equinetafrica.org EQUINET work on trade and health is available at the EQUINET website at www.equinetafrica.org
There are many occasions during the course of the year to pronounce about the pandemic. On the occasion of this World AIDS Day, I’d like to resist the temptation to run with hyperbole. Rather, I’d like to put two specific proposals which may seem obvious, but which speak, I believe, to the heart of the struggle against the virus.
The first involves dollars. The Global Fund to Fight AIDS, Tuberculosis and Malaria --- the best financial vehicle by far to help break the back of the pandemic --- is in terrible trouble. It is over three billion dollars short for 2006 and 2007, and that shortfall will doom millions to death in the following years unless something drastic is done, and fast.
What has happened was completely unexpected. The G8 leaders met at Gleneagles in July, and emerged with ringing promises of financial assistance for Africa. The first test of those promises came just eight weeks later, in early September, at the replenishment conference for the Global Fund. The G8 flunked the test. The assumption was that the Global Fund would go right over the top given the rhetoric of the Gleneagles Summit, but instead, having requested $7.1 billion, the Global Fund fell billions short.
It’s fair to say that everyone was stunned. It took only eight short weeks for the G8’s signed agreement to fall apart.
I’ve just spent the last three days in Rwanda at the regional conference of the Global Fund for East Africa and the Indian Ocean. It’s absolutely astonishing to see how determined the countries are to achieve the goal of universal treatment by 2010, but they’re frightened by the prospect of not having sustainable resources. They know they can’t interrupt treatment once it’s started, but what guarantee do they have, under present circumstances, that the G8 will be by their side as promised?
All they can count on, for certain, is betrayal.
That must somehow be reversed. The year 2005 showed that treatment is possible in great numbers, and there is a strong sense that if the momentum can be sustained, the back of the pandemic can be broken. But that will depend on a continuing, reliable flow of resources. It depends on the commitments of the G8 being honoured. With the loss of honour goes the loss of life.
However, in addition to keeping the pressure on governments, we need a new source of dollars. That source must be the private sector. It was always hoped -- indeed, even expected -- that private sector money from major multinational corporations would help to keep the Global Fund going. It hasn’t happened. The contributions are negligible. It’s as though most of the private sector doesn’t know the Global Fund exists.
I want to suggest that companies contribute 0.7% of pre-tax profits annually to the Global Fund. To maintain the symmetry with governments and the Millennium Development Goals, they should phase the money in and reach the full target by 2015. Which corporations? Pretty obviously, I think, the big multinational corporations that have exacted such huge wealth from Africa’s mineral, diamond, oil and other resources over the decades, and certainly the pharmaceutical industry, which resisted the lowering of drug prices for an unconscionable length of time.
But there may be an even better and fairer way to select the corporate contributors. The Global Business Coalition on HIV/AIDS has a membership of some two hundred multinational corporations. Many of these corporations deal admirably with their workforces, providing antiretroviral drugs to their workers where necessary, and sometimes to the workers’ partners and children. Others of these corporations make in-kind contributions, or investments in research and training centres. But the true expression of corporate social responsibility would be a 0.7% contribution to the Global Fund. If the principle spread, the dollars would mount unto the billions.
There’s no reason to feel cynical about such a proposition. People mocked when Gordon Brown talked of his International Finance Facility, but now it’s well and truly launched. People mocked when France advanced the idea of a tax on airline travel to fund development, but now President Chirac seems determined to proceed. There’s room for every genuine initiative.
This effort would show the world that the pandemic can be beaten.
Now allow me to switch gears and deal with a particular aspect of children and AIDS which reveals an appalling double standard, and must be dealt with. In fact, it should have been dealt with several years ago.
The overwhelming majority of HIV-positive children are infected by the virus during and following the birthing process. Children infected in early infancy usually die before the age of two. There are more than half a million deaths of children from AIDS every year.
In many countries, primarily in Africa, there are programs in place called PMTCT, Prevention of Mother-to-Child Transmission. Unfortunately, most of these are merely pilot programs: fewer than ten per cent of HIV- positive pregnant women have access to PMTCT. That, in itself, is scandalous.
In most countries the PMTCT program uses what is called single-dose nevirapine … one tablet of that drug to the mother during labour and a liquid equivalent of the drug for the child within 48 hours of birth. Incredibly enough, the transmission is cut by close to 50 per cent! Half the babies who would otherwise be born positive are born negative.
That, of course, is wonderful. But compare it with North America (or anywhere in the western world). North American hospitals do not use the drug nevirapine; they use full antiretroviral triple-dose combination therapy from approximately 28 weeks through to the end of the pregnancy. The result? The transmission rate drops to between one and two per cent!!
Why do we tolerate one regimen for Africa (second-rate) and another for the rich nations (first rate)? Why do we tolerate the carnage of African children, and save the life of every western child? Is it possible to do full therapy in Africa rather than single dose nevirapine? Of course it is. Doctors Without Borders does it in Uganda; Partners in Health does it in Rwanda; Saint Egidio does it in Mozambique. In fact, Rwanda is introducing a formal protocol to make sure that full therapy is provided in every setting where PMTCT is available. They are the first country to do so.
It leaves the mind reeling to think of the millions of children who should be alive and aren’t alive, simply because the world imposes such an obscene division between rich and poor. That’s about to change, but why does it always come after an horrific toll is taken?
There is another aspect of saving children’s lives that is much neglected and much rationalized. Even when transmission is prevented during pregnancy and birth, the virus can still be passed through breast milk. Therefore, we require safe solutions to infant feeding, including secure supplies of formula where feasible, with careful instruction about clean bottles and preparation, and all of it provided free: there’s just no possibility of rural village women in Africa being able to pay for breast milk substitutes.
Research available so far indicates that that, too, must become public policy wherever possible. And where it’s not possible or safe, exclusive breast-feeding for six months is undoubtedly the best course. It’s worth noting that it took almost a decade to finally develop antiretroviral drug preparations for children with AIDS. The time has come to reduce, dramatically, the numbers of children who begin their lives infected.
On this World AIDS Day, 2005, I have the deep impression that if only we could galvanize the world, we’d subdue this pandemic. We’re terrific when it comes to studies and documentation. Reports like the Epidemic Update issued by UNAIDS last week are models of statistical compilation, containing pockets of fascinating material. But the report itself acknowledges that real progress against the pandemic is hard to find.
We need a superhuman effort from every corner of the international community. We’re not getting it. At the present rate, we’ll have a cumulative total of one hundred million deaths and infections by the year 2012. We call ourselves an advanced civilization.