Health – a global public good?
IPHN bulletin Number 10: March 2002

The World Health Organisation is calling for a massive investment by the rich governments of the world into the health of the world’s poor. This is the conclusion of a report by the Commission on Macroeconomics and Health (CMH, 2001a), launched in London on 20.12.01. The report calls for an increased investment in health of US$27 billion per year by the year 2007. It is estimated that such an investment would save 8 million lives per year. Speaking at the launch, Jeffrey Sachs, the Commission’s chair reported that the new Global Fund for AIDS, TB and malaria (see IPHN bulletin 8 http://www.iphn.org/bulletin8.html) could be one of several vehicles for delivering such funds, delivering perhaps up to 30% of the total fund needed. He said, “We need to bankrupt the Global Fund as soon as possible to demonstrate that poor countries have the absorptive capacity and to force the US government to act.” This argument has strong similarities with calls from the United Nations Development Programme [UNDP] for health to be considered a ‘global public good’ (Kaul et al., 1999). The Commission itself refers to global public goods and defines them as ‘goods whose characteristics of publicness (nonrivalry in consumption and nonexcludability of benefits) extend to more than one set of countries or more than one geographic regions (CMH, 2001a, p.190).’ One of the six working groups was specifically focused on the subject of global public goods for health (CMH, 2001a, p.151 – see http://www.cmhealth.org/wg2.htm). A particularly strong emphasis in the commission’s report was on the status of health knowledge and information as a global public good (CMH, 2001a, pp.76-86).

What are Public Goods?

The concept of dividing goods into ‘public’ and ‘private’ goods arises from classical economics and can be dated back to the 18th century. According to this concept, characteristics of public goods include:

· Non-rivalry in consumption which means that one person’s use of a good does not prevent another person from using it (Kaul et al, 1999). This is termed by some as non-divisibility (Chen et al, 1999)

· Non-excludability, i.e. use of item is available to all people/groups of people (Kaul et al, 1999)

· Non-rejectability, individuals are unable to choose to forego consumption (Preker et al, 2000)

An example of a private good might be a piece of cake. If I eat it, no-one else can (i.e. it is rival). I may chose to share it with my friends, excluding others (i.e. excludable). I may choose not to eat cake (i.e. it is rejectable). On the other hand, traffic lights might be considered an example of a public good. My use of a traffic light does not prevent others from using it (i.e. it is non-rival). Traffic lights apply to all people (i.e. it is non-excludable) and it would be almost impossible to not use traffic lights (i.e. it is non-rejectable). Other examples of public goods might include peace, law and order and good macroeconomic management. However, this distinction between private and public goods is not always that clear cut. Although some goods might be purely private or purely public, there will be some that are mixed/impure. Goods which are non-rival amongst a certain group of people can be termed ‘club goods’ and those which are available to all but are rival can be termed ‘common pool resources’ (see figure 1). These ‘impure’ goods are more common than the pure type. Consequently, the term public good is often used to include both pure and impure public goods (i.e. the shaded area in figure 1 ) (Kaul et al, 1999). Commonly, five sectors of public goods can be identified, namely environment, health, governance, security and knowledge (Te Velde, 2002).

According to neo-classical economic theory, attempting to provide pure public goods through competitive markets will lead to sub-optimal quality, quantity and price (Preker et al, 2000). Two reasons for this can be identified for this. First, individuals motivated by self-interest only will tend to ‘free ride’ concerning the provision of these goods. Secondly, individuals will tend to make sub-optimal decisions on these issues if those decisions are made in isolation from others. Effective provision of public goods requires co-operation and measures which promote communication and build trust (Kaul et al, 1999). What are Global Goods?

In many cases, it is assumed that responsibility for provision of public goods rests with the nation state. However, there may be some cases where goods are global rather than national. Suggested criteria for deciding this include the requirement that global goods are quasi-universal in terms of:

· Countries, that is they involve more than one group · People, that is they involve several/all population groups, e.g. socio-economic groups, ethnic groups, gender, religion etc.

· Generations, that is they affect current and future generations In order to assess what kind of goods might be global in this regard, it may be useful to consider problems (i.e. global ‘bads’) which fulfil those criteria, for example banking crises, Internet crime and fraud, Ill-health due to increased trade and travel, drug abuse, smoking etc. (Kaul et al, 1999). Global public goods may be considered of two types. There are final global public goods which consist of desired outcomes and may be tangible, e.g. the environment or intangible, e.g. peace. For example, the World Bank recognizes five global public goods priorities, namely communicable diseases, environmental commons, information & knowledge, trade & integration and international financial architecture (World Bank, 2001). Secondly, there are intermediate global public goods which consist of international regimes, agreements and institutions which have the aim of delivering final global public goods. Examples might include frameworks for international transport and communication, health, the environment, demographics, judicial systems, human rights and macroeconomic policy (Kaul et al, 1999).

Is an Economics-based Definition of Global Public Goods Adequate?

So far, this paper has considered the concept of global public goods from the perspective of neo-classical economics. However, the validity of defining global public goods in this way has been challenged by some people. For example, Wolfgang Reinicke, Director of the Global Public Policy Project, an economist with long experience of working in the World Bank, said, “In most societies, the spectrum of public goods goes far beyond what a classic economic definition of joint consumption and non-excludability would capture. It is far more important for the members of each society to determine - in a transparent, democratic process - what is and what is not in the public interest (Reinicke, 2001).” Supplying Global Public Goods As seen earlier, classical economic theory predicts that competitive markets will provide public goods in a sub-optimal way. This leads to the problem of how public goods, in general and global public goods, in particular can be supplied. Two key factors have been identified in determining how sub-optimal provision through markets will be. These factors are the ‘degree of publicness’ of the goods and the number of beneficiaries. The latter factor is a particular problem for global public goods whose beneficiaries number billions and who are represented by more than 180 nation states. These states have their own self-interests and there are a diverse range of interest groups within the world’s population (Kaul et al, 1999). There is therefore a strong argument for international aid to be used to finance global public goods. Three building blocks for this argument are that:

· The private sector will not provide a sufficient amount of public goods · Individual countries have insufficient incentives to make an optimal contribution to global public goods because benefits do not accrue equally nationally · Poor countries lack the resources to make a full contribution to global public goods (Te Velde, 2002)

Increasingly, the World Bank is seen as a financing mechanism through which global public goods can be provided. The Global Environment Fund would be one such example and it has been proposed that the Global Fund for AIDS, TB and Malaria be administered in a similar way (Unknown, 2002). Global public policy networks are also seen as having an important role in the area of supply of global public goods because they bring together diverse interest groups and can address transnational issues which no single group can address alone. Examples include:

· Placing issues on the global agenda, e.g. landmines, Jubilee 2000 · Facilitating setting of global standards, e.g. World Commission on Dams · Developing mechanisms for producing/sharing critical knowledge, e.g. Consultative Group on International Agricultural Research [CGIAR] · Creating markets where they are lacking, e.g. GAVI · Developing mechanisms for innovative implementation , e.g. Global Environment Facility · Creating trust and promote participation - reducing democratic deficit – an example of what happens when this fails would be the demonstrations in Seattle and against the workings of the World Bank (Reinicke, 2001).

Is health a global public good?

Traditionally, diseases can be divided into three groups, communicable diseases, communicable diseases and injuries. Because treatment of infectious diseases produces benefits to people other than those treated (termed positive externalities by economists), the control of communicable diseases has been widely considered a public good. However, because most of the determinants of non-communicable disease appear to be individual lifestyle choices, e.g. diet, tobacco use, exercise etc. treatment of these diseases is widely seen as a private good (Chen et al, 1999). However, applying strict classical economic criteria to health goods would result in very few being considered ‘pure public goods’ because most have some degree of excludability, rivalry and rejectability. For example, a vaccine given to one person is not available for another and people may choose not to be vaccinated (Preker etal, 2000).

However, even if health is accepted as a public good, much of it is likely to be seen as a national public good rather than one with global implications. For example, Te Velde considers primary health care as a national public good and only the prevention of disease spread across borders as a global public good (Te Velde, 2002). However, others have argued that health has become much more of a global public good because of a number of influences of globalization. First, increased international linkages through trade, migration and information flows not only provide opportunity for cross-border transmission of infectious agents but also allow ‘transmission’ of behavioural and environmental risks. Secondly, increased pressure on common-pool global resources, e.g. air and water, brings its own threats (Chen et al, 1999). Examples of health effects which can be considered global public goods as a result of globalization might include:

· Health effects of environmental change, e.g. global warming, ozone depletion, toxic waste disposal · Tobacco usage – this is not only influenced by individual behaviour but by global marketing campaigns · Illicit drug use – globalization has made control of drug trafficking more difficult (Chen et al, 1999)

However, all these issues are based on the same logic as focusing on the cross-border transmission of infectious disease as a global public good, namely that the causes and effects of disease, particularly in an era of globalization, are not limited to national boundaries and need to be approached on a global level. Another logic for considering health as a global public good can be considered in terms of the global imperative for poverty reduction (Te Velde, 2002). This is being used by a number of politicians as a basis for investment in health and development, for example Gordon Brown, the UK’s Finance Minister. The basis of this argument is that investment in health is a key element of an effective poverty reduction strategy and reducing poverty in poorer countries is essential if conflict is to be reduced, communicable disease controlled and environmental damage minimized. In a presentation to the UK Health and Development Forum in London in February 2002, a WHO economist distinguished between ‘health as a global public good’ and ‘global public goods for health’. For an area of health to be considered a global public good he explained that efforts to promote it would need to produce global health and economic benefits. On this basis, control of communicable disease, e.g. polio eradication is widely considered a global public good. On the other hand, there are many global public goods for health, that is global public goods which have health effects. Examples would include medical technologies, tobacco control and trade agreements. He also stressed the importance of ‘access goods’ – those goods which allow a person to benefit from a global public good. For example, a radio allows a person access to the radio waves which can be considered a global public good. He argued for health systems to be considered an access good in relation to many of the technological advances in health which could be considered global public goods (Woodward, 2002).

Conclusions It seems uncontroversial that certain aspects of health can be considered a global public good, particularly the control of infectious diseases which can spread across national borders. However, in an increasingly globalised world, it can be argued that, more and more, the cause and effects of disease are transnational. Finally, it can be argued that all of health should be considered a global public good because it is a key component of another global public good, poverty reduction, and because the global community has determined that it should so be considered. The report of the Commission on Macroeconomics and Health is not always explicit about the way it is interpreting health as a global public good. The main argument of the report is that rich countries should invest in the health of poorer countries as a way of supporting economic development and contributing to poverty alleviation. This is presumably of value to the international community and could therefore be considered a global public good. Some of this thinking is seen in statements associated with the commission which claim that controlling the diseases of the poor will promote political and social stability (CMH, 2001b). This is also seen in some of the quotes attributed to the Commissioners. For example, Manmohan Singh, a former Indian Finance Minister said, “We have an historical opportunity to combine and use resources and know-how to ensure better health and greater economic growth in just a couple of decades. If we want equity and security in our lifetime and for future generations, we cannot afford to miss this opportunity.” Takatoshi Kato of the Bank of Tokyo-Mitsubishi said, “We must begin to see development assistance more in terms of an investment in the future – in the protection of the global well-being, including peace, healthy populations, a healthy environment and a more equitable economic system (CMH, 2001c).” These statements clearly see investment in the health of poor people as contributing to a wide range of global public goods including equity, security, peace and a healthy environment. However, when the report refers explicitly to global public goods, it does so in a much more limited way, for example to refer to the work of global institutions (p.13) and the importance of health information and knowledge (pp.76-86) (CMH, 2001a).

UNDP is perhaps the lead agency in trying to promote a broadening of the concept of public goods to embrace all aspects of health, presumably in an attempt to encourage rich governments to provide additional non-aid funds for global health based on self-interest arguments. However, many NGOs have reservations about this approach. These reservations include:

· Concerns about pursuing arguments based on classical economic models · Fear of marginalizing more basic concepts such as equity and health as a human right · Fear of promoting inappropriate solutions, e.g. more stringent immigration controls as a way of controlling infectious disease · Fear of promoting vertical programmes · Risk of promoting northern agendas and further marginalizing country priorities · The confusing nature of the concepts and terms (Keith, 2002)

Discussion questions Is the concept of global public goods useful to us? How do we wish to define this? Do we see health as a global public good? On what basis do we come to that conclusion? Does this cover all aspects of health or just certain parts?

WTO, health and equity
Meri Koivusalo

The World Trade Organisation (WTO) is concerned with equity and provides regulatory measures to maintain it; it is just not the kind of equity we mean when we talk about social equity or equity in health. The WTO concern with equity is that of trading services and goods, in which services and goods should be treated equally whether produced by multinational corporations or local communities as we have seen in the banana dispute settlement case. At a more general level the WTO social policies are based implicitly on a residualist model, where social policies are seen as poor relief rather than policies dealing with e.g. inequalities. Some agreements, such as the Agreement on Trade-related Intellectual Property Rights (TRIPS), are also considerably biased towards the corporate sector and its needs.

The TRIPS positions reflected in the Doha declaration appear to be a step forward in compulsory licensing in comparison to the positions of the EU and the US some years ago. On the other hand the relevance of the Doha public health declaration - and its interpretation - in practice remains to be seen. Further debates around TRIPS concerning parallel importing, compulsory licensing and exports and differential pricing are also taking place in the TRIPS council. These results of these debates may show to what extent measures to address problems of access to pharmaceuticals have become a means of supporting corporate greed of the pharmaceutical industry via regulatory requests rather than means to address health needs.

In health TRIPS is important, but we can expect that the General Agreement on Trade in Services (GATS) may become even more important. The WTO negotiations on the GATS are underway and pose many important questions both in terms of health services and equity as well as the possibilities to implement broad public policies e.g. regulatory prohibition of advertising of products hazardous to health. One example of the latter is a problem of health regulations and trade in advertising services. Those countries which have included advertising services under GATS commitments may have limited significantly their possibilities of regulating or prohibiting advertising of products hazardous to health. Many aspects of health services are also dealt with under other categories of services, such as professional or financial services. It is also important to note that while GATS is marketed as a regulatory agreement this regulatory role remains in the context of ensuring equity and equal treatment of service providers (NGOs/corporations - local/international). This regulatory role is thus concerned more about service provider interests than with social rights of citizens and equity in access to services.

Other matters relate to the Agreement on Sanitary and Phytosanitary Measures (SPS). Important items in these discussions relate to the extent to which precautionary measures as well as public health policies can be seen as trade barriers of rich countries by poorer countries with high implementation costs to poorer countries. The problem is that these arguments may become means of down regulation in health protection rather than ensure that all countries have sufficient support and resources for implementation of the SPS Agreement. The Doha declaration also successfully broadened the trade agenda to include some new areas, such as competition and investments, to the WTO negotiation agenda. There are some concerns that the negotiations on the new areas may in practice be means for inclusion of aspects of the Multilateral Agreement on Investment (MAI) to the WTO Agreements. These aspects could include such which could allow that in addition to countries also private sector corporations could be able to appeal to WTO dispute settlement.

In many ways health policies are easily undermined by corporate export and trade interests which are in practice an integral part of WTO negotiations. The WTO debates are thus biased towards the promotion of private sector interests. The usual emphasis on countries and their interests in trade policy debates also limits opportunities to see the common systematic health issues that affect most countries. While there is no point of taking all health matters to the WTO, it is a task for health activists to ensure that national and international health policies and measures to maintain equity are not compromised by trade policies.

Globalisation on trial: world health warning
David Legge, School of Public Health, La Trobe University, Australia

A high level WHO commission has warned the rich world that unless there is a dramatic increase in development assistance for health the legitimacy and stability of the current regime of global economic governance may be seriously threatened.

The WHO Commission on Macroeconomics and Health (CMH) was established by the Director-General of WHO in January 2000. The Commission was chaired by Professor Jeffrey Sachs of Harvard. It members and helpers included former ministers of finance, people from the World Bank, the International Monetary Fund, the World Trade Organisation, the United Nations Development Program, the Economic Commission on Africa and the Organisation for Economic Cooperation and Development. The Commission was financially supported by the Bill and Melinda Gates Foundation, the Rockefeller Foundation and the UN Foundation and by the governments of the UK, Luxembourg, Ireland, Norway and Sweden. The CMH presented its final report to Dr Bruntland in December 2001.

The Commission set up six working groups, on: health, economic growth, and poverty reduction; international public goods for health; mobilisation of domestic resources for health; health and the international economy; improving health outcomes of the poor; development assistance and health.

WHO Director-General Dr Gro Harlem Brundtland welcomed the report of the WHO Commission on Macroeconomics and Health on December 20th 2001: "This report is a turning point," she said. "It will influence how development assistance is prioritized and coordinated in the years to come."

The Commission’s report is an important health policy statement. It may prove to be as significant as the 1993 World Bank Report, Investing in Health , in providing a ‘credible’ policy narrative proclaiming concern about the health of the poor while reconciling health development objectives with the continuing operation of a brutal and unfair global economic regime.

It is a difficult report to analyse. The argument is tortuous and selective in its use of evidence. For example, despite its commission about the relations between macro economics and health, there is no reference in the whole report to the population health progress of Cuba which has not been as closely integrated into the global economy as most developing countries (see Lobe, 2001). There is one reference only to Kerala where it is suggested that the excellent health outcomes achieved there may have been due to the adequacy of the water supply (page 122).

In places it stretches fact, logic and credulity to the point of combustion. More challenging is the task of interpreting the strategic purpose of the DG in commissioning the report and that of the members of the Commission in framing their presentation. It is clear that the report is meant to be read at several different levels.

It is a big report and is accompanied by dozens of working group reports. There is a lot of material to absorb and consider. This raises questions about how Third World governments, health activists, NGOs and academics might respond to the report.

This commentary is prepared as an initial contribution to (what I hope might develop as) a collaborative process of analysis involving health activists, practitioners and academics associated with the struggle for health in the Third World. We may not be able to match the resources available to the Commission but through an internet collaboration we can draw upon a wide range of expertise and experience in considering the Commission’s report and participating in the wider discussion which will unfold. (See accompanying notes about how this internet collaboration might operate.)

This commentary has three parts. In the first part I summarise the broad argument presented in the report. In the second part I discuss this argument exploring some of their assumptions of fact and movements of logic. Finally I explore the politics of the report; what is the subtext; what are the hidden messages; what were the strategic purposes and expectations of the DG and of the Commission?

This is a preliminary commentary, explicitly designed to stimulate a wider discussion and more broadly based analysis of the report. I am looking forward to hearing what other critics think about the report. I have not read all of the working papers and my judgements should be understood as tentative at this stage.

Further details: /newsletter/id/29001

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We end the year, regrettably, with an apology to you all. Many (if not most) of you have not been receiving the newsletters for the last couple of months. Unfortunately we have experienced a number of problems related to a decision made by Kabissa, who have hitherto hosted our website, to move their server. As a result of this change, we were unable to transfer our domain name – equinet.org.zw – to the new server. To make matters worse, we have been happily proceeding with the production and distribution of the newsletter only to discover that, for reasons we were not able to fathom, mail was not being sent to you through the mail server.

We know that many of you find the newsletter useful, and we are sorry that you haven’t been getting it regularly. We hope that you will receive this, and that in the New Year, you will once again receive the newsletter regularly.

We take this opportunity to wish you all season’s greetings and wish you good health in the New Year.

Firoze Manji


Joint Statement by Oxfam, Treatment Action Campaign, Consumer Project on Technology (CPT), Médecins Sans Frontières (MSF) and Health GAP NGOs which are treating people with AIDS and working to improve access to medicines say patents block affordable, easier-to-take medicines from reaching people who need them. This is in sharp contrast to a 17 October communication co-authored by Amir Attaran of the Harvard Center for International Development and Lee Gillespie-White of the International Intellectual Property Institute, "Do Patents for Antiretroviral Drugs Constrain Access to AIDS Treatment in Africa". The publication claims that "patents in Africa have generally not been a factor in either pharmaceutical economics and antiretroviral drug treatment access."

The findings of this paper have been extensively used by industry to back their claim that patents are not an issue. The pharmaceutical company Merck has also funded one of the authors.

The NGOs agree with the "special communication's" claim that many barriers impede access to health care in Africa, and support their call for international financial aid to fund antiretroviral treatment.

However, they believe that the data presented in the paper do not support the conclusions drawn, but actually shed light on the extent of patent barriers to treatment. In African countries, the most practical and sought after combinations include fixed dose medicines (2 drugs in one pill) and affordable non-nucleosides. The most popular combination of AZT/3TC is patented in 37 out of 53 countries and the only affordable non-nucleoside (nevirapine in generic form) is patented in 25 out of 53 countries.

Many of the non-patented drugs listed in the study, including some of the protease inhibitors, are not practical as first-line treatments in resource-poor settings because of side effects (which need to be monitored) and cumbersome dietary requirements. The study data show that patents are concentrated in countries where pharmaceutical markets are the largest. In South Africa, which has 4.7 million people living with HIV/AIDS and represents half of the pharmaceutical market in Africa, 13 out of 15 antiretroviral treatments are patent protected. In fact, half of the people with HIV/AIDS in Africa live in countries with significant patent barriers on antiretroviral drugs.

The authors claim that even if prices of patented ARVs come down, African countries cannot afford them. But since generic triple therapies can now cost as little as US$ 30 a month, significant numbers of individuals and employers can afford the treatment, if it were not for patents. Patented prices are still three times higher than generic prices. This means that for a given amount of international aid, three times as many people can be treated if generic production is allowed.

This misleading "communication" seems to be an attempt to sabotage a process initiated by the developing world, which seeks to ensure that patents will no longer be a barrier for access to medicines. A draft declaration calling for a pro-public health interpretation of TRIPS was put forward by 60 developing countries in the September 2001 TRIPS council session on access to medicines. The declaration, signed by 41 African nations, states that "nothing in the TRIPS agreements shall prevent members from taking measures to protect public health." The declaration, which will be considered at the next WTO ministerial conference, has been opposed by the United States, Switzerland, Japan and Canada.

If nothing changes, beginning in 2006, all WTO Members will be obligated to grant twenty-year minimum patents for medicines. For this reason, it is critical that the false conclusions drawn from the data do not lead people to believe that patents are not an issue in access to life-saving medicines.

Special Issue on Globalisation, Equity and Health

This issue of Equinet is dedicated to covering some of the recent research and comment on the complex issue of globalisation and equity in health. Recent events signal that health has gained some profile as a global issue, whether in relation to the deliberations and campaigns around World Trade Organisation provisions on intellectual property rights and access to essential drugs, or in relation to the United Nations launch up of the Global Health Fund.

There are many questions about the impact of such initiatives in dealing with the real impact of globalisation on health, and its potential – or otherwise - to deliver greater equity in health. The conflict over TRIPS has highlighted contradictions between free trade provisions and access to existing technologies for health. Questions exist of how far a Global Health Fund addresses or diverts attention from the economic policies that generate the debt, poverty and marginalisation that produces a major share of the global burden of disease. As Fran Baum has written recently in the Journal of Epidemiology and Community Health "Can you imagine a world in which the spread of globalisation meant the world becoming a more just and equitable place? This seems like an impossible dream. All the indications are that the current forms of globalisation are making the world a safe place for unfettered market liberalism and the consequent growth of inequities. This economic globalisation is posing severe threats to both people's health and the health of the planet” (1).

There is debate on the health impacts of globalisation: David Dollar, in a recent World Health Organisation Bulletin on health and globalisation argues that economic globalisation has raised the incomes of poor countries, and that this has generally benefited poor people. Others argue that while globalisation has brought economic growth-promoting potential, these benefits have been restricted to a small number of countries, and have left the majority of developing countries excluded or even negatively effected by such growth potential. (2).

There is perhaps more wide consensus that changes are required to ensure that health outcomes are factored more centrally within globalisation processes. This means providing for measures to promote and protect health in globalisation as global public goods, and not as market or aid. It also means not waiting to act on those areas where health burdens are already accumulating under global economic and trade processes - such as in transfer of tobacco risks to youth in developing countries, or in the shift towards more casual jobs that lack adequate social protection. Nick Drager and Robert Beaglehole point out in the editorial of a special World Health Organisation Bulletin on globalisation and health:

“Public health scientists are still in the early stages of gathering concrete evidence on the effects of globalisation on population health. This evidence is required to inform policies and actions to protect and promote the health of the poor. The productivity of this research would be improved if there was an agreed framework for considering the various mechanisms by which economic globalisation affects population health status… It is already evident, however, that policy measures are required to rectify the adverse effects of globalisation on health and strengthen the positive ones. Policy should be guided by the following principles:(i) growth needs to be inclusive, equitable and sustainable, and this requires policy coherence between economic, social and environment sectors; (ii) opening up of borders should be gradual and preceded by appropriate protective conditions; (iii) international rules and institutions should promote the production of global public goods and the control of global public ‘‘bads’’; (iv) special attention is needed to increase the transfer of financial and technical resources to those left behind in the development process; (v) strong national health policies, institutions, regulations and programmes are essential; (vi) the public health workforce must be equipped with the knowledge and skills to engage with partners across sectors and across borders to achieve health and other social goals.” (3)

In the EQUINET September 2000 conference it was noted that during several decades of structural adjustment in southern Africa health scientists argued about the extent of negative impacts while populations became poorer, hungrier, more at risk of disease and less able to afford or access basic health services. By the time the negative impacts were acknowledged structural adjustment had been replaced by the much wider and more sweeping liberalisation and privatisation of the current phase of globalisation. Globalisation has increased the visibility and evidence of the global resources and opportunities available for health. This makes the contrast with the deprivation of such resources where they are most needed extremely stark.

1. Health, equity, justice and globalisation: some lessons from the People's Health Assembly. F Baum - J Epidemiol Community Health 2001;55:613-6. <a href=http://www.jech.com/cgi/content/full/55/9/613>http://www.jech.com/cgi/content/full/55/9/613</a>
2. Is globalization good for your health? David Dollar; Globalization and health: results and options; Giovanni Andrea Cornia. Bulletin of the World Health Organisation, Volume 79, Number 9, September 2001. <a href=http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html>http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html</a>
3. Editorial: Globalization: changing the public health landscape. Nick Drager & Robert Beaglehole. Bulletin of the World Health Organisation, Volume 79, Number 9, September 2001. <a href=http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html>http://www.who.int/bulletin/tableofcontents/2001/vol.79no.9.html</a>

Equity and inequity today: some contributing social factors
PHA background paper 2

Nadine Gasman and Maxine Hart


The 1999 United Nations Human Development report begins: 'The real wealth of a nation is its people. And the purpose of development is to create an enabling environment for people to enjoy long, healthy and creative lives. This simple but powerful truth is too often forgotten in the pursuit of material and financial wealth.'

The current trend of globalisation has contradictory implications. While the last 50 years have witnessed developments that augur better for the future of humanity-child death rates have fallen by half since 1965, and a child born today can expect to live a decade longer than a child born 20 years ago; the combined primary and secondary school enrolment ratio in developing countries has more than doubled-the world faces huge amounts of deprivation and inequality. Poverty is everywhere. Measured on the human poverty index-more than a quarter of the 4.5 billion people in developing countries still do not enjoy some of life's basic rights-survival beyond the age of 40, access to knowledge and adequate private and public services.

The quickening pace of globalisation has generated enormous social tensions that development policies have failed to tackle. The underlying assumption has been that once economic fundamentals are corrected, social issues will resolve themselves of their own accord, and that well-functioning markets will not just create wealth, but will also resolve problems of human welfare.

Current events reveal with awful clarity the depth of this fallacy. Millions of people are poorer than ever before, with growing indices of inequality between countries and within countries. Most countries report erosion of their social fabric, with social unrest, more crime, and more violence in the home.

Neoliberal advisors in the 1980s developed a vision of the ideal country: its economy would be largely self-regulating through open competition between private firms; its public sector would be relatively passive-providing the minimum services necessary to conduct private business efficiently and to protect society's weakest members.

This dogmatic economic prescription, concludes the United Nations Research Institute in Social Development (UNRISD), has not only had limited value, but has been dangerous. Even those countries that have been held up as economic success stories have been social failures. Most people in highly indebted African and Latin American countries have suffered a sharp drop in living standards.

Between 1980 and 1990 the per capita income declined markedly in developing countries. An International Labour Organization study of 28 African countries showed that the real minimum wage fell by 20% and more than half of Africa's people now live in absolute poverty. In most Latin American countries the real minimum wage fell by 50% or more. Coupled with this, people have suffered from severe cuts in public services-affecting nutrition, health, education and transport.

The UN Human Development Report of 1999 goes further: a comparison between the size of income of the fifth of the world's people living in the richest countries and that of the fifth in the poorest showed a ratio of 74 to 1 in 1997, up from 60 to 1 in 1990 and 30 to 1 in 1960.

The advocates of adjustment had hoped for a trade-off: long-term economic gain in return for short-term social cost. What they did not foresee was that the social impact could itself frustrate the desired economic effect. This temporary sacrifice for the poor is beginning to look like a permanent intensification of poverty.

UNRISD explains: 'When the market goes too far in dominating social and political outcomes, the opportunities for and rewards of globalisation spread unequally and inequitably-concentrating power and wealth in a select group of people, nations and corporations, marginalising others. Globalisation in this era seeks to promote economic efficiency, generate growth and yield profits. But it fails on the goals of equity, poverty eradication and enhanced human security.'

Economic growth, an important input for human development, can only translate into human development if the expansion of private income is equitable, and only if growth generates public provisioning that is invested in human development-in schools and health centres rather than arms. Reduced public spending weakens institutions of redistribution-leading to inequalities.


We face the challenge of setting up rules and institutions for stronger governance-local, national, regional and global-that put the health and well-being of each individual, community and nation at the centre. We need to create enough space for human, community and environmental resources to ensure that development works for people and not just for profit.

Globalisation expands the opportunities for unprecedented human advance for some, but shrinks those opportunities for others and erodes human security. It is integrating economies, culture and governance, but is fragmenting societies and ignoring the goals of equity, poverty eradication and human development.

Overcoming poverty must be seen as the main ethical and political challenge. Experience shows that the most appropriate programmes are long-term initiatives of a comprehensive/ multi-dimensional and multi-sectoral nature, aimed at breaking down the mechanisms that perpetuate poverty from one generation to another.

Development patterns need to be oriented to make equity-that is, the reduction of social inequality-the central pillar. This should be the basic yardstick against which we measure development. Education and employment present two master keys for development. Education has an impact on equity, development and citizenship, and therefore needs to be assigned top priority in terms of social policy and public spending, especially important is education of girls. Latin American studies have indicated that 11-12 years of schooling (completed secondary education) are required if people are to have a chance of escaping poverty. At the same time, a high-quality job-creation process needs to be put in place.

Some questions?

What are the social factors that influence the health situation in your community or countries?
Is violence a problem in your community?
What is the status of Women and children?
Is government responding to the people's needs? Why?

Further details: /newsletter/id/28794
ZAMBIA: Poverty and AIDS forces children onto streets
LUSAKA, 17 July (IRIN)

Pint-sized Edgar was 10 when he left his mother's shack in eastern Zambia to seek his fortune in Lusaka, the bustling capital of 1.3 million people.

The puny but plucky youngster had no inkling about life in the city, but he was not perturbed. Nothing, he thought, could be worse than the miserable life he had led in Lundazi.

It was an existence of few pleasures and endless chores. From morning, when he hauled several bucketfuls of water from a communal well half a kilometre away, to midnight, when the neighbourhood tavern at which he tried to sell his mother's hard-boiled eggs closed, the little boy knew no respite. When business was slow, his mother held him personally responsible and whipped him or denied him his supper, or both.

Two years on, Edgar has given up the quest for his fortune. He starts his day in the central business district, where he alternatively begs and runs errands to raise enough money for the imperative dose of "glue" - an intoxicating concoction of petrol and adhesives that the destitute sniff to dull the harsh realities of life on the streets. At midday, he walks over to Fountain of Hope, a non-governmental organisation outside the city centre that rehabilitates street children, for a free meal.

Edgar's life, multiplied many times over, represents the lot of thousands of the children that swarm the streets of Lusaka in a desperate quest for survival. Their number has risen markedly over the past few years, doubling to 75,000 since 1991.

The conventional wisdom is that the increase in their number is a direct consequence of HIV/AIDS. It is generally assumed that most of the children are forced onto the streets by poverty after one or both of their parents died of AIDS-related complications. According to the ministry of health, Zambia had around 520,000 AIDS orphans in 1999. That number is expected to rise to 895,000 by 2009 and to 974,000 by 2014.

"Perhaps half of all street children are orphaned children, indicating growing pressures on extended families to cope with the rapidly increasing orphan population," the ministry said in a report entitled 'HIV/AIDS in Zambia'.

However, new evidence suggests the HIV/AIDS pandemic is not necessarily the main reason that a growing number of Zambian children are living on the streets. To begin with, around half of the 75,000 street children in Lusaka are not orphans. Moreover, recent studies have revealed the lot of Zambian children with parents is no different from that of orphaned ones.

"There is little difference in economic status between orphan and non-orphan children. Seventy-five percent of orphan children are found in households living below the poverty line and 73 percent of non-orphan children are also living in households below the poverty line," the government's 1999 Situational Analysis of Orphans and Vulnerable Children points out. "These problems (of food shortages, poor health, inadequate education and bedding) actually affect all the children, orphan and non-orphan, and indeed, all the community members," the report added.

Moreover, there is a growing realisation that poverty is not the only factor that forces children to live on the streets. That, at least, has been the experience of Foundation of Hope, which deals with an average 500 street children per day, providing them with food, schooling and shelter.

"A lot of other factors besides poverty, including psychological pressures, force children to leave their homes. Some leave to escape abuse of one sort or another, and others are compelled to go on the streets by peer pressure,"
Fountain of Hope administrative officer Emmanuel Mukanda told IRIN.

According to Mukanda, children who leave their homes for reasons other than economic pressure tend to be more difficult to rehabilitate than those forced on the streets by poverty. "Those children who ran away from home often require intensive counselling. The others, who are forced onto the streets by poverty, are relatively easy to reform. Once their basic material needs are met, their main problems are over," he said.

The realisation that many children end up on the streets because of psychological pressures prompted Fountain of Hope to extend its counselling services to the parents of runaway children. "Many parents come here to look for their missing children, and we try to counsel them along with the children. Sometimes, we succeed in bridging their differences, and the children return home," said Mukanda.

Observers, including the government and UNICEF, see the misconception that destitution among Zambian children is largely AIDS-related as sometimes diverting communities away from effective interventions. They argue that while the plight of orphan and non-orphan poor children is broadly similar, their specific needs can be different.

"There is ... value in distinguishing between orphans and other vulnerable children when considering psychological support, protection of rights, interventions targeted to their specific status as orphans and epidemiological surveys," notes the government's Situational Analysis of Orphans and Vulnerable Children.

Moreover, Zambia, a country of 10 million people, has 19 non-governmental organisations whose core missions are to alleviate the plight of AIDS orphans. Few such organisations exist to address the concerns of destitute non-orphan children. However, there are signs that society is beginning to appreciate the fact that the problem of destitute children goes beyond AIDS orphans.

"Although communities start by looking at the needs of orphans, they soon reformulate their criteria to include other vulnerable children, namely those who are extremely poor," UNICEF notes in a report entitled, 'Children Orphaned by AIDS'.

Further details: /newsletter/id/28754
HIV/AIDS Implications for Poverty Reduction
Background paper prepared for the United Nations Development Programme, for the UN General Assembly Special Session on HIV/AIDS, 25-27 June 2001

by Dr. Rene Loewenson, Director, Training and Research Support Centre, Zimbabwe and Professor Alan Whiteside Director, Health Economics and HIV/AIDS Research Division, University of Natal, South Africa.
HIV/AIDS is having a disastrous impact on the social and economic development of countries most affected by the epidemic. In much of Africa and other affected regions, this epidemic will prove to be the biggest single obstacle to reaching national poverty reduction targets and the development goals agreed on at the United Nations
Millennium Summit. The challenge is immense: How do countries reduce the proportion of people living in poverty when up to a quarter of households are decimated by AIDS? How do countries
deliver on policies aimed at equity in access to economic opportunities and social services when AIDS widens economic differentials and undermines service delivery? How do countries deliver on promises to improve quality of life for coming generations when 40 million children will grow up orphaned by AIDS? How does a country like South Africa deliver on its goal of being a regional engine of growth with over 4 million HIV-positive people and the fastest growing infection rate in the world? The devastation caused by HIV/AIDS is unique because it is depriving families, communities and entire nations of their young and most productive people. The epidemic is deepening poverty, reversing human development achievements, worsening gender inequalities, eroding the ability of governments to maintain essential services, reducing labour productivity and supply, and putting a brake on economic growth. These worsening conditions in turn make people and households even more at risk of, or vulnerable to, the epidemic, and sabotages global and national efforts to improve access to treatment and care. This cycle must be broken to ensure a sustainable solution to the HIV/AIDS crisis. The response to HIV/AIDS so far has focused, rightly so, on the challenge of containing the epidemic and preventing new infections through advocacy, information and education campaigns, behaviour change communication, condom distribution, programmes targeting groups that are particularly vulnerable to infection, and other key interventions. The other part of the response is focusing on treatment and care for people living with HIV and AIDS — efforts that are expected to intensify as new treatments become more accessible and affordable. Both prevention and treatment are top priorities in not only saving lives and reducing human suffering, but also in limiting the future impact on human development and poverty reduction efforts.

However, despite intensifying efforts focused on
prevention and care, the epidemic continues to spread unabatedly, and as people infected by HIV become ill and die, its devastating impact is now being felt in the worst affected countries. Assuming that life-prolonging treatment will not be universally available in poor countries ‘overnight’, death rates from AIDS will continue to soar before leveling off. Recent estimates from the UN Population Division show that the population of the 45 most affected countries will be 97 million smaller in 2015 than it would have been in the absence of HIV/AIDS. Most of this loss is due to sharp increases in mortality among young adults. In the absence of national and global action to mitigate the developmental impact of HIV/AIDS, households, communities and civil society organizations will continue to bear the brunt of this tragic disaster. They are at the front lines of coping with the impact of HIV/AIDS, responding directly to the needs of people and often working with little government support. Communities are mobilizing themselves, showing great resilience and solidarity, despite their vulnerability to external shocks such as premature death of their most productive members. The response to HIV/AIDS has tended to ignore the bigger picture of the implications for development and poverty reduction. Research has been undertaken to study the impact of the epidemic, but very little has been done about it. Discussions on the implications of HIV/AIDS among development experts and policy makers has been extremely limited, and both national and global development targets and goals have been formulated without taking into account the added challenges resulting from sharp increases in AIDS-related adult mortality rates. With the same inevitability as the cyclonic and heavy rains which caused catastrophic floods in Mozambique twice in the last 18 months, with widespread devastation and loss of life, the current HIV prevalence forewarns an AIDS epidemic that is only beginning in many countries. The scale and scope of this epidemic over the next decade can be broadly predicted, planned for and mitigated. However, like people living on the riverbanks, we seem unable or unwilling to take action on the flood until we are knee-deep in water. This is not helped by the denial and the chronic, slow-moving and dispersed nature of both the epidemic and its impacts. It takes significant leadership to plan ahead, sometimes ahead of public perceptions, to deal with AIDS, and in so doing to divert resources from other more apparent problems. Yet taking meaningful steps towards mitigation demands visionary leadership armed with information on the scope and nature of the epidemic, its impacts and on options for responding. Creative, albeit scattered, individual, community and national efforts provide examples of good practice. The time is overdue to apply these more widely in those areas where we must make a difference, put in place plans to achieve this, and back them with resources.

Note: The Equinet Newsletter will pause for the month of August

Tobacco Control and the FCTC in Developing Countries:
Millions Dying but Where\'s the Outrage?

According to the World Health Organisation, tobacco use is set to cause an epidemic of heart disease and cancer in developing countries. Currently, 4 million people die each year from tobacco use, but that number is set to rise to 10 million a year by 2030. In addition to premature death, smokers suffer from an ongoing health problems due to smoking and inflict health problems on others due to secondhand smoke. Yet few countries are taking concrete actions to stem this epidemic. This is in part because of the political and economic power of multinational tobacco companies which have tried to define tobacco control as solely an issue for rich countries in order to protect their enormous profits from the developing world.

The aggressive marketing tactics of the multinational tobacco companies have greatly contributed to the tremendous increases in smoking in developing countries, particularly amongst women. These companies use their enormous political and financial power to influence governments and promote their products in every corner of the globe. The expansion of these companies into the developing world has meant that in the near future it is developing countries which will carry the majority of the burden of disease due to tobacco use.

Currently, approximately 80% of the world's smokers live in developing countries where smoking rates have risen dramatically in the past few decades. Yet it is the poor who can least afford to waste money on the purchase of tobacco products. Much of the tobacco industry is dominated by multinationals, so profits flow from poor to rich countries. Since most poor countries are net importers of tobacco, precious foreign exchange is being wasted. In addition poor countries are less able to afford the medical and other costs attributable to tobacco use.

The tobacco industry has become a pariah industry. For decades it has denied the truth about the harmful effects of tobacco addiction in order to protect its profits. However whilst it has come under attack in the courts and the parliaments of some countries, the majority of countries have felt powerless to restrain the industry with effective legislation and litigation. In fact, many continue to offer the industry tax breaks and other incentives.

Whilst some jobs are created by the tobacco industry those which are offered to people in developing countries are usually dangerous and badly paid. Tobacco farm workers are often exposed to dangerous pesticides and other chemicals and small farmers are often chained to a cycle of debt by a tobacco industry system whereby loan schemes are run to help farmers start farming tobacco, but then low prices are offered for the tobacco. In a number of countries the tobacco industry exploits the poor and powerless, employing children and paying starvation wages.

The Framework Convention on Tobacco Control (FCTC) is a global treaty currently being negotiated by governments which will address trans-national and trans-border issues, such as global advertising, smuggling and trade. Yet the FCTC will also serve as an important catalyst in strengthening national tobacco legislation and control programmes. The process of negotiating and implementing the FCTC will also help to mobilise technical and financial support for tobacco control and raise awareness among many government ministries about tobacco issues.

If properly negotiated, the FCTC could help turn the tide against the tobacco industry by weakening its political power and helping to end its reckless behaviour through regulation and legislation. But this will only occur if the voices of the people are heard.

The next FCTC negotiation is scheduled for November 2001 in Geneva, Switzerland. At this meeting, WHO member states will debate the draft treaty. It is paramount that NGOs from around the world lobby their governments and mobilise public support for a strong FCTC.

To ensure the success of the WHO FCTC in combating the global tobacco epidemic, non-governmental organizations must play a key role in the development and negotiation of the treaty.

· Join the Framework Convention Alliance;
· Educate yourself and your constituencies about global tobacco issues and the FCTC - the Alliance Website (www.fctc.org) has links to many good resources;
· Inform and get the support of the media in your country;
· Get resolutions passed in support of the FCTC;
· Find out what your country's delegates to the FCTC have said so far and meet with them in order to influence their future positions.

The Framework Convention Alliance (FCA), a coalition of over 150 organizations and networks from over 50 countries, serves as an umbrella for networks and individual organizations working on the FCTC. The Alliance facilitates communication between NGOs already engaged in the FCTC process and reaches out to NGOs not yet engaged in the process (especially those in developing countries) who could both benefit from and contribute to the creation of a strong FCTC.

Belinda Hughes, Coordinator, Framework Convention Alliance (FCA). Tel: (66-2) 278 1828 or (66-2) 278 1829. Fax: (66-2) 278 1830