User fees are once again a hot topic of policy debate. This time the question is whether to remove primary care fees. At its conference in June this year, EQUINET took a clear position on the issue. We called for these fees to be removed. But we also stated that this action is not a cure-all for the problems facing health systems in Africa. User fee removal must be accompanied by actions that increase overall national resources for public sector health services and that deal with international conditions and policies that undermine this.
The two reasons why primary care fees must go are that:
- They contribute to the unaffordable cost burdens imposed on poor households;
- They signal to poor households that society does not care about them.
Fees at primary care are relatively low. Even so, there is widespread evidence to show that fees encourage self-treatment (using herbs or poor quality medicine bought in unregulated market places), deter people from taking full doses (so increasing the chances of drug resistance), and act as a barrier to early, or even any, use of health facilities. In these ways the small level of fees can increase the costs poor people bear when ill. So even though fees represent a smaller proportion of the total costs of accessing health care than transport or lost income, they contribute to levels of cost burden that can, in some instances, impoverish poor households. At one level, impoverishment results from selling key assets, cutting down on other necessary expenditures, or borrowing, often at exorbitant interest rates, to pay for health care. At another level, charging fees adds cost to the other immense barriers of accessing care, such as distance and abusive treatment. It signals to poor people that they are not valued or cared for by society.
However, removing primary care fees is not enough by itself to tackle the range of existing health care challenges in Africa. Other actions are also required.
First, the levels of funding available for health care must be increased. At least 15% of government budgets should be invested in the public health sector, as committed by African governments in Abuja. Only one country in southern Africa, Mozambique, is currently reported to be achieving this. This will support the sustained quality increases necessary to improve health system performance, as well as allowing the system to respond effectively to the utilization increases likely to result from fee removal.
Linked to this African country debt should be cancelled. The EQUINET June 2004 Conference called for international action to remove the debt burdens imposed on African countries, and for national action to increase the level of government funding to health systems. These changes in financing also need to be underpinned by changes in terms of trade for African countries that result in huge resource outflows from Africa, including market barriers in industrialized countries to trade in food products and the poaching of health personnel.
Second, the removal of fees must be undertaken in a way that actively strengthens the health system.
In particular, the responses of health workers and managers must be deliberately managed to avoid negative impacts on morale and performance. As front-line providers and managers are the point at which patients meet the health system, their morale and performance has a direct influence over how patients experience health care, and how policies are implemented. In South Africa, while the removal of fees had a powerful positive effect on health outcomes, health workers said they were not adequately informed or involved, and were thus unprepared for the resulting increases in utilization. This can lead to unnecessary tensions at primary care level, and patients complaining that health workers treat them badly. In countries where fees have been retained, they have allowed managers and local communities some control over the decision of how to use the revenue. In others they have been used to fund agreed incentives for staff. These issues need to be managed and alternative ways found of providing for local resource control and staff incentives to avoid demoralisation.
Experience from a wide range of policy actions indicates that managing this policy change must involve:
1. Giving a specific government unit the task of implementing fee removal in ways that strengthen the health system;
2. An effective public relations campaign to communicate the change with the general public, and to signal that removal of fees is about valuing patients and providers;
3. Ensuring that the policy goals are clearly explained to managers and health workers to promote support for the policy at all levels of the health system;
4. Preparatory planning to ensure adequate levels of drug and staff availability to cope with the likelihood of initial utilization increases -
and longer-term planning for how to tackle wider drug and staffing, including motivation, problems;
5. Establishing new, manager-controlled funds at local level that allow management freedom on small-scale spending decisions;
6. Clear communication with health workers and managers about what and when actions will be taken - through meetings, supervision visits, special information letters;
7. Expect that there will be unanticipated problems with implementation, and so set up monitoring systems that provide a basis for identifying what other actions need to be taken: monitoring utilization trends, including the relative use of preventive versus curative care, and giving health workers and managers opportunities to feed back on health facility experiences.
Tackling the human resource barriers to effective fee removal will inevitably require the wider action that is necessary to address the overall human resource crisis in Africa. On this issue EQUINET has called for human resource policies and measures at national, regional and international level that promote the retention and improved working conditions of health personnel in public sector health systems, backed by compensation for regressive south-north subsidies incurred through health personnel migration. An editorial later this year will provide more detail on this.
User fee removal clearly provides an opportunity to begin to address the needs of poor people. However, their removal is not enough by itself. EQUINET calls for this to be backed at national level by increased public financing for health and at international level by a cancellation of debt. In addition, user fee removal must be implemented in ways that strengthen the health system. User fees were actively promoted internationally during periods of efficiency and market led health sector reforms that produced a huge cost to equity in health in southern Africa. User fee removal must be underpinned by actions at international and national levels that provide for the resources to achieve human rights to health and health equity goals.
* Information on EQUINET work on fair financing is available on the EQUINET website at www.equinetafrica.org EQUINET welcomes feedback to its editorials, suggestions, information and follow up enquiries to the EQUINET secretariat at TARSC, email admin@equinetafrica.org
Editorial
Cereal production in Southern Africa has remained stagnant for over a decade since 1990 at 22 million MT, despite a growth in population of 60 million in the period. This fact highlighted at the SADC Heads of state summit on food security brought sharp attention to unacceptable and mounting shortfalls in food security in the region. Rates of childhood stunting in Africa are predicted to increase to above 25 percent by 2015, more than double the Millennium Development Goal (MDG) for that year. Only 3 out 10 African countries have experienced an improved maternal nutritional status in the last decade.
The EQUINET steering committee highlighted at the June 2004 regional conference its agreement with SADC heads of state that food security and food sovereignty are now an important focus to achieve wider goals of health equity and social justice in the region. The gross statistics were further debated as they mask the fact that it is the lowest income rural and urban communities, women and children who are most at risk of food insecurity and its consequences.
Mary Materu, from the Centre for Counselling, Nutrition and Health Care (COUNSENUTH), Tanzania highlighted the massive inequity of the fact that “when the world is producing enough food to feed everybody, more than 800 million people, most in developing countries, do not have enough food to cover their nutritional needs.”
Mickey Chopra, from the University of the Western Cape School of Public Health, highlighted the wider fallout from this deprivation of the right to food: “Adequate food and nutrition is a basic right. The deprivation of this right has immense consequences for addressing inequities across the region. Poor nutritional status stunts educational development as well as increasing the risk of acquiring, and the severity of, infectious diseases (including HIV/AIDS). The lack of household food security has led to increased vulnerability, especially of women, to diseases such as HIV. If the huge cost of burden of disease suffered by the poorest is to be tackled addressing lack of household food security and malnutrition is essential.”
This deprivation arises from a combination of increasing food prices and falling food production. These immediate causes are driven by macro level factors such as trade relations, domestic food and agricultural polices and micro level factors such as intrahousehold food distribution, gender roles and caring practices.
The EQUINET steering committee noted that the current food insecurity cannot be traced purely to drought or to AIDS. “The 2002/3 food crisis in Southern Africa was more widespread and impacted much more severely on households than could be predicted from rainfall patterns. The destructive effect of AIDS on household labour and incomes clearly compounded other threats to food security, such as inequities in access to productive resources and to market access, particularly for women.”
Current trade policies were identified as having a profound and negative impact on food security in Africa. Chopra highlighted how OECD subsidies to agriculture between 2000 and 2002 of about US$250billion placed protectionist barriers against food imports from Africa, undermining returns from production and thus effectively suppressing production. Kenya, for example, more than doubled production of processed milk between 1980 and 1990. When subsidised milk powder imports could be sold more cheaply than Kenyan processed milk, imports soared, increasing from 48 tonnes in 1990 to 2 500 tonnes in 1998 and domestic production of processed milk plummeted by almost 70 percent. Kenya's ability as a nation to diversify into processing was undermined. More importantly small producers bore the brunt of this decline in demand for local milk. At national level production for export has led to decreasing land areas planted with food crops for domestic consumption. Domestic food production has also been weakened by falling investment in agricultural research.
These trade and economic barriers, harming small producers and thus women farmers, worsen the impacts of HIV/AIDS on household-level labour, assets and skills, on burdens of care and household productive capacities that have set up a vicious interaction between malnutrition and HIV. Mary Materu of COUNSENUTH further highlighted the need for improved nutrition to be supported by access to education, water and sanitation.
This understanding of the immediate and underlying factors driving food insecurity and malnutrition underlined the view at the EQUINET conference that addressing food security and nutrition called for action across a wide range of sectors. At global level it was clear that Millennium Development Goals that call for improved nutrition cannot co-exist with trade policies that undermine the production basis for achieving the goals in the most vulnerable regions of the world. At regional and national level Chopra presented evidence to show that improved food security calls for more equitable access to land, improved investment in small holder farming, and increased access by women farmers to production inputs.
Dr Erika Malekia of the Southern African Development Community (SADC) echoed this call for “an integrated plan of action, focused on addressing inequalities in areas such as land distribution, gender equity.”
The conference delegates resolved to advocate for trade and agricultural policies that ensure food sovereignty and household food security through land redistribution and investment in small holder farming in ways that promote gender equity and sustainable food production. EQUINET will be following up on this resolution in a more focused future programme of work on food security and health equity. The conference suggested that EQUINET support for SADC regional strategies for food security should include two critical components, particularly if equity issues are to be addressed. The first is to strengthen and inform from a health perspective the challenges to trade policies that undermine national food production. The second is to inform and strengthen the health dimensions of policies and programmes that support land redistribution, smallholder production and increased access by women smallholder farmers to production inputs.
The EQUINET Conference abstract book and resolutions are available on the EQUINET website at www.equinetafrica.org and the conference report will be posted on this site in the coming month. EQUINET welcomes feedback to its editorials, suggestions, information and follow up enquiries to the EQUINET secretariat at TARSC, email admin@equinetafrica.org
* “Equity in health implies addressing differences in health status that are unnecessary, avoidable and unfair. Equity in health implies directing more resources for health to those with greater health need. Equity in health means having the power to influence decisions over how resources for health are shared and allocated.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.
* “In the highly unequal societies of southern Africa, our health challenges demand health systems that assertively redistribute the resources for health and policies that reflect values of equity, solidarity and universality. This can be achieved through rising investment through the state and public sector.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.
* “The gains of neoliberal globalisation?
- 4% GDP lost in unfair terms of trade 1970-1990
- Africa's FDI share from MNC investment 25% in 1970's, 5% in 1990s.
- Income gap richest to poorest 53x in 1960 and 121x in 2000
- 185 million people out of work
- 55 million people live on <$1 a day
- Southern outflows increased.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.
* “Despite a hostile global environment, which has the potential to subjugate us to political and economic imperatives not of our choosing, we can and must mobilize collective action to chart and implement our positive vision and policies on the equitable health systems that we want.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.
* “ Impact of malnutrition on development:
- [A study of the long term impacts of the 1982-84 Zimbabwe drought on 665 children]…resulted in a loss of stature of 2.3 centimeters, 0.4 grades of schooling, and a delay in starting school of 3.7 months.
- [It is estimated] that this loss of stature, schooling and potential work experience results in a loss of lifetime earnings of at least 7 - 12%.” - From a presentation on 'Household Food Security, Nutrition and Equity.'
* “Only 3 out of 10 African countries show a decrease in severe maternal nutritional status in the last decade.” - From a presentation on 'Household Food Security, Nutrition and Equity.'
* “31 countries in Africa do not meet the 'Health for All' standard of a minimum of one doctor per 5000 people.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.
“External debt of the USA is $2.2 trillion - almost the same as the $2.5 trillion owed by the entire developing world…Every American citizen owes the rest of the world $7,333 while every citizen of all the developing countries only owes the rest of the world $500.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.
* “Estimating the cost of training a GP in the SADC Region to be $US60 000, then it can be assumed that there is a reverse subsidy from the developing world of $500m per annum for health personnel alone.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.
* “UNCTAD estimates that US$184,000 is saved in training costs per professional and that US saved US$3.86 billion as a result of importing 21 000 Nigerian doctors.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.
* “Things are pretty bad here you know. South Africa is not the Tropicana Hotel [in Durban, where the conference took place]. Since independence the rich have been getting richer and the poor poorer.” - Trevor Ngwane, Anti-Privatisation Forum, commenting in a parallel workshop session.
* “The green rooms [negotiating forums at the World Trade Organisation criticised for their lack of transparency] are basically where the bully countries call in the smaller countries, beat them up and then send them home with a message to their mothers.” - Riaz Tayob, SEATINI, replying to a question on a presentation on global trade and health.
Noting:
* The 1997 Kasane meeting on Equity in Health that confirmed the commitment to equity in health at all levels in southern Africa; the 1999 Southern African Development Community (SADC) Protocol on Health, the 2003 Maseru Declaration on HIV and AIDS and the resolutions of the SADC Heads of States Summit on food security held in Tanzania, 2004;
* The formation of EQUINET and our work since 1998 in support of these commitments, to strengthen the understanding of, the evidence for, advocacy of and implementation of this policy commitment to equity and social justice;
* Our conception of equity and social justice in health, which aims to address unfair differences in health and in access to health care through the redistribution of the societal resources for health, including the power to claim and the capabilities to use these resources;
* The widening constituency we are building for equity and social justice in health amongst governments, parliamentarians, health professionals, trade unions and other organs of civil society, researchers and communities at national and regional level;
* The challenges posed by neoliberal globalisation to our values of equity and social justice, to government ability and flexibility to implement the public policies that we choose and to the public sector health and essential services and that are critical for our health;
The June 2004 EQUINET conference in Durban South Africa affirmed that we stand for:
* Equity and social justice in health;
* Public interests over commercial interests in health;
* International and global relations that promote equity, social justice, people's health and public interests;
* Increased unconditional resource flows from the North and fairer terms of trade;
* Reduction and where possible restitution of flows of resources from South to North;
* A conception of human rights that affirms the agency of communities in claiming social and economic entitlements, the primacy of vulnerable groups and that captures African traditions of communitarianism;
* Equitable health systems that provide healthcare for all and redistribute and direct resources towards those with greatest needs;
* Rising investments in the state and public sector in health;
* Health (care) systems which promote collective, population oriented strategies for health and comprehensive primary health care;
* Trade and agricultural policies that ensure food sovereignty and household food security through land redistribution and investment in small holder farming in ways that promote gender equity and sustainable food production;
* At least 15% of government budgets invested in the public health sector, as committed in Abuja, together with debt cancellation;
* Progressive tax-based funding of health systems;
* Fair financing for health, in which the rich contribute a greater share of their income to health than the poor, with strengthened cross subsidies for solidarity and risk pooling;
* Equitable and affordable access to generic drugs, with application of essential drug policies across all health providers;
* Ethical and equitable human resource policies at national, regional and international level, backed by compensation for regressive south-north subsidies incurred through health personnel migration;
* Equitable public health and multisectoral responses to HIV and AIDS for prevention and health promotion, treatment and care and to mitigate the impact of the epidemic, particularly within and for young people and vulnerable groups;
*The expansion of access to anti-retroviral therapy for people living with AIDS in Southern Africa as an urgent priority, through funding and approaches that strengthen, and do not compromise, our public health services and systems;
* Democratic and accountable states, with full authority to exercise policy measures necessary to protect the health of people;
* Powerful and effective participatory and representative mechanisms at all levels of our health and social sectors and in the state more generally;
* Effective and accountable mechanisms for public and stakeholder contribution to decision making in health;
* Regional integration and co-operation within Africa to strengthen democratic states, advance the health of people and challenge injustices to health;
* Values based leadership across organisations working to promote equity in health.
The conference set out a programme of work and action for EQUINET and its partners to implement these goals.
* * Visit the Values, Policies and Rights, Health equity in economic and trade policies, Poverty and health, Human Resources, Resource allocation and health financing, Equity and HIV/AIDS and Governance and participation in health sections of the newsletter for more details about papers presented at the conference. The full abstract book and other conference documents will be available on the EQUINET website (www.equinetafrica.org) by the end of this month. Please send all comments to admin@equinetafrica.org
Historically, the state has played an important role as a social actor. Indeed, the social function of the state was as critical to the constitution of the social contract as the quest for a secured territorial framework within which individuals and groups could exercise their livelihoods. The high point of the development of the social state came in the period after the Second World War with the growth and spread of different variants of social democracy and welfare states.
Not surprisingly, African states at independence were invested with broad-ranging social responsibilities which they pursued with varying degrees of success. However; the onset of the African economic crises in the period from the early 1980s onwards and the rise on a global scale of the forces of neo-liberalism encapsulated the confluence of factors that culminated in the retrenchment of the social state - including from an institutional and expenditure point of view - and the enthronement of a narrow, market-based logic in the provision of social services - including, among other things, the pursuit of cost recovery, the imposing of user fees, the promotion of privatisation, and the employment of new public sector management strategies in the social sectors.
At the same time, the social sectors, including especially the health system, were to suffer a serious erosion of capacity that was connected to the drain of talents, the degradation of the infrastructure of service, and the collapse of professionalism. Perhaps much more serious is the decoupling of social policy from macro-economic policy-making and its treatment as a residual category to which targeting strategies such as safety nets, various programmes for the alleviation of the social effects of economic structural adjustment and a plethora of poverty reduction strategies would be applied. It is suggested that this decoupling of social and macro-economic policy making is at the root of the expansion of the boundaries of exclusion that defines the structural roots of injustice in the social sectors generally and the health sector in particular.
The prospects for the restoration of a socially-conscious state will depend on the capacity of governments to adopt an approach in which social policy is treated as an integral part of macro-economic strategies for growth and development.
* Adebayo Olukoshi, Professor of International Economic Relations and currently the Executive Secretary of the pan-African Council for the Development of Social Science Research in Africa (CODESRIA) which is headquartered in Dakar, Senegal. He has previously served as Director of Research at the Nigerian Institute of International Affairs, Lagos, Nigeria and as a Senior Fellow/Research Programme Coordinator at the Nordic Africa Institute, Uppsala, Sweden. His current research interests centre around the politics of reform and transition in African politics, economy and society.
In just over a month delegates from all over southern African will be converging at the third EQUINET Southern African Regional Conference on Equity in Health being held in Durban, South Africa on the theme ‘Reclaiming the state: Advancing peoples Health, Challenging Injustice’. This conference theme has been chosen to reflect the commitment by EQUINET to go beyond mapping the problems in and challenges to health equity and social justice in southern Africa and to proactively build the alternative vision, analysis, perspective and practice needed to meet those challenges.
The conference will debate the actions and systems needed to advance people’s health equitably, fairly and within the broader context of social justice. EQUINET proposes that such systems must integrate principles and practice:
- of public health, viz the protection and promotion of population health and prevention of ill health
- of providing relevant, quality health services and care for all according to need and financed according to ability to pay
- of building the human resources and knowledge to shape and deliver public health and health services, and
- of protecting and ensuring the social values, ethics and rights that underlie health systems, including to participation and involvement.
The conference will also review through various areas of work the proposal that health must be supported by redistribution of the resources for health in an equity oriented policy agenda supported by the state. The conference will explore options for policies and systems that are explicitly centred on rising investment in health through the state and public sector. What does it mean conceptually and practically at national and global level to reclaim the central role of the state for equitable health systems?
Efforts by states and citizens in the region to equitably meet the health needs of their people confront the challenge posed by a globalization process based on unfair global trade relations, dominance of transnational corporation interests, reduced role and authority of the state and political and economic marginalization of southern and low income populations. Such conditions contribute to a huge ‘brain drain’ of health personnel, growing household food insecurity, massive constraints in meeting the drug and other inputs to health care and privatization of essential services, all with damaging implications for equity in health.
The conference will present and discuss the perspectives, shared values and options for challenging the injustices undermining people’s health. We will draw from the experiences of work with government, parliaments and civil society. We will examine the rights and governance approaches that are needed to support such action for health.
We invite all those with ideas, issues and options to contribute to this process, whether or not you are coming to the conference! Send us your feedback, resolutions, and contributions with your name and institution to admin@equinetafrica.org and we will integrate it into the inputs to the conference resolutions and keep you informed on the outcome. What do you see as the major challenges and contributions to advancing people’s health in southern Africa? What policies and actions are needed to strengthen the role and performance of the state and public sector in health? How can southern Africans more effectively challenge the injustices that undermine health? What should EQUINET do, as a network based on shared vision and values of equity and social justice, to strengthen our analysis, actions and institutions to better deliver on our collective aspirations for health equity and social justice? What role would you like to play in this?
EQUINET is pleased to announce the launch of its new website.
Visit http://www.equinetafrica.org/
The new website has been designed with minimal graphics to make it easier for those with low bandwidth connections to access the website with ease.
The full range of EQUINET's publications are available online. You will find a searchable database of all our publications, including our monthly newsletter, Equinet News, and Briefings, with archives of all previous issues. Policy papers, discussion documents, and other essential materials for the struggle for equity and health - all can be found at this easy-to-use website.
Our Annotated Bibliography on Equity in Health in Southern Africa is now available online for the first time in a searchable database, and information will now be updated regularly by the EQUINET secretariat at TARSC and the steering committee.
You can find the latest information about EQUINET's activities, research grants, training courses and reports from theme and country coordinators.
We welcome submission of news and other information online. Please send us news of work on health equity, publications for the annotated bibliography, news, policies and reports of meetings and research within the theme areas, information on grants and training opportunities and other information on health equity work in the region.
Send your contributions for the website and publications
bibliography to admin@equinetafrica.org and send your news to editor@equinetafrica.org.
We hope that this makes the site more useful to you and helps you in your work. We hope that it contributes to a stronger, more informed and more organized region in support of health equity goals.
For general queries on Equinet please email admin@equinetafrica.org or visit the Equinet website at www.equinetafrica.org.
The EQUINET website has been developed and designed, and is maintained by:
Fahamu - learning for change (http://www.fahamu.org).
Fahamu uses information and communication technologies to serve the needs of organisations and social movements that aspire to progressive social change and that promote and protect human rights.
The Regional Network for Equity in Health in Southern Africa (EQUINET), Oxfam GB in co-operation with SADC, government, UN, civil society, health sector and international agency partners met in February 2004 to review the options for a sustainable and equitable path to realising the urgent imperative of making antiretroviral therapy (ART) available to southern Africans and the long term imperative of universal treatment access. The organisations identified principles to guide a sustainable and equitable response that would address the urgency of the need to act and the demand to do this in ways that build and do no harm to the already fragile public health systems in southern Africa. There is an opportunity for a virtuous cycle where programmes aimed at delivering ART strengthen health systems and thus widen access to ART. There is also a threat of a vicious cycle of programmes aimed at delivering ART diverting scarce resources from wider health systems and undermining long term access both to ART and to other critical public health interventions. These principles are the basis for the virtuous cycle. They are presented as a discussion document for wider dissemination, discussion and feedback. Feedback is welcomed! Please email your feedback to admin@equinetafrica.org.
1. WHY TREATMENT ACCESS THROUGH SUSTAINABLE PUBLIC HEALTH SYSTEMS?
- Approximately 15 million adults and children in southern Africa are currently infected with HIV and an estimated 700 000 - 1million currently have AIDS. With only one eligible person in 25,000 currently on treatment with antiretroviral therapy (ART), the shortfall is enormous, and widest for the low income communities using peripheral and rural health services. Responding to this scale of disease and shortfall will not be possible through scattered programmes and projects. It requires a comprehensive and co-ordinated approach that embeds treatment within an effective, accessible health system.
- Treatment is only one of the multiple responses to the risk environments and factors that produce HIV and to the many areas of household vulnerability due to AIDS. Household food security, access to primary health care, social security, gender equity and income security are important factors linked to HIV and AIDS in southern Africa. Treatment programmes may excessively shift attention to drugs as the response to AIDS if they do not reinforce the prevention, care and socio-economic programmes that deal with these factors influencing HIV infection and the impacts of AIDS.
- After decades of macroeconomic measures weakening health systems, the capacities lost to public health systems, including the human resources for health, need to be systematically rebuilt to plan, manage and use the significant global and international resources for treatment of AIDS coming into Africa. Treatment activism has opened a real window of opportunity for meeting rights of access to treatment and overcoming unjust barriers to ART. It now needs to join with broader public health activism to ensure that these goals can be realised for all through sustainable, effective and equitable health systems.
- All southern African Development Community (SADC) member states have policies on AIDS and treatment guidelines and some are developing explicit treatment access policies. While legal, clinical and pharmaceutical aspects of these policies are now developed, there is a gap in the health system aspects. This gap needs to be filled if treatment policies are to be implemented in the practical conditions found in southern Africa health systems and to reinforce wider health and social goals.
The current situation does not lend itself to prescription. Southern African countries vary widely in socio-economic status, health system development and in the availability and organisation of resources for health. The choices around how scarce resources are used need to be made in an informed, transparent and participatory manner at the national level. These guiding principles are thus intended to support fair country level processes to develop strategies based on the capabilities, resources and demands of national health systems.
2. PROPOSED GUIDING PRINCIPLES
2.1 Fair, transparent processes to make informed choices.
The choices to be made around use of resources, around the clinical, social and systems criteria for rationing and around opportunity costs and trade-offs call for governments and relevant international and national non-government organisations to provide clear, transparent and accountable mechanisms for public and stakeholder consultation and debate to develop policy and to make policy choices.
2.2 Joint public health and HIV/AIDS planning.
Strategic and operational plans as well as monitoring and evaluation frameworks at national and district levels should be produced through a process that integrates HIV / AIDS planning into broader public health planning. This includes integrating AIDS treatment programmes into HIV/AIDS prevention and social care programmes. Integrated planning should be supported by investments in public health leadership and in the management and monitoring capacities needed to implement plans.
2.3 Integrating treatment into wider health systems.
Governments, international and national agencies should integrate HIV and AIDS prevention, treatment and care programmes into a programme of health systems strengthening and development. Key elements of this programme include:
Strengthening inclusive public health systems:
· Prioritising district and primary level facilities and services as points of entry for ART services over tertiary level services.
· Locating treatment programmes within an effective District Health System, supported by effective district health management structures that provide all basic services for HIV and non-HIV related illness in an integrated and locally appropriate manner.
· Ensuring adequate human resources for treatment programmes integrated within district health systems.
· Co-ordinating and building national networking of information and experience from district sites.
· Services provided by non-profit organisations should be integrated in the public sector framework.
· Private sector provision should complement public provision and not compete for public funding.
2.4 Realistic targets for treatment access with clear guidelines and monitoring systems for ensuring equity in access and quality of care.
The rapid expansion of ART can be achieved through targeting HIV positive current users of the health system, (particularly PMTCT, TB and VCT clients) and certain social and occupational groups (such as those with medical insurance or health workers). Such rapid expansion options should take place with simultaneous and equal investments to build the district health system and PHC infrastructure in areas without the current capacity to sustain effective ART services within clear time frameworks for wider rollout.
2.5 Treatment resources integrated into regular budgets, supported by long term external commitments and through fair financing approaches
Dedicated AIDS funding should be integrated into regular budgets and comprehensive health sector plans. The transfer and use of earmarked funds for AIDS should be transparent. ‘Emergency transfers’ to meet specific system shortfalls should be time-limited with plans for their integration into regular budgets and comprehensive health sector plans.
Additional funds and resources dedicated to HIV/AIDS should be system supporting (covering prevention, treatment, district health system and PHC responses) and include expenditure on broader health care infrastructure where required. This calls for longer term commitments from international agencies (minimum 5 years), in support of joint national HIV/AIDS and health plans, linked to budget and sector wide support with agreed exit strategies. Global and international funds should build predictable, consistent, long term and co-ordinated funding. African governments should increase their health budgets to 15% of total budgets in accordance with the Abuja declaration, and strengthen their governance and management capacities for resource planning and management. Ministries of finance should now integrate health systems demands into financial planning and budget frameworks and review their Medium Term Expenditure Frameworks with the IMF to take account of additional resource inputs demanded for system strengthening.
2.6 Prioritise human resource development in the health sector.
Strategic plans, developed in consultation with health personnel, are required for the health personnel needs and commitments for a health systems approach to treatment access. This should include effective and sustainable in-service and institutional training approaches, provisions for clear career paths, effective human resource management (payroll management, supervision and training), incentives for health workers to work in under-staffed areas and provisions for safe work. Plans for treatment access should not involve deliberate policies of recruitment of staff from other African countries or diversion of scarce personnel from broader health systems into vertical programmes. Any proposed new investment in HIV/AIDS or treatment expansion should include resources and measures for the training, sustaining and retaining of relevant health personnel and for their safe work environments and infection control.
2.7 Strengthen essential drugs policies and systems at national and regional level.
National legislation should now take full advantage of the TRIPS flexibilities and the Doha declaration, particularly provisions for parallel importation and compulsory licensing. Drug regulatory and medicine control authorities should be strengthened, together with drug procurement and distribution systems. The expansion of ART should be included within the essential drugs programmes, through review and update of the essential drugs list. The essential drugs policy should cover the private sector and provide where necessary for mandatory generic substitution (available generic equivalent drug provided when brand name drug prescribed). SADC as a regional body should use TRIPS flexibilities and the Doha commitments to support regional strategies for procurement, price monitoring and negotiation, and quality control of drug supplies. Southern African governments and civil society should promote monitoring, regulation and advocacy within the region and internationally to prevent excessive profiteering and unfair monopolies in the pharmaceutical sector.
3. CONCLUSION
These principles are proposed as central to ensuring that actions to expand access to ART are reinforced, sustained and meet equity policy goals through strengthened health systems. They are proposed:
- for national debate,
- for translation into practical strategies and programmes,
- to gather and share evidence on options for good practice,
- to provide a wider framework for understanding the costs and benefits of approaches to ART access,
- to inform international agency policy and practice and
- to inform advocacy and activism.
They are proposed as a framework for monitoring and evaluating our efforts to expand treatment access. They are as important as targets and are more directly linked to our longer term capacities and aspirations to sustain and expand access to treatment for all those who need it.
* Treatment Action Campaign (TAC)/AIDS Law Project (ALP) Memorandum on the United States/Southern African Customs Union Free Trade Agreement Negotiations. Prepared by: Jonathan Berger (Law and Treatment Access Unit, AIDS Law Project) and Njogu Morgan (International Desk, Treatment Action Campaign.
Introduction
On 4 November 2002, United States Trade Representative (USTR) Robert Zoellick formally notified US Congressional leaders of President Bush's intention to initiate negotiations for a free trade agreement (FTA) with the Southern African Customs Union (SACU), which includes Botswana, Lesotho, Namibia, South Africa and Swaziland. These negotiations are now underway, with the next round scheduled for 23 February 2004 in Namibia. As far as we are able to ascertain, the negotiators plan to conclude their discussions in or around October 2004, with a US-SACU FTA being signed before the end of the year.
The Treatment Action Campaign (TAC) and the AIDS Law Project (ALP) believe that trade between nations, when conducted within the framework of a reasonable and fair set of rules that adheres to the triple-bottom line of environmental, social and commercial sustainability has the potential to act as a tool for attaining developmental priorities. Our support for the ongoing negotiations would therefore be predicated on the agreement strictly adhering to these principles. Yet the US position, as clarified in Mr Zoellick's correspondence with Congress, raises cause for concern.
In his letters to the Speaker of the House of Representatives and the President of the Senate, Mr Zoellick set out reasons for entering into such negotiations, as well as the USTR's “specific objectives for negotiations with the SACU countries”. In particular, Mr Zoellick raises the following US objectives:
“We plan to use our negotiations with the SACU countries to address barriers in these countries to U.S. exports - including high tariffs on certain goods, overly restrictive licensing measures, inadequate protection of intellectual property rights, and restrictions the SACU governments impose that make it difficult for our services firms to do business in these markets. We also see the negotiations as an opportunity to advance U.S. objectives for the multilateral negotiations currently underway in the World Trade Organisation (WTO)." In our view, a number of the specific objectives identified have the potential to undermine the financing and provision of health care services in SACU countries, both in the public and private health sectors, as well as the rights of people living with HIV/AIDS. In particular, if translated in binding commitments, many of these objectives have the potential to limit the ability of the South African government in discharging its constitutional obligations, primarily in respect of the right of access to health care services. In our view, such undertakings would be an unconstitutional exercise of power.
This memorandum highlights our concerns in respect of two key areas: intellectual property (IP) and trade in services.
Intellectual property
With respect to intellectual property rights, the US government's specific objectives are as follows:
" - Seek to establish standards that reflect a standard of protection similar to that found in U.S. law and that build on the foundations established in the WTO Agreement on Trade-Related Aspects of Intellectual Property (TRIPs Agreement) and other international intellectual property agreements, such as the World Intellectual Property Organisation Copyright Treaty and Performances and Phonograms Treaty, and the Patent Cooperation Treaty.
“ - Establish commitments for SACU countries to strengthen significantly their domestic enforcement procedures, such as by ensuring that government agencies may initiate criminal proceedings on their own initiative and seize suspected pirated and counterfeit goods, equipment used to make or transmit these goods, and documentary evidence. Seek to strengthen measures in SACU countries that provide for compensation of right holders for infringements of intellectual property rights and to provide for criminal penalties under the laws of SACU countries that are sufficient to have a deterrent effect on piracy and counterfeiting.”
Quite clearly, the US sees the SACU negotiations as an opportunity to extract standards of intellectual property protection in excess of what the Agreement on Trade-Related Aspects of Intellectual Property (or TRIPS) currently requires. This is consistent with its approach to other regional and bilateral trade negotiations. A review of a range of such trade negotiations initiated by the US indicates that it has sought to extract greater concessions than those provided under existing international trade rules, largely to the detriment of developing countries.
To meet "standards of protection similar to that found in U.S. law", SACU nations would be required to adopt a range of TRIPS-plus provisions, including limiting compulsory licenses to national emergencies or to governmental, non-commercial use only. This is clearly in conflict with the Declaration on the TRIPS Agreement and Public Health adopted at the WTO Ministerial Conference at Doha in November 2001, which unambiguously states that "[e]ach Member has the right to grant compulsory licences and the freedom to determine the grounds upon which such licences are granted". Further, SACU members would be required to bar parallel trade, to extend patent monopolies for administrative delays, to link drug registration rights to patent status, to enhance protections for clinical trial testing data and to adopt criminal enforcement for patent violations, including improvidently granted compulsory licenses.
In short, the specific objectives in respect of IP would significantly undermine the ability of SACU member states' to make use of the regulatory flexibilities and public health safeguards identified in the Doha Declaration. If implemented, the negotiating objectives would severely limit access to essential medicines used in the prevention and treatment of a range of health conditions, including but not limited to HIV/AIDS. In addition, by seeking to impose TRIPS-plus provisions on SACU members, the USTR would be violating the principal negotiating objectives in the US Trade Act of 2002, which require "respect [for] the Declaration on the TRIPS Agreement and Public Health, adopted by the World Trade Organisation at the Fourth Ministerial Conference at Doha, Qatar on November 14, 2001", as well as Executive Order 13155, which deals specifically with access to "HIV/AIDS pharmaceuticals or medical technologies".
Trade in Services
With respect to trade in services, the US government's specific objectives include pursuing "disciplines to address discriminatory and other barriers to trade in the SACU countries' services markets." As mentioned above, the US plans to use the negotiations to address "overly restrictive licensing measures" and "restrictions the SACU governments impose that make it difficult for our services firms to do business in these markets."
If implemented, these negotiating objectives would render a range of legislative provisions in the South African Medical Schemes Act, for example, as unlawful. Such provisions increase access to health care services, by ensuring that unfair discrimination on the basis of health status is prohibited and by ensuring that medical scheme beneficiaries are guaranteed a minimum package of care, regardless of financial contribution.
It is not only trade in health care services that is of concern to TAC and the ALP. Similar arguments apply with equal effect, for example, to any regulatory steps taken by the state to ensure access to financial services for people living with HIV/AIDS. In our view, the state has a constitutional obligation to regulate the insurance services industry in such a manner, to ensure that people with HIV/AIDS have access to life cover and funeral benefits, as well as access to insurance services necessary for accessing financing for housing.
Conclusion
The ALP and TAC are concerned that the US/SACU FTA negotiations have the potential to result in binding commitments on SACU member states that undermine access to health care services, the rights of people living with HIV/AIDS and the ability of such states to comply with their domestic, regional and international human rights obligations. In our view, such an agreement would not only unlawfully conflict with certain national constitutions and human rights instruments, but would also serve to advance the interests of the US at the expense of the health and welfare of the people of Botswana, Lesotho, Namibia, South Africa and Swaziland.
* Please send comments for publications in the Letters section of Equinet News to editor@equinetafrica.org
FIRST CALL CLOSES ON MARCH 31 2004. THE BEST APPLICANT WILL QUALIFY FOR
SUPPORT TO ATTEND THE EQUINET JUNE 2004 CONFERENCE IN DURBAN SOUTH AFRICA
This briefing describes the new programme of student research grants in
EQUINET and invites applicants for the first round of grants.
The Regional Network for Equity in Health in Southern Africa (EQUINET)
promotes policies for equity in health across a range of priority theme
areas (See www.equinetafrica.org) EQUINET has over the years, organized its
work in various theme areas, including: economic and trade policy and
health; human rights, governance and participation, equity in health sector
responses to HIV/AIDS, human resources for health; monitoring and
surveillance and others. Within these areas of work EQUINET aims to
identify, recruit and build capacity and analysis. After a successful
pilot initiative in 2003 in co-operation with the Malawi Health Equity
Network member in the EQUINET steering committee, EQUINET has now launched a
programme of student research support that provides small research grants
for students at college or university in various programmes in east and
southern Africa. The programme will give priority to student research
applicants who propose projects in areas of research relevant to EQUINETs
priority areas of theme work, and who provide evidence of supervision from
expertise in these areas.
This first round of the EQUINET student research grant programme (SRGP) is
being implemented in February 2004. EQUINET will award a number of small
grants to post graduate students and undergraduate students in East and
Southern Africa for research proposals in the areas of
? Equity in Human Resources for Health
? Equity in health sector responses to HIV/AIDS and treatment access
? Using health rights as a tool for equity in health
? Health equity in economic and trade policies
? Fair financing in health
? Governance issues in health equity
? Understanding and analyzing policy processes
? Equity issues in food security and nutrition
The grants are for students to carry out supervised, small research projects
in the course of their studies and are set at a maximum of $750. Applicants
are requested to provide brief information in 2-3 pages on
? The name, institution, course and year of study of the student
? The name, department and institution and contact email/fax for the
proposed supervisor for the study
? The theme area of the proposal
? The hypothesis, research question or research objective(s)
? The methods to be used, and indicators / (quantitative, qualitative
information) to be collected and the intended analyses to be carried out
? The time frames and budget
The application should be made jointly by mentors / supervisors and their
students. The grants will be open to all EQUINET members, undergraduate
and postgraduate students, students from all disciplines. Applications
should be submitted to admin@equinetafrica.org with STUDENT GRANTS in the
subject line or by fax to 263-4-737220 by March 30 2004.
In this round the student providing the project proposal rated highest on
grounds of analytic and technical quality and relevance will qualify to be
supported to attend the EQUINET conference in Durban South Africa, June 8-9
2004 (see www.equinetafrica.org) and formally granted their award at the
Conference.
The selection of grants will be made on the basis of relevance of subject
area and quality of proposal but with some attention to ensuring equity in
the distribution of grants across countries in the region. Applications in
French or Portuguese will be considered.
EQUINET web based resources, newsletter and expertise in the theme areas
will be available to the students. The reports of the research projects
will be made available on the EQUINET website. Publication from the research
is encouraged, with acknowledgement of the support from EQUINET. EQUINET
will also have the right to use the research in its theme work and will
encourage the students participation in future EQUINET activities and
information exchange.
Focal points for queries on this programme are Dr R Loewenson/G Musuka at
the EQUINET Secretariat (TARSC) and Dr A Muula at the Malawi College of
Medicine/ Malawi Health Equity Network. Please send queries through
admin@equinetafrica.org. For general information on EQUINET and its work
please visit our website at www.equinetafrica.org or email the secretariat
at admin@equinetafrica.org.