Mark your calendars. On December 1, the globe will celebrate World AIDS Day. The theme, as it has been for the last two years, is "Stop AIDS: Keep the Promise." This is to serve as a reminder to the world community of its promise to among other things provide universal access to treatment, reduce prevalence rates, and implement effective prevention programs. As the prevalence rate of those living with HIV continues to climb in most countries in southern Africa, it is clear that we are far from fulfilling this promise by 2010, the campaign’s target year.
Almost a third of those living with HIV live in southern Africa. Despite the infusion of funding and the attention of national governments and international bodies, the prevalence rate in the region (surprisingly, apart from Zimbabwe) is continuing to rise. In Botswana, Swaziland, and Lesotho over one-fifth of the population is infected with HIV. The high prevalence rate fails to be matched by adequate access to treatment. Access to anti-retroviral therapy in sub-Saharan Africa has increased in the last year but remains at a miserable 28%.
As anyone living in southern Africa knows, the tentacles of the virus reach across all sectors of the community, but they tend to prey more on those who are the most removed from access to and the protection of the law—among them, women, children, prisoners, and those living in poverty.
Despite this or maybe because of this, the law remains an underused weapon in the fight against the effects of HIV and AIDS in the southern Africa region. Apart from South Africa—where the galvanizing work of the Treatment Action Campaign, AIDS Law Project, and others supported by a robust Constitution and judiciary has resulted in significant legal successes—there have been few cases brought on behalf of those infected and affected by HIVand AIDS in the region. In Namibia, the AIDS Law Unit of the Legal Assistance Centre successfully brought a case challenging the Namibian military’s denial of employment to an HIV positive individual who was otherwise physically fit.
In Botswana, the courts have issued decisions on a handful of cases involving the privacy rights of HIV positive individuals. In the rest of the countries in the region, courts have yet to issue a single significant legal decision on an HIVand AIDS related case.
In recognition of the underutilization of the law and litigation in southern Africa, the Southern Africa Litigation Centre established a new HIV and AIDS programme focusing on providing resources, support, and training to lawyers and advocates in the region to bring cases supporting the rights of those infected and affected by HIV/AIDS in national and regional courts. The programme does not intend to duplicate the groundbreaking work already being done by local, national, and regional organizations on these issues, but will aim to bolster the work of local and other regional actors to increase the use of the law and litigation to advocate for the rights of those living with HIV, and those rendered vulnerable by the pandemic.
Accessing the law through litigation can be a powerful tool for changing policy and social attitudes. Litigation can also provide a public platform on which the voices of those generally silenced can not only be heard but magnified. In South Africa, the role of lawyers and litigation in exposing the hypocrisy of the apartheid state and ultimately contributing to its demise is undeniable. More recently, a Constitutional Court decision, Minister of Health and others v Treatment Action Campaign and others, requiring the South African government to make nevirapine, a drug known to significantly reduce the likelihood of mother-to-child transmission of HIV, available in all public hospitals and clinics resulted in the drastic reduction of mother-to-child transmission.
This is not to say that the law and courts alone can stem the devastating impact of HIV and AIDS, or that litigation is the appropriate strategy all of the time. The use of the law must be pursued in tandem with other advocacy tools, including public education and campaigning. In addition, legal victories have little meaning without the close involvement of local community-based organizations, and networks of people living with HIV, who can ensure the translation of a successful court decision into concrete change in the reality of people’s lives.
I am not naïve. I do not think the use of courts and the law will miraculously change the progression of the pandemic. But if we are to have any chance of turning the tide we need to use all of the tools available to us in fighting this epidemic.
Priti Patel is Project Lawyer for the Southern Africa Litigation Centre’s (SALC) new HIV/Aids Litigation Programme; she can be contacted via the SALC website at http://www.southernafricalitigationcentre.org/salc/. Visit the EQUINET website www.equinetafrica.org for further information on rights as a tool for equity and health systems responses to HIV and AIDS. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
Editorial
The global attention to equity and to Africa has grown. The 2006 United Nations Human Development Report, the 2005 UN Report on the World Social Situation and the 2006 World Bank World Development Review focused on inequalities and equity, while a WHO Commission on the Social Determinants of Health will report in 2008 on a global inquiry into options to improve health equity through action on the social determinants of health. Africa has been the focus of Commissions and special programmes. In 2007, the World Health Organisation Director General stated that improved health in Africa was one of the organisations’ top priorities.
Within Africa, millions of people experience deprivation of the most basic rights to water, shelter and food, millions of children have lost parents due to early adult death, a majority do not have secure incomes and many live in situations of conflict and social disruption. Also within the continent, health workers, teachers and others provide valuable services, state officials and university staff take on intense workloads with limited resources, and civil society and community organisations implement innovative local ways of improving life.
An enormous gap continues to exist between global attention and local reality.
On October 23 2007, EQUINET is launching a new publication- an analysis of equity in health in east and southern Africa. The book, “Reclaiming the resources for health: A Regional analysis of equity in health in east and southern Africa” explores the challenges and options for overcoming persistent inequalities in health in east and southern Africa (ESA). It is written by the EQUINET steering committee and jointly published by EQUINET with three African publishers, Weaver Press Zimbabwe, Fountain Publishers Uganda and Jacana publishers, South Africa.
The book presents a synthesis of the evidence gathered from a range of sources, including eight years of work in EQUINET, published literature on and from the region, data drawn primarily from government, intergovernmental, particularly Africa Union and UN sources and the less commonly documented and heard experience within the region, found in grey literature, in interviews and testimonials and gathered through participatory processes. In the analysis, we do not seek to simply describe our situation, but to understand it in ways that generate and inform affirmative action from within the region.
The evidence in the analysis points to three ways in which “reclaiming” the resources for health can improve health equity:
• for poor people to claim a fairer share of national resources to improve their health;
• for a more just return for ESA countries from the global economy to increase the resources for health; and
• for a larger share of global and national resources to be invested in redistributive health systems to overcome the impoverishing effects of ill health.
The region has the economic and social potential to address its major health needs. Yet improved growth has often occurred with falling human development indicators and increased poverty. In many ESA countries, widening national inequalities in wealth block poor households from the benefits of growth, while substantial resources flow outwards from Africa, leaving most of its people in poverty, and depleting the resources for health. The analysis adds evidence to the growing call for a more fair form of globalisation, and a more just return to Africa from the global economy. The report maps the trade, investment and production policies and measures that have strong public health impact, the options to address outflows, and to promote access to food, health care and medicines within economic and trade policies. National measures that redistribute these resources for wider economic and social gain provide clear pathways for equitable use of funds released from debt cancellation, improved terms of trade, increased external funding and other global measures.
While many of these actions lie outside the health sector, the analysis argues that health systems can make a difference, by providing leadership, shaping wider social norms and values, demonstrating health impacts and promoting work across sectors.
Drawing on a diversity of evidence and experience from the region, the analysis describes the comprehensive, primary health care oriented, people-centred and publicly led health systems that have been found to improve health, particularly for the most disadvantaged people with greatest health needs. While resource scarcities and selective approaches weakened these universal systems in recent decades, the lessons presented from the roll out of prevention and treatment for HIV and AIDS continue to demonstrate their relevance, particularly at district level.
The persistence of disadvantage in access to health care in those with highest health needs is thus of concern. The analysis explores the reasons for this, within the way health systems are funded and organised, and the barriers that disadvantaged people face in using health services.
Addressing these problems demands a strengthened public sector in health. Current average spending on health systems in the region is below the basic costs for a functional health system, or even for the most basic interventions for major public health burdens. Therefore one priority is for governments to meet the as yet largely unmet commitment made in Abuja to 15% of government spending on health, excluding external financing. We argue, however, for “Abuja PLUS” - for international delivery on debt cancellation and for a significantly greater share of this government spending to be allocated to district health systems.
The analysis presents progressive options for mobilising these additional domestic resources for health systems without burdening poor households, and for increasing spending on district and primary health care systems. One of the areas of increased spending is on health workers. Without health workers there is no health system. In the face of massive shortfalls and significant outflows of health workers, the analysis explores incentives countries in the region are using to train, retain and ensure effective and motivated work of health workers, and the strategic capacities and role of health workers in designing and implementing these plans.
These approaches are not without challenge, whether from local elites, competing approaches or global trade pressures. Yet health is a universal human right, and international and regional conventions call for a ‘bottom line’ of rights and obligations to protect people’s health. One basis for the positive potential for achieving equity in health in the region is in the significant social pressure for these goals, and the social resources, networks and capabilities that exist to achieve them. The analysis points to the many ways health systems can act to empower people, stimulate social action and create powerful constituencies to advance public interests in health. Tapping these potentials calls for a robust, systematic form of participatory democracy and a more collectively organised and informed society.
To champion these values, policies and measures, to monitor progress and enhance accountability, the analysis proposes a set of targets and indicators that signal progress in key dimensions of health equity, and towards meeting regional and global commitments. EQUINET, as a network of institutions in the region, is committed to implementing and supporting the building of knowledge, skills and learning to meet these goals.
The analysis is presented as resource for the people, institutions and alliances working in and beyond the region towards goals of improved health and social justice. EQUINET, as a network of institutions within the region, itself remains committed to generating knowledge, facilitating dialogue and analysis, and supporting practice to deliver on these goals within the region.
The book” Reclaiming the Resources for Health” will be available after its launch on 23rd October from EQUINET (admin@equinetafrica.org)or from the publishers in the region (Weaver Press, Fountain Publishers and Jacana). See EQUINET Updates below for contact information. For feedback on this brief please contact the EQUINET secretariat at admin@equinetafrica.org. For further information on the issues raised in this brief please also visit the EQUINET website at www.equinetafrica.org.
With the major public health challenges that are found in Africa, making progress in public health clearly demands a significant spread of public health skills. While health workers are making tireless efforts to address preventable diseases across the continent, and many successful experiences exist, revitalizing primary health care oriented systems calls for revitalized public health leadership and skills.
Part of the challenge is filling the gaps created by out-migration. At a conference held in mid-June 2007 on 'Sustaining Africa’s Development through Public Health Education', hosted by the University of Pretoria School of Health Systems and Public Health, Professor Erich Buch, health advisor to NEPAD, depicted the prevailing health worker situation in Africa, including the extensive brain drain, low funding and insufficient, often inadequately compensated, staff. He emphasised the need to shift focus from the current responses taking place country-by-country to building wider continental responses, informed by vision, leadership, and energy. This leadership demands public health skills, and Professor Buch asserted that building 'centres of excellence and networks in Africa are key … to strengthen[ing] public health capacity at public health schools and institutions across the continent'.
The meeting discussed options for how to achieve this. With limited financial and institutional resources, governments and institutions can best maximise what is available by sharing existing African expertise across organisations and countries, and strengthening formal mentorship programmes for public health practitioners. This needs to be backed by investments in user-friendly technology to support the communication, collaboration and networking between research institutions, and to stimulate collaborative research and discussion forums and strong alumni systems.
Networking between institutions and professionals in Africa is sometimes weaker than between Africans and colleagues in the developed world. Building African networks needs active support and investment. One key area of concerned raised in the NEPAD strategy is establishing and maintaining an inventory of public health education capacity in Africa, enabling standardisation and accreditation of training institutions and encouraging innovative methods of training and the use of technology supported learning. As Professor Buch stated “We need to … build more cost-effective capacity on the continent'.
In line with these goals, the AfriHealth Project at the University of Pretoria recently completed a three-year mapping project of public health education and training institutions in South Africa. The project has developed a database of public health workers and educators to inform collaborations in Africa. While the mapping focused on South Africa, the information would be useful to strengthen the networking of institutions and individuals in Africa and to share these institutional resources. The AfriHealth Project seeks to secure a Pan-African Public Health body that is effective, inclusive, scientifically and politically supported, and well-resourced. The project has identified the strategic importance of developing a continental approach to improving public health in line with new socio-political realities, strengthening public health capacity by networking institutions, programmes and individuals, and promoting technology-supported learning and communication.
These initiatives do not see current skills scarcities as being an insurmountable block to development of new skills. Mentors can be drawn from existing academic institutions. But public health education must also move beyond universities, to provide other skills not always available from university education, such as for cultural sensitivity in health practice, or for strategic management. Short courses for public health practitioners can also bridge the gap between different entry levels and Masters' degrees in public health. Public health educators and researchers must also bridge the gap in research to reduce the drop out rate in Masters' courses.
There are new and emerging challenges to public health in the rapidly changing global environment. The content of public health training needs to match the new needs and opportunities for action in public health.
Gender issues have a major impact on health in the continent, and institutions should include gender in public health curricula. Improving women’s rights, eliminating violence against women and advancing health rights more generally calls for recognition of the central role played by women in providing health care. This doesn’t only mean looking at women's roles. As Dr Alena Petrakova from WHO (Geneva) noted at the conference, mainstreaming gender in public health curriculum design and development also means involving men and examining their impact on health. A recently-formed African Network for Public Health Educators on Gender (ANPHEG) is taking the issue of how gender is mainstreamed in the public health curricula on a sustainable basis.
Achieving the commitments set out in the continent and those set globally, like the Millennium Development Goals, calls for clear skills to best protect, use and advance the health resources in the region. Much focus has rightly been placed on retaining and valuing health workers. Beyond this, equal concern is now being voiced in the continent that those who do work in African health systems are adequately equipped at all levels with the knowledge and skills to lead effective and innovative responses to the continent's public health challenges.
K Tibazarwa is a masters' student, School of Public Health at the University of Cape Town. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
IMF policies are blocking the scale of public spending and hiring of doctors, nurses and teachers African countries need to meet health and development goals. Three recent reports respectively by the IMF’s Independent Evaluation Office (IEO), the Center for Global Development (CGD) and ActionAid International’s Education Team suggest that IMF policies place unreasonable limits to spending of available aid and to scaling-up public spending through overly austere policies that lack empirical justification.
The IMF's mission is to keep inflation under control and promote “macroeconomic stability”. Country access to World Bank aid and other bilateral foreign assistance is contingent upon “thumbs-up” approval from the IMF on macroeconomic policies. The multiplier benefits of major investments in public health and education can take 15 to 20 years to appear in the form of higher GDP growth and productivity rates. Each macroeconomic policy option has its own short-term and long-terms costs and benefits, but because the IMF is always demanding short-term fiscal solvency at any given time, many reasonable alternative macroeconomic policy options for hiring more doctors, nurses and teachers or making long-term investments in the health or education systems are not even being allowed for consideration or debate. So are IMF demands blocking the scale-up of public spending needed to fight AIDS and achieve the Millennium Development Goals (MDGs)? The three reports examine these issues.
The IEO report “The IMF and Aid to Sub-Saharan Africa,” available at http://www.ieo-imf.org/eval/complete/pdf/03122007/report.pdf, examined IMF loan programs to 29 Sub-Saharan African countries from 1999-2005 and found significant percentages of foreign aid were not programmed to be spent because:
* about 37 percent of all annual aid increases were diverted into building international currency reserve levels. Even in countries with sufficient currency reserves, only about $3 of every $10 in annual aid increases was programmed to be spent; the IMF redirected or diverted the remaining $7 out of every $10 into paying domestic debt, building international currency reserves, or both. Having so much new aid not being spent was certainly not the intention of the donors, or citizens in donor countries.
* aid spending was curtailed due to the IMF’s insistence on very low inflation levels. Countries that failed to achieve to 5-7 percent inflation a year were only allowed to spend 15 percent, or just $1.50 of every $10 of their annual aid increases. At a seminar in London in April 2007, Joanne Salop, lead author of the report, said the IEO report team recommended that as the 5-7 percent threshold was the operative IMF policy, it should be publicly stated and clarified - but the IMF Executive Board and management rejected the recommendation.
The IEO report found the IMF Executive Board and senior management were not enthusiastic about donors' emphasis on “poverty reduction” or new efforts to scale-up aid and spending for the MDGs. Without strong leadership directing real policy changes in this regard, the report found, staff simply reverted to prioritising macroeconomic stability over other goals. Yet IMF leadership is overly cautious about deficit spending “crowding out” available credit for the private sector, despite mounting evidence for the reverse, as noted by IMF’s Sanjeev Gupta in a 2006 IMF report (“Macroeconomic challenges of scaling up aid to Africa: a checklist for practitioners,” IMF, 2006. p.26).
The CGD report “Does the IMF Constrain Health Spending in Poor Countries? Evidence and an Agenda for Action,” available at http://www.cgdev.org/doc/IMF/IMF_Report.pdf further explores the implications of this IMF austerity. Produced by fifteen experts from policy-making positions in developing countries, academia, civil society, and multilateral organisations, it reviews experience from Mozambique, Rwanda and Zambia. The report found that: “IMF-supported fiscal programs have often been too conservative or risk-averse”, and have led to underspending of development aid, as they have “not done enough to explore more expansionary, but still feasible, options for higher public spending.” The report calls on the IMF to “explore a broader range of feasible options,” with “less emphasis on negotiating short-term program conditionality.”
The ActionAid International Education Team report “Confronting the Contradictions: The IMF, wage bill caps and the case for teachers,” (http://www.actionaidusa.org/imf_africa.php), found that IMF policies - by varying degrees of influence in setting the level of funds available public sector employees' wages or “wage bill ceilings" - require many poor countries to freeze or curtail teacher recruitment. This leads to persisting chronic and severe teacher shortages. In all three countries studied, inflation-reduction and deficit reduction targets and the wage bill ceiling is too low to allow governments to hire enough teachers to achieve the 40:1 pupil-teacher recommended by the Education for All-Fast-Track Initiative, thereby compromising the quality of education in these countries.
For health and education advocates who are trying desperately to maximize budgets, wages and get every last doctor, nurse and teacher hired, such empirically unfounded economic policy-making is totally unacceptable. An array of reasonable alternative policy options for increasing public spending is being unnecessarily omitted from consideration.
The ActionAid report calls for IMF advice to provide a range of policy options so that governments and other stakeholders – including parliaments and civil society –can make informed choices about macroeconomic policies, wage bills and the level of social spending.
The report also highlights the growing policy contradiction in the foreign aid system: as the richest donor countries try to scale-up spending and foreign aid, they also block the ability of many poor countries to spend that aid because of the IMF loan programs they have approved. A July 4, 2005 New York Times editorial appropriately summarized this current contradiction in donor policies: “There is a desperate need for greater policy coherence in a period when many national governments, including Washington, are sensibly exhorting African governments to spend more on primary health care and education, while international financial institutions largely controlled by those same Western governments have been pressing African countries to shrink their government payrolls, including teachers and health care workers.”
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit www.actionaidusa.org.
From the 1-3 July 2007, African leaders will meet in Accra, Ghana at the 9th Ordinary Session of the Assembly of the African Union. The major agenda item is the proposal and plans for the United States of Africa. Africa’s Under-development as manifested in its public health catastrophe is not on the AU summit agenda. This raises the crucial question of the kind of unity African leaders wish to achieve. Significantly the debate about the proposed union has revolved mainly around political issues without commensurate attention to the development issues which were no less important to the founders of the Pan African movement.
It is now six years since Heads of State of African Union member states pledged in Abuja in 2001 to commit at least 15% of national budgets to health. To say it is tragic that in 2007 only two out of fifty three AU member countries (Botswana and Seychelles) have clearly met that pledge does not even begin to describe the situation. It is beyond tragedy.
In these past few weeks, all roads led to the G8 Summit in Germany. In what has become an annual ritual since the turn of the century, international campaigners Bono, Bob Geldof and an impressive assortment of Development and AIDS related organisations led the calls for more aid to Africa, and for Africa not to be forgotten in the clamour over climate change. As usual, selected African leaders turned up with begging bowls and for photo calls. Leading international campaigners have since described the aid pledged by the G8 this month as 'a farce' and 'grossly inadequate'.
We know that many of the more developed countries have played historical roles in under developing Africa. 400 years of industrial scale slavery, in addition to colonialism, ruthless exploitation of Africa’s resources, cynical ‘interventions’ and the debt burden have cost Africa dearly. The ‘foreign’ aid to Africa is a percentage of what has been taken out in human and natural resources, and is but a small step towards repairing the damage done to Africa.
But we also know that African leaders cannot seriously expect other countries to commit to, or meet pledges to ‘save’ Africa when they themselves appear indifferent to Africa’s future. To be going forward with plans for African unity without simultaneously meeting the most fundamental commitment to African development – that of health - is misguided to say the least.
It is comical for us to be calling on the G8 countries to meet the recent Gleneagles pledges when the vast majority of AU member states have not met their own Abuja 2001 pledge. This is not a pledge we can afford to pass unfulfilled. The Africa Public Health Rights Alliance (APHRA) and its '15% Now!' Campaign revealed on Human Rights Day (December 10) 2006 that by crossing continental, sub regional, country, health, disease specific and development information from a wide range of agencies and institutions we computed that an estimated 8,000,000 Africans are dying annually from preventable, treatable and manageable diseases and health conditions – mainly Malaria, TB, HIV, child and maternal mortality. This figure does not include organ related disease (heart, liver, kidney and lung diseases), an assortment of cancers, vaccine preventable diseases and so forth which could very easily add another million – or more. The consistency of these figures over the past six years alone means that Africa has suffered an estimated 48,000,000 preventable deaths since 2001.
By coincidence, the dream of the United States of Africa is planned to be actualised by 2015, the same year the Millennium Development Goals are to be met. If Africa’s health catastrophe continues unabated we could loose another 72,000,000 lives by then. This is the equivalent of whole nations dying out within a year or a decade. Many African countries (such as Botswana, Burundi, Eritrea, Gambia, Lesotho, Liberia, Libya, Namibia and
Swaziland) have populations of between 1-8,00,000. Most of the island countries have populations of less than a million. Even Africa’s most populous countries (DRC, Ethiopia, Kenya, South Africa, Sudan - with the exception of Nigeria at 130,000,000) all have populations of between 30-80,000,000.
It would therefore not be an exaggeration to describe over 120 million preventable deaths between 2001 and 2015 as genocide – by inaction. In this case and for every life lost, government indifference to Public Health is the equivalent of an Interehamwe machete or Nazi gas chamber. If we were set up memorials to the preventable deaths from one year alone, we would need 100 stadiums in Africa with the capacity to each host 80,000 skulls – each a stadium of shameful silence, and a monument to government without responsibility.
Africa Must Unite! But for it to be a meaningful unity it must not be a unity of the dead. It must not be unity as a continental graveyard.
Meeting the 15% pledge will be a significant indication that African leaders care for their countries and are prepared to live up to their primary responsibility of keeping their citizens alive and healthy. No meaningful and sustainable development of Africa can happen without sustainable financing for health care. Indeed the status of public health is the most significant indicator of social and economic development. This is why the Right to Health is the most crucial Right of all – we all have to be alive and well to exercise any other Rights. The dead have no Rights – except perhaps the ‘Right to a decent burial’.
To postpone the meeting of the 15% pledge to the future is to accelerate the death of Africa. We call on the African Union to place the 2001 15% pledge on the July 2007 summit agenda and at the very least to introduce it as urgent business [under item vii, AOB]. We further call on them to make it a major agenda item of the next summit or to call a special summit dedicated to meeting the 15% pledge. This should be preceded by a special summit of Finance and Economic Development Ministers
To further illustrate the full scale of Africa’s health disaster, it is not enough to demonstrate only the unprecedented scale of preventable death. It is also crucial to demonstrate the scale of Africa’s impotence and one example will suffice.
Without health workers, no amount of free medicines can be delivered to citizens, and all ‘foreign’ AID is meaningless. Yet many African governments have no clue how close to death their countries are due to shortage of health workers of all categories.
The DRC with a population of 57 million, roughly equivalent to the populations of UK, France and Italy has only 5,827 doctors compared to the
France’s 203,000, Italy’s 241,000 and the UK’s 160,000. But it is not just a case of the most developed countries being able to train more health workers, or to poach from Africa to make up their shortfalls. Cuba with a population of about 11 million has roughly the same population as Malawi, Zambia or Zimbabwe. But Cuba has 66,567 Doctors compared with Malawi’s 266, Zambia’s 1,264 and Zimbabwe’s 2,086. Not surprisingly, Cuba has roughly the same life expectancy (77 years) as the G8 Countries, the Scandinavian and other developed countries while the average life expectancy for African countries compared to it here is 37 to 40 years. The success of Cuba in the areas of health care and education demonstrates it can be done. Despite issues with the Castro government, western countries have visited Cuba to study how they have achieved their health success. To come anywhere near meeting the World Health Organisation recommended health worker’s to patient ratio or meeting the health based MDG’s these African countries compared to Cuba will need to train and retain roughly 59,000 Doctors each in 8 years. The DRC will need to train and retain at least 150,000. The numbers for nurses, pharmacists and most categories of health workers are comparable across board. This should be Africa’s priority.
In other words, there is no alternative to long term in country sustainable financing to rebuild Africa’s Public Health systems including health workers and improved working conditions and remuneration for them, adequately equipped clinics and hospitals, improved sanitation and environmental health, clean drinking water and so forth. Without these Africa may achieve its dream of continental unity, but it will be a fools paradise.
We are for a United Africa. But it must be a unity of the living, and of a healthy African people – able to enjoy full civil, social, economic and political Rights - not a unity of the diseased, dead and dying.
Successfully unity can only be based on successful development of which health is the corner stone.
The Africa Public Health Rights Alliance and its 15% Now campaign call on you to join the undersigned below in signing the petition calling
on AU member countries to fulfil their 15% Abuja pledge as the first genuine step towards a healthy United States of Africa.
You can sign by sending your name, position, organisation and country to
africa_15percentnowcampaign@yahoo.com - Also stating if signing in a personal or organisational capacity.
*Signatories to the petition do not necessarily endorse the views expressed in this article.
Article originally published by Pambazuka News, 21 June 2007: http://www.pambazuka.org/en/category/comment/42108
EQUINET calls for Abuja PLUS! EQUINET advocates for governments to meet their Abuja commitment to 15% government spending on health, excluding external funding, PLUS debt cancellation and international support to meet at least US$60 per capita on health systems. Information and publication on EQUINET work on health financing is available at the EQUINET website at www.equinetafrica.org.
We are African organisations deeply committed to improving the health of the people of our continent. Yet we are deeply concerned about the lack of progress, and in some countries reversal of progress, resulting in millions of preventable deaths that continue to burden our countries each year. It is clear that as long as our health systems remain weak in many dimensions and our countries face a health workforce crisis, the current unacceptable trends will persist.
In spite of this slow progress, we remain optimistic. We have observed progress in some regions and countries, and identify with the deepening commitment to the health of many of our Government and institutions. Our Regional Economic Communities have assumed an important leadership role within the continent in catalyzing actions required to strengthen health systems and achieve health MDGs. We are convinced that the engagement of our partners locally and globally can translate into the political will, resources, and efficiency required to transform health on our continent. With so many lives at stake, our neighbors, our children, and ourselves, we must succeed.
Cognizant of the continuing intolerable burden of disease, African Union ministers of health have developed an Africa Health Strategy 2007-2015 that seeks to “provides a strategic direction to Africa’s efforts in creating better health for all.” At the core of the Africa Health Strategy is the strengthening of health systems based on carefully costed National Health Plans that incorporate the commitments made by African governments, including achieving the Millennium Development Goals and universal access to HIV/AIDS treatment, care, prevention, and support by 2010.
The chief responsibility for the success of these plans lies with our own governments. We will hold our governments accountable. We will insist – and are demanding – that they take the necessary steps to achieve the promises of good health, a foundation of healthy societies. Collectively, we will hold our governments accountable to increasing health sector investments to at least 15% of the national budget, improving the efficiency in allocation and application of these resources, and the implementation of health workforce and systems strengthening strategies capable of providing quality health care to all people. We further commit to work with our governments to identify sustainable financing strategies that can replace point-of-service payments (i.e., user fees) for essential health services and to meet their other commitments and responsibilities including as part of the human right to health.
However, the successful implementation of the National Health Plans requires support from Africa’s development partners, especially from the nations that comprise the G8. Even if African governments significantly increase their own funding for National Health Plans, these plans will have significant financing gaps. Many of the actions required for these plans to succeed will require solutions and expertise that crosses national and even continental boundaries.Building health systems must include building partnerships between health care providers and the communities that use those services. It requires donors to listen to African communities to find out what their needs and concerns are, so that services are tailored to those needs, as opposed to imposing systems that may be effective elsewhere but not in Africa. It is about using the opportunities that exist within communities to advance health care, by harnessing the knowledge, resources, and energy in the community and applying it to work together with the formal health system.
We call upon the upcoming G8 summit in Germany to recognize the Africa Health Strategy developed by our health ministers and to engage in substantive dialogue with communities, civil society, governments, regional economic communities, and the African Union.
This dialogue should be backed by firm commitments about steps that we know will be required of wealthy countries if African National Health Plans are to succeed. We call upon the G8 countries to fulfill existing pledges, including the commitment of 0.7 per cent of their own Gross National Income (GNI) to Official Development Assistance (ODA), the doubling of aid to Africa by 2010, and to adhere to the commitments of the Paris Declaration on Aid Effectiveness, including those that relate to alignment and harmonization of aid investments with country plans and leadership.
We ask that this G8 summit also make the following commitments, which are required for African National Health Plans to succeed:
Fiscal Space
1. Provide long-term, predictable funding to cover financing gaps identified in National Health Plans and plans for universal access to HIV/AIDS treatment, care, prevention, and support, and harmonize health assistance with country-driven National Health Plans.
2. Work with International Financial Institutions and developing country governments and civil society to ensure that fiscal and monetary policies are aligned with the best estimates of the fiscal space required to achieve the MDGs and other human development goals and commitments.
3. Accelerate debt cancellation and ensure that debt cancellation supplements rather than displaces aid.
4. Provide the needed financial and technical support to developing countries to design and implement sustainable financing schemes that can support the elimination of point-of-service payments (user fees) for essential health services and that are designed to enable all people, including the poor, access to quality health services.
Health Systems and Workforce
5. Work with the AU and other continental partners to identify a basic package of health systems interventions, implemented at the community and district levels, that can provide the backbone for the delivery of health service packages required to achieve the MDGs and universal access to the best attainable health care.
6. Support the development and implementation of inter-sectoral and comprehensive health workforce strategies that are integrated with a broader health sector response and public service reforms to address numbers of health workers as well as other variables such as internal distribution, skills mix, work environments, productivity, and management capacity.
7. Engage developing countries to formulate a comprehensive strategy to address health worker migration that emphasizes co-development, including by adopting policies to develop self-sustainable workforces within OECD countries and to follow ethical recruitment practices.
8. Increase support to developing countries to fully utilize TRIPS flexibilities to improve access to medicine, including by helping build capacity to utilize these flexibilities and by avoiding any restrictions to such flexibilities – or any other provisions that may be detrimental to health – in trade agreements.
Mutual Accountability
9. Support initiatives and programs that promote peer and independent mechanisms to track the progress of our governments and their partners to the commitments and declarations made at global, continental, and regional fora.
10. Through diplomatic levers, technical assistance, and other strategies, support African civil society efforts to hold our own governments accountable to their commitments and responsibilities.
Signed by 82 organisations and individuals.
The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET. Please send feedback or queries on the issues raised to the EQUINET secretariat admin@equinetafrica.org.
"Universal access to antiretroviral treatment in SADC remains elusive... Of the 13 SADC states for which information is available, only two countries, Botswana and Namibia, had achieved antiretroviral treatment coverage of more than 70% of those who needed it by December 2005."
Evidence of commitment and action, but also lack of progress on universal access to AIDS treatment, care and prevention, and thus on realising the right to health for people living with AIDS and vulnerable communities. These were key findings of an ARASA report released in April 2007 entitled: 'HIV/AIDS and Human Rights in SADC: An evaluation of the steps taken by countries within the Southern African Development Community (SADC) to implement the International Guidelines on HIV/AIDS and Human Rights'.
This ground breaking report is the first in the region to attempt to measure the successes and failures of SADC countries in responding to HIV in a human rights based framework. Given that sub-Saharan Africa has just over 10% of the world’s population but is home to more than 60% of all people living with HIV, HIV and AIDS is a key human rights issue with tremendous civil, political and socio-economic implications.
Many countries in the region have risen to the challenge of responding to the HIV epidemic but are confronted with financial, structural and political barriers to the implementation of law and policy reforms and the establishment and scale-up of programmes to effectively address the epidemic.
Although respondents interviewed in thirteen of the fourteen SADC countries felt that there was political commitment to addressing HIV and AIDS (evidenced by the declaration of HIV and AIDS as a national emergency or by politicians being open about their status) only six countries passed muster in terms of translating commitment into action, particularly in the area of human rights, civil and political rights, and social and economic rights.
One overarching problem identified was lack of commitment to implementation. Although Swaziland, Tanzania, Zimbabwe and Zambia declared HIV and AIDS a national disaster, they were reported to have made little significant progress in the review or reform of laws to ensure the protection of basic human rights so critical to the success of national responses to HIV and AIDS. But even if laws and policies exist, alone they do not solve the problem: 50% of SADC countries have less than 15% antiretroviral treatment coverage and similarly dismal figures for coverage of mother-to-child-transmission treatment and other key HIV and AIDS interventions.
Therefore, resources are needed to implement existing laws and policies if people are to be enabled to enjoy their right to the highest attainable standard of health. Access to resources at individual, community and national levels poses a barrier to access to prevention, treatment and care programmes and requires urgent attention at government, regional and international levels.
Although eleven SADC countries have laws or policies prohibiting unfair discrimination on the basis of HIV status, human rights abuses hamper the implementation and utilisation of existing prevention, treatment and care programmes for people living with HIV and AIDS. The prevalence of gender-based violence and inferior treatment of women and children continues to fuel the epidemic. Much of this can be ascribed to individual attitudes and beliefs, which laws and policies alone cannot change. Changing these social norms is made even more difficult when political commitment is superficial.
If we are to make progress on HIV and human rights, on HIV treatment and prevention, tokenistic commitment must be replaced with true leadership - leadership not only within governments but at every level of civil society as well. This requires the engagement of our leaders, from the village chiefs up to the offices of presidents and prime ministers. Political rhetoric is no substitute for leadership that translates into action.
The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET. Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat admin@equinetafrica.org. For further information on the issues raised or to access the full report referred to, please visit ARASA www.arasa.info or EQUINET www.equinetafrica.org.
Amekwi Lokana, a mother of six from Kenya, said some years ago 'These days, if you are without money, they leave you to die. If my children are ill, and I have money from selling sisal and firewood, I take them to the nearest town. If there's no money, I use herbs … if God takes them, we have done our best.'
It should never be the case that those without money cannot access health care. The most basic obligations that governments have are to respect and protect the survival and health rights of citizens. For governments in east and southern Africa, this is done in a context of the greatest intensity of AIDS globally, high levels of poverty and many other health challenges.
Meeting this obligation is not simply a matter for Ministries of Health. Increasingly finance and trade sectors are having a powerful bearing on health through the agreements they make. Most recently this issue has emerged in the Economic Partnership Agreement (EPA) currently being negotiated between east and southern Africa (ESA) and the European Union (EU), with the aim of signing a final agreement in December 2007.
The "Cotonou Agreement", signed between the EU and African and Caribbean countries in June 2000 makes clear the two central objectives of EPAs: to eradicate poverty and to enhance global integration. The challenge ESA countries face however is that the “global integration” pursued is through liberalisation and commercialisation measures that threaten poor communities' access to the goods and services essential for their health. In past experience this has increased - not reduced - poverty and poor health outcomes, particularly in an international trading system heavily stacked against African countries.
An EQUINET / SEATINI report released earlier this year points to a number of areas in which the EPA currently under negotiation can affect health and health care, unless specifically dealt with.
Firstly the EPA can affect access to essential medicines. It does not yet clearly make a commitment to give ESA countries rights to make maximum use of flexibilities in the WTO TRIPS agreement. These are essential to ensure access to medicines and medical technologies. Although this commitment has been verbally stated by the EU, it is not yet reflected in the EPA. Prior experience of EU free trade agreement (FTAs) with South Africa on this issue suggests that ESA countries and their parliaments and civil societies need be vigilant. The draft text put forward by ESA countries to provide full TRIPS flexibilities and capacity support for their implementation needs to be written into the EPA before it is concluded.
The EPA has not yet specified provisions for trade in health related services. Although most EU countries rightly protect their own public sector as the major provider of health services, there is pressure for service liberalisation in the EPA. ESA countries may thus be put be under pressure to make commitments to liberalise their health services. However for countries in the region to ensure that the poorest draw an equitable share of resources to meet health needs, governments need to regulate health service provisioning and to redistribute funds for health through public sector services. This contradicts commitments to liberalisation of health services. The EPA should exclude any such commitments to liberalise health care services, and should further include health impact assessments in other sectors prior to commitments being made, where these may have an impact on health.
The EPA promotes market access and reduced tariffs and subsidies in agriculture. In a region where undernutrition is high and increasing, all trade policies in agriculture need to be scrutinised for their health impact. In the context of the extreme and longstanding inequalities between EU and ESA agricultural production systems, it is likely that local and smallholder producers will not benefit from the current proposed measures, unless they are deliberately recognised and invested in under the EPA. Until all subsidies on agriculture in the EU are removed, it would not make sense for African countries to lift their own protective subsidies, particularly if this will lead to a further increase in food imports, further undermine local producers and further increase undernutrition.
The EPA raises a more fundamental issue. In the trade agreement, health and health care are put in the context of tradeable goods and services and treated under the aim of enhancing global integration, rather than as key contributors to the stated priority of poverty eradication. We argue that:
• the health implications of the EPAs need to be explicitly recognised
• health officials should be included in negotiations
• health impact assessments should be carried out where relevant, such as in any areas where service liberalisation may impact on health; and
• EU and ESA countries ensure that the EPA is fully compliant with all regional and international health protocols and conventions before it is concluded.
These calls were also made by Zimbabwe civil society in April this year as part of a wider process of Africa and Europe wide activities on the EPAs on April 19. One recurring point of these events was that EPAs as currently constituted would disadvantage developing countries. The EU negotiates as a bloc, with a powerful functioning bureaucracy and a team of skilled negotiators who will speed the pace of the negotiations. However at stake for ESA countries is a deeper bottom line – the health and survival of their people. ESA states thus have an obligation to apply the “precautionary principle” in the EPA negotiations where potential health impacts exist: countries need to be satisfied through evidence produced that the measure negotiated provides greatest possibility, authority and policy flexibility for protecting health and access to health services, and does not lead to negative health outcomes.
Addressing these issues will surely begin to meet the stated joint commitment to poverty eradication. Alternatively, with people's health at stake, the precautionary rule surely applies: No deal is better than a bad deal!
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue or the full report referred to please visit SEATINI (www.seatini.org) or EQUINET www.equinetafrica.org.
What can Africans expect from the World Health Assembly (WHA) on 14 May 2007? Judging from past experience, the Assembly will be a forum where African countries will find issues critical to public health being raised, but not resolved without a struggle.
Kenya, supported by other African countries, proposed in a resolution on Malaria that, countries’ provide legislation to use “to the full” the flexibilities allowed under World Trade Organisation (WTO) agreements to increase access to anti-malarial medicines, diagnostics and technologies for prevention. The US has strongly opposed this. The WHO Executive Board therefore decided in January 2007 to send the draft resolution to the WHA with both the alternate US and Kenya proposals in bracketed text, indicating a lack of consensus. Inexplicably, the draft resolution posted on the WHO website did not reflect the Kenyan proposal and it took many days before it reflected the decision of the Board. The Kenya proposal needs to be supported to protect the legitimate legal rights that countries have under WTO.
Despite the negative US position, at the 2006 WHA many countries recognised that the current intellectual property rights system does not adequately provide for research and innovation on treatments for diseases that disproportionately affect developing countries. To address this, an Inter-Governmental Working Group on Public Health, Innovation and Intellectual Property was established to prepare a global strategy and plan of action. This Working Group will table a report at the WHA.
A resolution will also be tabled on the rational use of medicines, in light of a finding of irrational drug use in over 50% of medicines in developing countries, with weak application of essential medicines, particularly in the private sector. African countries could potentially treat double the number of people within the same budget if this were addressed. The issue of rational use of medicines has been discussed at the WHA since 1985, and countries have urged greater leadership, evidence based advocacy and support from WHO to advance implementation of rational drug use.
While these issues are on the WHA agenda, there is concern about what is happening in practice on intellectual property rights and health. In research on the small pox vaccine, WHO’s relatively open approach to ownership of the research outcomes has enabled private companies to derive exclusive patent rights from such research, such as the US patents have been registered on treatments by the University of California in April 2004 and April 2006. Such patenting could hamper access to vaccines for many countries in the future.
While small pox was eradicated in 1977, many countries still hold unofficial stockpiles of the small pox virus, with only the US and Russia holding official stockpiles. Backed by recommendations of the Committee on Orthopoxvirus Infections, in 1996 African countries pushed strongly for the destruction of the remaining stocks of the virus, given that the risk posed by deliberate or accidental release outweighed any benefits from retention. In a counter initiative, several developed countries including the US and Canada, drawing on recommendations from a new and differently constituted Advisory Committee on Variola Virus Research, are seeking to block the destruction dates so as to retain the right to seek approval for "scientifically interesting" research, including genetic modification of small pox.
WHO is now applying the same open approach to the Avian Flu virus, i.e. sharing specimens without ensuring provider and other countries have adequate access to treatments and vaccines. Countries like Indonesia, who share viruses, have found that they either cannot afford or cannot secure access to the vaccines because of limited production capacity, leaving their citizens vulnerable to infection. The WHO Guidelines (March 2005, listed but not available on the website) state that WHO Collaborating or Reference laboratories will neither share viruses or specimens, nor publish research results without permission from the originating country. Yet the sharing of specimens has not followed these guidelines, allowing private appropriation of the research outcomes.
Indonesia stopped sharing its viruses with WHO in 2007 even though sharing facilitates research into treatments and vaccines. Indonesia took action, not for commercial interest, but because it could not secure adequate access to vaccines for its people, who were offered vaccines at a prohibitively expensive US$20 per dose. Indonesia did say it was willing to share the viruses on more equitable terms, but WHO has thus far not been able to create equitable conditions for either virus sharing or access to Avian Flu treatments for countries in need (in Africa, Nigeria, Djibouti and Egypt have reportedly experienced Avian Flu). These cost barriers to access vaccines or treatment carry massive risk for the countries concerned: according to the US Centre for Disease Control (http://www.cdc.gov/flu/avian/gen-info/facts.htm) the Avian Flu mortality rate can reach 90 to 100% in 48 hours. In 2005, Indonesia experienced this problem when Roche refused to supply Tamiflu because of advance orders from other countries intent on stockpiling, even while Asian countries were experiencing an outbreak. Roche has sought to remain the sole producer of Tamiflu, despite donating some medicine to WHO.
Access to vaccines by developing countries may be further compromised by the limited global vaccine production capacity. Vaccine producers have taken advance purchase orders for vaccines. The resolution on Avian Flu to be considered by the WHA provides an opportunity for countries in Africa and elsewhere to ensure that access to vaccines is not a privilege primarily for wealthy countries, and that WHO facilitates wide access in response to need.
These upcoming issues at the WHA signal both the continued importance of international collaboration on health issues, as signified in the WHO constitution, as well as the need for constant pressure for and vigilance over its practice.
This editorial reflects the author's individual views. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at admin@equinetafrica.org.
There is a dire shortage of professional health care workers to deliver essential health services in sub-Saharan Africa, including life-saving antiretrovirals (ARVs) for people living with HIV and AIDS. Donor support for disease-specific interventions for AIDS, tuberculosis, and malaria has increased markedly in recent years. However, funding for recurrent costs for these interventions, such as increasing salaries and creating new posts, has remained taboo.
The Global Fund to Fight AIDS, TB and Malaria (GFATM) was created largely due to pressure from activists and non-governmental organisations (NGOs) who fought to have a global financing facility that would pay for ARVs – something that was considered off-limits to donors before 2002. In 2005, a specific "window" of funding was created to support health systems, including human resource costs. Since then the option has been integrated within specific disease components.
Although there is some degree of uncertainty about the scope of GFATM support for human resource costs in future rounds, country applicants have an opportunity to request such support in Round 7. The GFATM should provide unambiguous and continued support for funding salaries and other "recurrent" human resource costs. Bilateral donors should follow suit.
Lesotho is a case in point. The country has the third highest HIV prevalence in the world after Swaziland and Botswana – and is the poorest of the three. It is struggling with a catastrophic health worker situation that threatens to make it impossible for the country to scale-up and sustain HIV care and treatment for the more than 270 000 Basotho presently living with HIV and AIDS.
In January 2006, Doctors Without Borders/Médecins Sans Frontières (MSF), an international medical humanitarian organisation, launched a programme in Lesotho in Scott Hospital Health Service Area (HSA), a rural health district with a catchment population of 220 000. The programme provides decentralised HIV care and treatment, including ART, integrated into existing primary health care services. In the first year, more than 3 500 people were enrolled in HIV care and over 1 000 had initiated ART at Scott Hospital and 14 rural health centres.
Scott Hospital HSA has a higher than average health worker coverage rate. Still, according to an assessment of workloads in Scott Hospital HSA carried out by MSF in August 2006, there are up to 45 consultations per nurse per day not including HIV-related consultations. With the introduction of dedicated HIV services, the workload in the past year has increased dramatically. The World Health Organisation recommends that nurses should conduct no more than 20 consultations per day.
Between January and July 2006, at least 18 nurses left the HSA for "greener pastures". Ten new nurses were hired after July 2006, but six additional nurses left, leaving more than a quarter of nursing posts vacant.
With more than 35 000 people estimated to be living with HIV and AIDS in Scott Hospital HSA alone, at least 5 000 of whom are in urgent clinical need of ART, the needs far outstrip the capacity of health facilities and health workers. MSF has employed several strategies to cope with these shortages – from providing mobile MSF medical teams to bring "in-service" support to nurses to task-shifting to new cadres of community health workers to introducing measures to improve staff retention.
Ultimately, however, immediate measures will need to be put in place at the national level to recruit and retain skilled nurses and other professional health care workers, including as a necessary first step, increasing their salaries. Without major investments in retention of skilled staff, ART programmes – including the MSF-supported programme – are vulnerable to collapse.
The GFATM, bilateral donors, and all other relevant actors, must clearly state, with money on the table, their support for funding salaries and other interventions to support human resources for health. Affected-country governments must then meet this commitment with emergency plans to address the human resource crisis.
As for Lesotho, an emergency human resource plan needs to be developed and donors need to step up to the plate. The US Millennium Challenge Account is committing an unprecedented US $140 million for health infrastructure. "Brick and mortar" projects are welcome, but without support for health care workers, this construction/renovation programme will be tantamount to supplying computer hardware without software to run programmes.
Funding salaries on a recurrent basis and supporting other initiatives to stem the loss of health workers and bring relief to overburdened staff and the thousands of patients they serve is a critical requirement in order to expand and sustain HIV/AIDS care and treatment.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, admin@equinetafrica.org. Further information on MSF and its programmes can be found at www.msf.org and on EQUINET work on AIDS and health systems www.equinetafrica.org.