Human rights and public health: More than just about civil liberties
Leslie London, School of Public Health, University of Cape Town

Recent media attention in South Africa has drawn attention to an outbreak of Extreme Drug Resistant (XDR) TB and the need to contain infectious diseases such as XDR TB by extraordinary methods such as quarantine. Such measures, typical of the public health approach to community health problems, involve the limitation of individual rights in the interests of the public good. In this case, the need to contain a costly, highly dangerous and virtually untreatable form of TB by forcibly quarantining patients with this form of TB, were said to outweigh the rights of the patient to autonomy and freedom of movement. Rightly, discussions in South Africa focused on whether the restrictions of the rights of the individual in the interests of the greater good could be justified.

At one level, this is an important debate because it is typical of many other public health conflicts (e.g. in relation to HIV or claims on scarce resources), where individual rights run into conflict with interests that represent a collective or social benefit. Resolving such conflicts in ways that retain respect for human rights whilst advancing public health is important for public health planners, and methods to do so have increasingly emerged in the human rights and public health literature that help public health practitioners negotiate these difficult trade-offs. Thus, in considering whether a limitation on individual autonomy could be justified in the public interest, one would expect that:
- the objective of the policy, such as quarantine, has an objective of legitimate interest and is provided for in terms of a due legal process;
- the policy will be effective in realising that objective;
- the policy is strictly necessary in a democratic society to achieve that objective;
- there are no less intrusive means available to achieve the same objective; and
- the policy’s application is not arbitrary, discriminatory or unreasonable.

Often many public health measures are applied routinely without careful reflection as to whether these criteria are met. Calls for HIV notification, for example, are often made without clear policy objectives, or, where objectives are intended, without any evidence that notification will meet these objectives better than any other methods that are less restrictive of individual autonomy.

However, it is the case that, under certain circumstances, and given certain requirements being met, limiting rights for the public interest can well be justified in terms of international human rights law. Indeed, the limitation of rights may well be viewed differently when one realises that states have obligations imposed by international human rights law to positively realise various obligations to control the spread of infectious diseases (ICESCR, article 12) and to meet requirements for general welfare (ICCPR, article 4).

However, on another level, the public health objective itself is often the expression of a rights obligation of government to realise, for example, an environment not harmful to health (Section 24 of South Africa’s Bill of Rights), or the right of access to health care. Such socio-economic rights obligations are themselves necessarily collective in nature, and the trade off is not so much between individual civil liberties and public health objectives, but between different kinds of rights, such as individualist rights to autonomy, and social rights such as the those relating to health care access or a safe environment, both of which are needed to realise health. Protecting individual autonomy is important for the effectiveness of treatment programmes to ensure patient adherence and build trust in the health service, as much as social measures being required to control the spread of infectious diseases.

Popular misconceptions of rights as being solely or predominantly about civil liberties and formal parliamentary democracy have been fostered by a combination of the ascendance of neo-liberal economic policies in international policy making, as well as the unopposed exercise of power by the USA and its allies in the post-Cold War period in ways that entrench narrow individualist views of rights. Indeed, recognition of the indivisibility of rights and the equal importance of socio-economic entitlements and equity run counter to market-oriented development policies fostered by international development agencies.

Thirdly, human rights are not just about limits to state power but also speak to realising human potential in ways that confer agency.

When faced with public outcry or a health emergency, public health responses frequently fall back on traditional population interventions that obviate any role for individual and community action. The resort to autocratic traditions of central command and control has a strong anti-democratic history in public health and is based on a deep suspicion that humans can be trusted to make decisions in their own collective interest. It is not surprising, therefore, that many of the pioneering anti-smoking public health measures originated in the health programmes of Germany’s Nazi government and were entirely compatible with the ferociously anti-democratic and inhumane ideology of the Nazi regime. What a human rights approach brings to public health, therefore, is to ensure that social justice is a counterbalance to unchallenged utilitarianism, and that checks on power serve to protect the vulnerable, in ways that confer agency on communities to determine the policies and programmes that affect their health.

Increasingly, human rights advocates are realising that the sources of power in society who must be held accountable are not just states, but non-state actors, including multilateral agencies and multinational corporations whose de facto control of resources determines access to the conditions required for health to a far greater extent than does that of many states. International human rights law is increasingly providing “soft” law guidance through issuing of codes of conduct, norms and standards to ensure non-state actor accountability for human rights. Given that human rights are a product of developmental struggles, these frameworks will only be translated into meaningful instruments for accountability through strong civil society pressure on governments to turn such codes and standards into law.

Rights are not just about empowering vulnerable groups, but are themselves the products of contestation of power, at local, national and international level. And where power is contested, we should expect that the products of this contestation will reflect the relative balance of forces of different actors. For this reason, the exclusive emphasis on good governance, parliamentary democracy and civil liberties that has emerged as the dominant paradigm in some development discourses driven by Western governments has ironically contributed to a depoliticisation of rights and of development, because it strips struggles for health of any dimensions that challenge power imbalances – at local, regional and international levels. Yet power imbalances are what underlie health inequalities. This has led many to question “Why rights, why rights now?” since when the language of rights becomes denuded of power, it is turned into a technical exercise of compliance with norms.

Unchallenged, therefore, we should not be so naïve as to imagine that human rights will of necessity benefit poor people, poor communities or poor countries. Rather, by using and shaping rights towards pro-poor choices, human rights become transformative rather than simply easing human suffering. When human rights discourses, for example, begin to challenge and overturn obstacles posed by trade commitments to the realisation of the right to health, then the transformative nature of human rights emerges.

In this paradigm, the role of civil society organisation (CSOs) is absolutely central to realizing the agency that makes human rights approaches transformative. Yet many CSOs undertaking work in the health sector may 'do' human rights work, but are often not aware of the rights implications of their work on the ground. Is 'doing' human rights enhanced by 'acting' (i.e. conscious awareness of) human rights as well? Pilot research in the Western Cape with three health CSOs points to the multiplicative effect that a rights paradigm adds to their impact. By framing (health) needs as rights to which duty-bearers can be held accountable, not only is the demand for pro-poor services strengthened but beneficiaries of these services are enabled to be active agents in securing the conditions for their health, rather than passive recipients of state or NGO services. Moreover, placing demands in a right framework challenges service providers to see their role as realising states’ human rights obligations rather than simply delivering services. It is particularly in the field of socio-economic rights that the duality of service provision as fulfillment of human rights is evident and where it is clearest that human rights are more than just civil liberties.

CSOs engaging with rights approaches can build much stronger advocacy through sharing experiences and learning best practice. EQUINET, through its health rights theme, plans to explore the establishment of a learning network for CSOs in the region using rights approaches as a mechanism for enhancing civil society participation in the development of national health systems that are comprehensive, people-led and people-centred. We invite participation from CSOs and activists throughout the region in developing this network and look forward to your input and contribution to this debate.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org for attention to School of Public Health, University of Cape Town, Leslie London. Further information and publication on EQUINET work on health rights as a tool for health equity is available at the EQUINET website at www.equinetafrica.org.

Still Paying the Price: Revisiting the Cholera Epidemic of 2000–2001 in South Africa
David Hemson for the Municipal Services Project

In 2000/1 South Africa endured a cholera epidemic that spread throughout the eastern coastal region and to other provinces. It resulted in 265 deaths in five provinces and 117,147 people, mostly in the KwaZulu-Natal province, were infected. The epidemic was, according to the World Health Organization, the biggest such outbreak in Africa for the reporting period.

According to rural development researchers and the South African government, the policies of cost recovery had disadvantaged those for whom even a small charge of about R20 a month was too much. At its epicentre, those who could not afford new charges implemented in August 2000 were returning to traditional and untreated water sources and were falling victim to the disease.

The government declared the cholera epidemic an emergency and promised to provide a free six kilolitres of water to every household every month. A Municipal Services Project Occasional Paper 10, “Still Paying the Price: Revisiting the Cholera Epidemic of 2000–2001 in South Africa” examined the extent to which the response to the epidemic has led to sustained provision of safe water and improved sanitation to the poor. The evidence presented in the report suggests that there is a clear relationship between cost recovery for water, indifferent management leading to interruptions in supply, and vandalism.

In two communities - one at Nqutshini, a small settlement near the town of Empangeni on the banks of the Mhlatuzi River; and the other at Nkobongo, a developing low-cost housing area with continued informal settlements near Ballito, 40km north of Durban - there was some concealment and denial of the disease because of the stigma it carries.

In a number of cases where people fell ill, the family members were uncertain how to respond. Often the cholera victim tried to conceal and deny the disease, and this led to significant delays in seeking treatment. In one instance, a young girl died after hiding her symptoms for some time; in another, an older man had to be heavily persuaded before going to the hospital. The stigma associated with cholera complicated the acceptance of the need to avoid using river water, to treat this water, and, if sick, to seek medical assistance.

There were varying responses to the messages put out by the authorities on radio and television and carried by the Community Health Workers. Many in Nqutshini found it difficult to acknowledge that the river, from which they had always collected water, should be the carrier of disease. Some accepted that the water they were collecting from the river may be contaminated and need treatment, but others did not. Some saw the warnings against using river water as a way of forcing people to pay the monthly charges. It appears that for a period water was treated with Jik (bleach) by many, but this dropped off rapidly when the bleach was no longer available for free.

Scepticism about the official view was also associated with ideas reflecting a view of hostile external forces aiming to undermine the community, e.g. the belief by some that whites were spreading the disease through low-flying aeroplanes. In all cases, the MSP report on the epidemic presents vivid personal recollections of those who were afflicted, the dread it evoked, and the speed at which people’s health declined.

Comparisons between conditions during the epidemic in 2000/1 and at the time of fieldwork in 2003 revealed a number of improvements: Most people now accessed piped water closer to their residence or through yard connections and most used Ventilated Improved Privies (VIPs). Most people at the time of the survey felt their water to be safe to drink and did not treat the water.

However, there were ongoing complaints of frequent interruptions in the water supply through vandalism, burst pipes and for non-payment. In the two communities, the state was not providing Free Basic Water as promised, although the communities are both poor and thus generally vulnerable to cholera. At Nqutshini piped water was not flowing at all. Partly because of the dysfunctional water supplies, there was increased water storage by community members - an additional factor associated with cholera.

The incidence of diarrhoea among children in the household was found to be associated with extreme poverty, as were problems with accessing sufficient water, the ability to pay for water and the household having prior experience of cholera. All these factors - in particular the continued cycle of water-related disease in households over time - point to poor health conditions and continued vulnerability to disease among those living in extreme poverty.

The government’s policy of Free Basic Water has been unevenly implemented and greater attention needs to be given to meeting the needs of the rural poor and those in poor peri-urban communities who would most benefit from its provision. Poor communities need a reliable water service, which requires better municipal management. Interruptions lead to long storage of water, which poses a health risk to those who consume this water. Communities and households with a prior experience of water related diseases seem most vulnerable to recurrence. Health and municipal authorities should give priority to those communities with a history of water-related disease to end the cycle of disease.

The Municipal Services Project is a multipartner research, policy and educational initiative examining the restructuring of municipal sservices in southern Africa. See http://www.queensu.ca/msp/ to contact the project at Rhodes University South Africa to obtain copies of the full report.

Combating childhood malnutrition in Sub-Saharan Africa
Mickey Chopra: Medical Research Council, South Africa

Sub-Saharan Africa is the only region in the world where the absolute number and proportion of under-nourished children has increased in the last decade. East Africa is the sub-region experiencing the largest increases in numbers of underweight children –projected to increase by 36% from 1990 to 2005. Findings for stunting (chronic under-nutrition) and wasting (acute under-nutrition) are similar. Under-nutrition is the underlying cause of over half of child deaths. Even mild to moderate malnutrition can lead to significant deficits in cognitive and physical development.

One reason for the dismal nutritional status of children in Africa is the continual lack of food for many in the region. In less than four decades, Sub-Saharan Africa has been transformed from a continent that was a net exporter of food to one that is now heavily dependent on food imports. According to the Food and Agricultural Organisation, Africa’s food imports have risen from 8% in 1985 to 18% of world imports in 2001. A decline in agricultural and rural investment in Africa has led to a 12% decline in agricultural productivity for the workers in the region in the 1990s. Any growth in agricultural output has thus been achieved mostly from expanding the area under cultivation.

The United Nations Millenium Development Goals Hunger Task Team in 2004 summarised the consequences of this path to meeting food needs:
“Expanding the area under food production is inherently unsustainable, as the supply of new lands in densely populated areas of Africa is largely exhausted or must be maintained as natural systems for biodiversity conservation and other ecological services. The first effect in Africa and elsewhere in the tropics has been to expand into land that was previously available for fallows. Leaving land fallow allows land under cultivation the necessary time to recover from the effects of the crops taking nutrients from the soil. As a result of the reduction or elimination of fallows, soil fertility has fallen dramatically in many places, and yields are reducing with time. As the land becomes exhausted, there develops a serious tendency to continually sub-divide land among family members, which leads to smallholdings that are too small to produce a family’s food”.

Significantly, the yields of most important food grains, tubers and legumes (maize, millet, sorghum, yams, cassava and groundnuts) in most African countries are no higher today than in 1980. The environmental impacts of deforestation and drought, floods and the loss of topsoil are being compounded by the lack of investment. Only about 4% of land under cultivation in Africa is irrigated. This compares with 14% in Latin America and the Caribbean, a region with similar population densities and resource endowments. Fertilizer application is 15% lower today than in 1980. The number of tractors per worker is 25% lower than in 1980 and the lowest in the world. Africa’s share of total world agricultural trade fell from 8% in 1965 to 3% in 1996.

However, poor food security or poverty alone is not the whole story. Otherwise how does one explain the experience of many countries and populations that managed to achieve significant reductions in malnutrition before similar reductions in poverty? How does one explain the presence of malnutrition in situations where food is widely available? If one compares, for example, the experience in one region of Sri Lanka, Indonesia, the Philippines and Thailand, in the 1980s and 1990s, Sri Lanka and Thailand showed rapid improvement in nutrition, Indonesia showed slower but consistent improvement, and the Philippines little progress. Malnutrition in Latin America decreased from about 21% in 1970 to 7.2% in 1997, while income poverty decreased by only about 1% over the same time period.

Clearly reducing malnutrition is not solely dependent on increases in income. Gains in Latin America are attributed to good care practices (such as improved complementary feeding) access to basic health services, including family planning, safe water and sanitation and to women’s education and the cash resources they control.

Policies providing for female education, social safety nets, affordable food and public health services have contributed to improvements in nutrition even with minimal changes in poverty levels. In Sri Lanka, high levels of female education have been linked to improved child nutrition and child survival. Sri Lanka’s impressive performance in nutrition is also attributed to the establishment of social safety nets, especially the free or heavily subsidised distribution of rice, providing a minimum consumption floor. More recently, Save the Children UK in 2004 pointed to the universal, equitable and efficient public health system in Sri Lanka as an important reason for the low levels of maternal and child mortality in the country. Thailand incorporated nutrition as an important part of its National Economic and Social Development Plan (NESDP). This led to the establishment of an extensive community-based network of village health communicators and volunteers with existing village committees and leaders. These groups focus in communities on the fulfilment of basic needs such as optimal nutrition, provide education for this and monitor progress this through community-based growth monitoring.

A similar mobilisation of communities, health systems and national resources is required if we are to make a start in combating childhood malnutrition in Africa. This is an essential step if there is to be sustainable development in the region. Co-ordinated by the Health Science Research Council, EQUINET has embarked on a programme in east and southern Africa to collect and share information on case studies of how health systems address the wider social and economic factors affecting nutrition and lever action on these factors.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat email admin@equinetafrica.org. EQUINET work on food security and nutrition is available at the EQUINET website at www.equinetafrica.org. Work by the Medical Research Council of South Africa (MRC) is available at www.mrc.ac.za.

Developing country trade and health issues demand attention at 59th World Health Assembly
Riaz K. Tayob, SEATINI

Developing countries took several initiatives at the World Health Organisation's (WHO's) 59th World Health Assembly (WHA) in May 2006 to raise the need for WHO more strongly assert its global role in protecting health in the global economy.

A resolution was passed to increase coordination between WHO and the World Trade Organisation (WTO) on Trade and Health. It mandated the WHO to assist countries that are negotiating trade agreements that have an impact on their health sectors. Ministers at the East, Central and Southern African Health Community 42nd Regional Health Minister’s Conference in February 2006 called for such training for government and civil society to facilitate better understanding of the TRIPs agreement. Towards this EQUINET has developed a training toolkit on trade and health and carried out pilot workshops in Malawi, Zimbabwe and Tanzania. These confirm the call for greater support to country teams in negotiating new issues on trade and health. Countries are currently dealing with the General Agreement on Trade in Services (GATS) and the implementation of flexibilities under the WTO's Trade Related Intellectual Property Rights (TRIPs) agreement. TRIPs flexibilities relate to access to patented medicines or legally produced generics. The GATS deals with the liberalisation of health and health related services and has implications for cost recovery, cross subsidisation, health insurance, the regulation of commercial or competitive health services and indirectly related sectors like distribution.

Critics of the GATS have, for example, pointed out that it can and has limited the ability of governments to regulate health services towards the necessary cross subsidies and equity measures needed to promote universal access. EQUINET has resolved in its past forums that in a situation of high inequality in access to services, governments should enjoy full flexibility to regulate their health sectors in the public interest, unconstrained by WTO disciplines. The WTO Secretariat countered such criticisms in a publication “GATS - Fact and Fiction”, responding that countries were free to make commitments only in sectors they choose and could therefore limit liberalisation. This poses a problem for countries like Zambia who have already committed their health services in GATS, and may now want to regulate areas of health service provision. A ruling in April 2004 of the WTO's dispute settlement body in a case between the US and Mexico raises even greater concerns for countries like Zambia, as the dispute settlement body decided that the right of a country to promote development was not as important as its commitments to trade in services under the GATS.

In the TRIPs negotiations, flexibilities for developing countries for local production or import of pharmaceuticals under compulsory licenses have also led to relatively stiff resistance to proposals for improved flexibilities. Countries have also had to deal with bilateral trade agreements that erode these flexibilities. Some Latin American ministers at the WHA made a separate statement saying that TRIPs obligations should not be increased under bilateral/regional agreements. At the same time, the ECSA Regional Health Ministers noted that countries in the region still need to fully utilize these flexibilities and embed them in their national laws.

WHO clearly has significant challenges to address to promote health under WTO agreements. The mandate of the Trade and Health resolution is broad and will need to be closely monitored to ensure that the co-ordination promotes public health priorities and challenges the WTO's stronghold in health, particularly for developing countries.

One area of ground work for this has been in the WHO Commission for Intellectual Property Rights and Innovation in Public Health. The commission report was tabled at the WHA and made a number of recommendations on the IPR system for health, including that needs-driven health research should follow public health and development priorities; and promote innovation to develop solutions to health problems.

Parallel to this report an Intergovernmental Working Group was established by a resolution of the WHA, proposed by Kenya and Brazil. The proposal responded to the limitations of the current risk-reward innovation system of IPRs. This profit driven model fails to provide incentives for research into diseases affecting developing countries. Because the expectation of profit is limited in these “neglected diseases,” drugs are not researched and developed. The Working Group was mandated to produce a strategy and action plan on ways of promoting research for the prevention and management of these diseases and to examine the impact of this research on public health. This too will be an area where inputs from Africa will be important, given the extreme inequities that exist between public health burden and access to the technologies, diagnostics and drugs to prevent and manage disease.

African countries again raised the issue of the “brain drain” at the WHA, and the effect it has on their ability to cope with health demands. They requested compensation and ethical recruitment practices in sometimes tense debates. The African proposals were contested by the some developed countries, including those recruiting and receiving health personnel from Africa. The debates were not resolved, and the WHA resolution adopted committed rich countries to increase funding for health worker education in developing countries, inadequately addressing the wider demand for mechanisms that fairly and sustainably address perverse subsidies and enable African health sectors to value and retain their own health workers. At the same time, countries in the region need to be aware of the implications of the commitments they make under the GATS agreement on the movement of persons. Countries that make commitments that include liberalising the movement of people in the health sector may weaken their claims to compensation for that movement. Given the significant impact the shortfall in health workers is having in access to health care in east and southern Africa, we need bolder, more challenging global arrangements to manage issues of migration and resource transfers than have been the case to date.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org and to SEATINI (www.seatini.org). EQUINET work on health equity in economic and trade policy is available at the EQUINET website at www.equinetafrica.org.

Preserving disorder: IMF policies and Kenya\\'s health care crisis
Soren Ambrose , Solidarity Africa Network, Nairobi. This editorial was originally published in Pambazuka News 257.

Compared to 20 years ago in Kenya, people live for ten years less on average, more children die in infancy and a greater proportion of those who survive face stunting. Why? Soren Ambrose makes a case for holding the International Monetary Fund (IMF) responsible, arguing that the institution's obsession with low inflation rates - one of the foundations of trade liberalization - starves economies and hurts the poor.

On March 6, Kenya's Assistant Minister for Health, Enock Kibunguchy, told the press that Kenya urgently needs to hire 10,000 additional professionals in the public health sector, blurting out: “We have to put our foot down and employ. We can tell the International Monetary Fund and the World Bank to go to hell.”

These are strong words for a high-ranking government official to put on record regarding the most powerful international financial institutions (IFIs), and in particular the IMF, a body whose power extends to being able to call for the withdrawal of virtually all external assistance to a country.

Minister of Health Charity Ngilu had in fact been rumored to have made similar accusations in meetings with IMF officials and civil society representatives; since Kibunguchy's declaration she has confirmed she shares his view. Similar allegations have also been made by several civil society organizations focused on the IMF and on health rights. Indeed, in the last two years a number of organizations have identified IMF restrictions as a serious disincentive to hiring desperately-needed health professionals not only in Kenya, but in many other African and Global South countries as well.

Specific IMF policies, in particular the low ceilings it sets for inflation rates and wage expenditures in borrowing countries, are demonstrably illogical and detrimental. Together with the dubious defense the IMF mounts for maintaining such restrictions, cases like Kenya's provide a strong argument that those controlling the IMF should re-examine the restrictions it places on borrowing governments. The logic of demanding continual decreases in public wage bills is likewise suspect, as are the IMF's routine inflation targets. With increased funding from new sources, improved standards of living are within reach of even the most impoverished countries, if only the IMF would allow it.

The Health Care Crisis
Kenya's health care crisis has been 20 years in the making. Its dimensions are spelled out in the 2004 Poverty Reduction Strategy Paper (PRSP) - a government document written in consultation with the IMF and World Bank and approved by both bodies' boards. Life expectancy declined from 57 in 1986 to 47 in 2000; infant mortality increased from 62 per thousand in 1993 to 78 per thousand in 2003; and under-five mortality rose from 96 per thousand births to 114 per thousand in the same period. The percentage of children with stunted growth increased from 29% in 1993 to 31% in 2003, and the percentage of Kenya's children who are fully-vaccinated dropped from 79% in 1993 to 52% in 2003.

Why this deterioration? As in most African countries, Kenya's health care system was hit hard by the “structural adjustment” policies imposed by the IMF and World Bank as conditions on loans and as prerequisites for getting IFI approval of the country's economic policies. Those policies were introduced in the 1980s, and have left a lasting mark on Kenya's health. As usual with such programs, the emphasis was on cutting budget expenditures. As a result, local health clinics and dispensaries had fewer supplies and medicines, and user fees became more common. The public hospitals saw their standard of care deteriorate, increasing pressure on the largest public facility, Kenyatta National Hospital in Nairobi. As a consequence, that hospital, once the leading health facility in East Africa, began, like so many other African hospitals, to ask patients' families to provide outside food, medicine, and medical supplies. Most beds at Kenyatta and the regional and local hospitals accommodated two patients. Professional staff have taken jobs - some part-time, some full-time, at private healthcare facilities, or migrated to Europe or North America in search of better pay.

An October 2005 communication from an NGO coalition to the November 2005 “High Level Forum on Health MDGs (Millennium Development Goals)” notes that “between 1991 and 2003, the [Kenyan] government reduced its work force by 30%” - cuts that hit the health sector particularly hard.[3] For the period between 2000 and 2002 alone, the government was scheduled to lay off 5,300 health staff.

Those requirements were externally imposed. A World Bank Group document from November 2003, written to justify waiving a loan condition calling for a workforce reduction, notes: “This condition required retrenching 32,000 personnel from civil service over a period of two years. In practice, 23,448 civil servants were retrenched in 2000/01 before the program was interrupted by lawsuits. A specific commitment in the updated [agreement] is to reduce the size of the civil service by 5,000 per year through natural attrition.” The very same document supports Assistant Minister Kibunguchy's assessment of the sector's current needs - “the health sector currently experiences a staff shortage of about 10,000 health workers.” The document, however, draws no connection between the shortage and the insistence on cutting more workers.

The impact of the layoffs and budget slashing in the health sector over the last 15 years was cited recently by Member of Parliament Alfred Nderitu as the primary motivation for his motion of censure against the IMF and World Bank in the Kenyan Parliament. His initiative would insist that any future loans from the institutions get Parliamentary approval.

Clinics Without Nurses
Many African countries have shortages of medical staff because of lack of training capacity; in Kenya this is not the case. Thousands are unemployed or underemployed, eager to take up full time positions.

Both the Kenyan government and the IFIs regularly announce that health spending will increase substantially. With all these promises of increased resources for health care, with the World Bank's acknowledgement of a staff shortage, and with all those unemployed nurses, one might expect that the government would waste no time in hiring the thousands of nurses Kenya so desperately needs. And indeed, frequent promises are made by government officials to that effect. But the promises are almost never kept.

According to the Chief Economist in the Ministry of Health, S.N. Muchiri, the reason is that while the IFIs support increased expenditures on health, they forbid spending that money to pay staff wages. This is accomplished through insisting on a ceiling on wage expenditures; in Kenya, the targets are 8.5% of GDP in 2006 and 7.2% by 2008. The IMF doesn't specify that hiring in the health sector specifically must be limited, but when the entire wage bill must be suppressed, the chances of hiring the personnel needed are slim indeed.

So when IFI staffers call for more funding for clinics, as they do in their critique of the government's draft PRSP, they mean buildings, equipment, and medicine. Unfortunately, personnel are required to run the clinics. It is the choice by those institutions to prioritize targets for reduced spending on public salaries and on inflation, says Muchiri, that prevents Kenya from hiring health workers.

Muchiri provides valuable “inside” confirmation of charges made with increasing intensity by civil society organizations over the last two years. Advocates point out that while recent funding initiatives like the Global Fund for AIDS, Tuberculosis & Malaria and PEPFAR have made stemming the most critical health crises in Africa more possible, the IMF's power over borrowers' economic policy and its narrow focus on keeping inflation and payrolls as low as possible is actively discouraging governments from putting the available funds to use.

Numbers, Not People
On one level, it seems like commonsense for an organization like the IMF to seek out ways in which governments can reduce the amount spent on salaries, especially in countries like Kenya, which have had troubles with “ghost employees” on public payrolls in the past. But the self-defeating nature of this quest quickly becomes apparent. If the government were simply expected to identify and eliminate ghost employees, that would obviously lighten the government's burden and enable it to target its resources more wisely.

But the IMF's conditions deal with bottom-line expenditures, not with going to the root of the problem. Kenya's PRSP spells out the implications: “…achieving the 8.5 percent target by 2005/06 will require that any awards to be provided to the civil servants or any additional awards will be matched by a proportionate downsizing of the civil service.” Any hiring of nurses, for example, would require that some other public employees be eliminated - regardless of how much the nurses may be needed, or how vital the other positions may be. Indiscriminate targeting like this only demonstrates the prioritizing of abstract economic statistical standards over real-life outcomes, including those most likely to have a positive material impact on poverty and on contributing to the overall health of both Kenya's population and the economy.

So if the health budget is to rise - as both the IFIs and the government repeat often - then the PRSP must remind us that: “The fiscal strategy assumes that these health expenditures will be focused on non-wage non-transfer expenditures and will thus enable the rapid increase in basic health services.” Indeed, Muchiri reports that funds are often available for facilities or supplies, but not for staff. The result is that more people may seek out health services, but the ministry will actually be less able to provide them because of lack of personnel to administer the drugs or operate the machinery.

Inflation, Inflation, Inflation
But why does the IMF, with its power to exclude a country from the global economy by declaring it “off-track,” insist on reducing government payrolls? Adding employees to the government payroll, especially if accomplished with aid money, is considered by orthodox economists like those at the IMF to increase inflationary pressures in a developing country. And an increase in inflation is anathema to the IMF.

The IMF quite openly prioritizes inflation targeting over almost any other factor in the countries where it works. Pressed on the question, as they have been in the debate over health spending, its officials will invariably respond that inflation is a “tax” that hits the poor the hardest.

But is that true? Anis Chowdhury points out that:
“The poor have very limited financial assets; they are largely net financial debtors. Thus inflation can benefit the poor by reducing the real value of their financial debt. Meanwhile, the IMF's cure for inflation - raising interest rates - can actually harm the poor because this increases the servicing costs of their current debts. The poor fare worse when unemployment rises and persists, especially when there is no adequate safety net or social security system. At the same time, the real value of their household debt rises with falling inflation rates. Hence the poor have more reason to be averse to unemployment and less averse to inflation than the elite in society."

After this seemingly obvious point is made, it seems only too easy to point out that those who stand to lose the most from inflation are those who hold large amounts of money - financiers, investors, bankers. Yes, there are risks to the poor in high and/or persistent inflation, but increases in inflation below a certain point are far more likely to cause pain to those whose incomes depend on relatively minor fluctuations in currency values. For the impoverished, as Chowdhury explains, such increases in inflation are likely to be more beneficial than harmful.

As is so often the case, it is easiest to discern the interests of policy-makers not from their rhetoric, but from whose interests are most vigorously protected by their policies - by who “wins” as a result. The IMF's longtime prioritization of inflation over all else lends weight to those who accuse it of using its powers to protect the interests of the wealthy over those of the impoverished, regardless of their rhetoric that maintains the reverse.

IMF official Andy Berg recently admitted as much: “Higher inflation tax[es] people who hold cash or whose nominal incomes are fixed.” But Berg's next sentence restores IMF ideology, and at the same time exposes its flimsiness: “And this tax discourages private investment and tends to fall on those least able to adapt - in other words the poor.” Berg relocates the pain from the rich to the poor, but offers no logic for that move.

Drawing a Reasonable Line on Inflation
To challenge the IMF, the question must be where to draw the line - at what point, to use Berg's phrase, is “inflation out of control,” or at risk of spinning out of control? Berg says “in poor countries the danger point is somewhere between 5 and 10 percent.” The good news is that this figure is actually less conservative than the standard used in most IMF programs. In most countries with IMF loans, the conditions call for inflation to decline and stay below five percent.

Few economists outside the IMF opt for a level as low even as 10% in defining a healthy rate of inflation for a growing economy in a developing country. Terry McKinley, an economist with the United Nations Development Program (UNDP), declares: “As long as current revenue covers current expenditures, governments can usefully borrow to finance [social] investment. […] Fiscal deficits should remain sustainable as ensuing growth boosts revenue collection. The resultant growth of productive capacities will keep inflation moderate - namely, within a 15 percent rate per year.”

There is no room for neutrality in this debate. Adhering to IMF standards in order to avoid trouble will, according to McKinley, likely sabotage any hope of genuine development:

“Moderate inflation can, in fact, be compatible with growth. But low inflation can be as harmful as high inflation. When low-inflation policies keep the economy mired in stagnation or drive it into recession, the poor lose out, often for years thereafter, as their meager stocks of wealth are wiped out or their human capabilities seriously impaired. […] Without jobs and income, people cannot benefit from price stability.”

Tactfully avoiding mentioning the IMF by name, McKinley argues: “The new 'politically correct' justification for minimizing inflation is that it hurts the poor. However, this misreads the facts: very high, destabilizing inflation (above 40 per cent) definitely hurts the poor; and very low inflation (below 5 per cent) can also harm their interests when it impedes growth and employment.”

Rick Rowden points out that Latin American countries and “East Asian tigers” like South Korea grew rapidly despite inflation rates of around 20%. But that was before the IMF moved into the development world in the 1980s, and re-wrote the rules - without any definitive evidence to support their claim that doing so was advantageous to the poor.

The IMF appears to be caught in a classic case of “fighting the last battle.” When the IMF started lending to developing countries in the early 1980s, they were afflicted with astronomical, runaway inflation. It still apparently believes that hyperinflation is the most dangerous threat. But hyperinflation has been eliminated almost everywhere (apart from crisis or pariah countries like Zimbabwe); indeed most developing countries now have inflation rates well below 10%, and many below 5%. This is largely as a result of the IMF's hyper-vigilance over the last 25 years. The problem today is not hyperinflation, but IMF-induced stagnation.

More and more economists - outside the IMF - are taking a more complex view of growth and inflation. Rather than insisting that a country have a demonstrated “absorptive capacity” before increasing the flow of revenues, they look at the likely impact of increased flows. In the case of increased spending on health care, not only is employment created (if wage ceilings are set aside), but the population's overall economic capacity improves, and private-sector activity, rather than being discouraged by public funds, is spurred by the increasing availability of resources.

Muchiri, in Kenya's Health Ministry, concurs with McKinley's positions on inflation targeting, and with the view that public spending, especially on healthcare, will encourage growth. He acknowledges that his government has committed to a low inflation target - its “Letter of Intent” to the IMF states: “The monetary program for 2004/05 is designed to reduce underlying inflation to 3.5 percent.” And thus far Kenya seems to be meeting that goal.

But, says Muchiri: “3.5 percent is too low for an economy that is supposed to grow by 5 percent. A certain level of inflation is healthy - you can't grow otherwise.” This recognition moves Muchiri to criticize officials of a nearby country who have told him they must limit expenditures on health care - even refusing funds from the GFTAM - in order to prevent any risk of inflation rising. That line of thinking is clearly reflected in the recent statements by Kibunguchy and Ngilu.

But Finance Ministers who have committed to the IMF's inflation targets, and in many cases made those targets the centerpiece of their macroeconomic policy, are deeply reluctant to do anything that might raise that rate. Not only would doing so risk IMF disapproval and blacklisting, but it would also be seen as reversing a position they have publicly, and politically, committed to. Until this logjam is broken, a higher quality of life - even life itself - will continue to elude many thousands.

Muchiri counts as a significant victory the recent concession made by the IMF, after substantial negotiations, that Kenya could hire more health professionals if it could find donors willing to provide extra funds who themselves were comfortable with the impacts - economic and otherwise - that hiring additional health staff might have. It is this concession that recently allowed Kenya to announce that it will use funds from the Clinton Foundation, PEPFAR, and the GFATM to hire upwards of two thousand new nurses and other health professionals. Unlike with previous pledges, advertisements for the positions are now appearing in newspapers.

But the very existence of these policies, and the fact that he must invest so much in winning exceptions to them, cause Muchiri to reflect on his experiences of watching mothers and children die in hospitals for lack of surgeons or a lack of capacity to offer preventive care, and speculate that the IMF and World Bank could reasonably be charged with genocide. “The only difference from what happened in Rwanda is they don't use pangas [machetes]. They use policies.”

Reproduced with permission from the author from Pambazuka news 1 June 2006. http://www.pambazuka.org/en/category/features/34800

A tribute to Dr LEE Jong-wook, Director-General of WHO
EQUINET Steering Committee

Dr LEE Jong-wook, Director-General of the World Health Organization, died on 22 May 2006 following a short illness. EQUINET joins the many who have paid tribute to Dr Lee for his contribution to global public health, and send deep condolences to his family and colleagues.

Dr Lee was a national of the Republic of Korea and a world leader in public health. His contribution to global health has been commended from a wide spectrum of the global community: Treatment and health activists have recognized his decisive and bold leadership in declaring AIDS a global emergency in 2003 and in mobilising WHO organizational resources to deliver on the global commitment to provide 3 million people with Ante-retroviral treatment by 2005. While many challenges remain in this, the over 700% increase in the number of people in Sub-Saharan Africa on treatment between 2003 and 2005 is testimony to this leadership.

According to the WHO website (http://www.who.int/dg/lee/tribute/en/), Dr Lee, in explaining his vision of "universal access" to staff a few days before his death, indicated that there could be no 'comfort level' in the fight against HIV, and that the commitment to universal access to treatment by 2010 would be measured by an outcome in 2010 that no-one dies because they can't get drugs. In another editorial in this issue we explore some of the issues this poses globally, and for the region.

The United Nations Secretary-General Kofi Annan declared " The world has lost a great man today. LEE Jong-wook was a man of conviction and passion. He was a strong voice for the right of every man, woman and child to health prevention and care, and advocated on behalf of the very poorest people."

In his very first speech to WHO staff as Director-General, Dr Lee vowed that WHO would do the right things, in the right places. The WHO tribute makes clear that to him, the right places were the countries that most needed WHO's support. He considered WHO's job as one of huge responsibility to its 192 Member States, and the health needs of their people. This country focus sharply raised a glaring issue: that of equity and the inequalities within and across countries in health and health care. In his address to the Fifty Seventh World Health Assembly in 2004 Dr Lee noted “We have yet to get to grips with the links between health, equity and development. The underlying theme of my first year as Director-General is equity and social justice”.

To support work in this area, WHO set up a Commission on the Social Determinants of Health to gather evidence on the social and environmental causes of health inequities, and how to overcome them. EQUINET values the focus that Dr Lee gave to these inequities in health and health care, and the wider responsibility he articulated for action on the conditions and policies causing them within the whole global community. As he noted in 2004: “Hopes of peace and security in the world fade where these inequities prevail”. We pay tribute to Dr Lee for his championing, at the helm of the WHO, these values and goals of equity and social justice. They are deeply shared by EQUINET.

Under the Rules of Procedure of the World Health Assembly, and in accordance with the decision of the Director-General, WHO has indicated that Dr Anders Nordström - currently Assistant Director-General for General Management - will serve as Acting Director-General.

For information on the institutions in the EQUINET Steering Committee see www.equinetafrica.org or contact EQUINET through admin@equinetafrica.org

Ensuring universal access to AIDS treatment through strengthened health systems
Rebecca Pointer, Rene Loewenson EQUINET, Gregg Gonsalves, Gay Men’s Health Crisis

When the United Nations General Assembly meets in June to review progress in tackling the AIDS epidemic it will be reminded by civil society globally of the commitment made to ensure universal access to treatment for AIDS by 2010. This commitment has greatest resonance in sub-Saharan Africa where AIDS related mortality is highest. Two years ago, in June 2004 the regional EQUINET conference of civil society, state, academic and parliamentary delegates resolved that the health challenges in east and southern Africa demanded health systems that are universal, comprehensive, equitable, participatory and publicly funded. This also has urgency in a region where poverty is undermining progress in meeting the most basic Millennium Development Goals.

How do these two sets of imperatives relate to each other? Do they reinforce each other or are they competing for policy attention and resources? Does giving urgency to addressing the right to treatment for AIDS boost or weaken efforts to rebuild fragile health systems? This was the focus of debate at a meeting in Cape Town in early May this year that gathered international AIDS activists, people living with HIV and AIDS (PLWHA) and health activists. The meeting was organised by Gay Men’s Health Crisis with support from the Rockefeller Foundation, and focused on “Identifying public policies for scaling up antiretroviral therapy (ART) and strengthening health systems in developing countries”

The gathering of AIDS and health systems activists itself signals a widening social debate on health and health systems, raising the social, economic and political profile of health after decades of market reforms that have undermined equity and solidarity in health and that have weakened public health systems. It builds on new and increased resources that AIDS brings to health systems, and a growth in social movements for health that can strengthen relationships between health services and communities.

Delegates recognised that access to treatment for AIDS is a right, and so too is access to essential health care. An advocacy and public policy agenda that recognises both of these rights of necessity calls for health-systems friendly, people (especially PLWHA) driven approaches to the establishment, scale-up and long-term sustainability of AIDS treatment programs. There has been past debate on whether the speed of responding to treatment rights compromises this goal of building sustainable systems. The AIDS epidemic is an emergency, and the level of avoidable infection and death calls for measures to bring HIV prevention and AIDS treatment services rapidly to community levels. At the same time it is a chronic long term issue that calls for sustainable systems and measures beyond emergency responses.

How can this be achieved? The meeting reinforced the more general call within the region for people centred health systems. The role people play in decision making in the health sector is important, and often weakly recognised. Specific measures were called for to remedy this.

For example it was proposed that decision making structures and processes include the active participation of PLWHAs, their communities, health care workers and other stakeholders from civil society. However, the governance of the health sector is weak in many countries and the acceptance of the role of civil society is contentious for many governments, thus making real participation a challenge in most settings. In order to pave the way for greater involvement, this participation needs to be backed by regulatory frameworks, guidelines, clear policy messages from governments and effective mechanisms and processes to manage this engagement, including for transparently managing conflicts in the interests and priorities of different groups.

Delegates agreed that involvement in decision making and delivery raises a corresponding obligation of PLWHAs and communities to be literate on both HIV prevention and AIDS treatment and on how health systems work. Building on community-based AIDS treatment literacy, health systems literacy is needed to build community knowledge on public health, and the health systems through which prevention and treatment are delivered. Just as AIDS treatment literacy has become a vehicle for mobilising communities around rights of access to ART, so health systems literacy should be a tool to mobilise communities around their collective rights to health and health care.

The desire to move at ‘AIDS speed’ has led to vertical programming to meet short term demands and delegates at the meeting agreed that some verticality is needed in the short term in response to the epidemic. However vertical programmes can only sustain the long term, lifetime delivery of ART if they are integrated within the wider health system. The issue of vertical programming and the integration in health systems is not unique to AIDS, and affects many other disease based programmes. The resources flowing to AIDS programmes gives it specific prominence, however, as the positive and negative systems effects can be pronounced. This issue naturally arose in the dialogue: delegates at the meeting recommended that plans for AIDS treatment programs need to assess which components can be immediately integrated into general health systems and which require vertical implementation in the short- to medium-term. Delegates also raised the need for plans to be set up front for how all vertical components will be integrated into the health system in the medium- and long-term. Whether initial decisions are made to vertically implement certain components of AIDS treatment programmes or to immediately integrate these components into general health systems, delegates raised the need to recognise, monitor and address problems that might arise from whatever approach is adopted. As the meeting noted, this calls for national information systems and research that is able to identify these effects. It also calls for policy processes that are responsive to this information and flexible enough to rapidly correct problems.

EQUINET has raised that fair financing and valuing of health workers is central to rebuilding national health systems in the region. These issues were also central in the dialogue at the meeting.

The absolute shortage of trained health care workers, at crisis levels in some African countries, is now a major impediment to treatment access, and needs short-term action linked to long-term measures. Health systems and AIDS activists agreed on this. Efforts by some governments in east and southern Africa to tackle this issue were noted, and need to be supported, spread, and backed by consultation with health workers. This calls for targets for training and employing health workers, new resources to employ and pay incentives to retain health workers and removal of any international finance institution conditions or fiscal restraints that undermine the application of these measures. The meeting delegates expressed frustration at the slow pace of global discussions and measures to cancel debt, mobilise aid and lift fiscal restraints to support these health system measures, relative to the speed with which these resources are needed.

The meeting agreed that a point of synthesis of all these points is that of support for bottom-up district level planning as this brings communities and health service providers together around priority health needs, including AIDS treatment. A number of key features were raised, for example:
• bottom-up level district planning that involves communities in a substantive way;
• respect for district planning by governments, international agencies, non government organisations and donors;
• ensuring free access to AIDS treatment (and primary health care services) at point of service and addressing other barriers to accessing care, such as transport to health services;
• resource allocation systems that are responsive to district planning.

To this we may add ensuring that health workers at district and primary health care levels are adequate, valued and retained, including ensuring their own access to AIDS treatment, strengthening district level health information and planning systems and revitalising and resourcing the community health worker and primary health care approaches that strengthened the interface between communities and health services.

Finally, the stewardship of global public health, AIDS programs and health systems, needs independent and rigorous external monitoring. The promises made at the 2001 UNGASS were largely promises broken and the new promises made at the 2006 UNGASS in New York need to be held open to greater scrutiny in the years ahead. Stronger mechanisms for monitoring of good practices and stewardship in health at global, regional and country level must be established and led by institutions from developing countries.

The dialogue at the meeting in Cape Town in May provided a useful opportunity to identify shared goals and paths to strengthening health systems and ensuring universal access to AIDS treatment. It now provides a useful ‘watching brief’ for health systems activists and AIDS activists to see how far the dialogue at UNGASS addresses our shared expectations.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org . EQUINET work on equity and health systems strengthening in health sector responses to AIDS is available at the EQUINET website at www.equinetafrica.org . Information on Gay Men’s Health Crisis can be found at http://www.gmhc.org/

Rebuilding African health systems through equitable health care financing
Di McIntyre, Lucy Gilson, Vimbayi Mutyambizi, Health Economics Unit, University of Cape Town and Centre for Health Policy, University of the Witwatersrand

The issue of appropriate health care financing mechanisms is once again high on the policy agenda of African governments. Not only have a number of governments (including South Africa, Uganda and Zambia) abolished some or all fees at public health facilities, which looks set to have ripple effects around the continent, but international organisations are placing considerable importance on health care financing in their engagements with African governments.

This is occurring in a context where:
• funding of health services from government tax revenue is very low, with about 60% of African countries devoting less than 10% of government expenditure to health care, despite the commitment by African Heads of State in Abuja in 2001 to commit 15% of their funds to the health sector;
• there is a heavy reliance on donor funding, with donors accounting for over a quarter of total health care financing in about 35% of African countries;
• there is very limited health insurance coverage; and
• the single largest source of health care finance is in most cases out-of-pocket payments – more than half of all health care expenditure is financed in this way in 40% of African countries.

It is critical that African governments are empowered to make their own decisions on appropriate ways of financing health services in their specific context. This is necessary to avoid the devastating consequences of financing policies imposed on Africa by international organisations over the past two decades. The most striking example is the World Bank and IMF requirement that governments reduce their funding of health services and increasingly rely on user fees as part of their Structural Adjustment Programs. This has not only contributed to the systematic devastation of public health systems but has impoverished households through the costs of illness. International organisations are already fighting for the hearts and minds of African policy makers. Some like Save the Children and the British agency DfID are pushing for rapid removal of user fees but with insufficient consideration of the need for wider action to develop the locally sustainable financing systems necessary to reconstruct national health systems. Others, specifically the World Bank, are pushing for private insurance for those working in the formal sector, with no acknowledgement of the equity problems of such financing mechanisms. The 2005 World Health Assembly adopted a resolution encouraging member states to pursue social and other forms of health insurance. WHO-AFRO is currently preparing a resolution on health care financing for review by African Ministers of Health. There is thus an urgent need for greater awareness of health care financing issues to promote locally relevant and equitable financing options.

It is particularly important that a set of equity principles are adopted at an early stage, against which alternative financing mechanisms can be evaluated within individual country contexts and which can be used to counter the arguments of international organisations and others attempting to impose inappropriate mechanisms. These include:
• The mechanism(s) should provide financial protection. No one who needs health services should be denied access due to inability to pay and payment for health care should happen before rather than at the time of use of services, such as through tax and/or health insurance.
• Contributions to health care should be based on ability-to-pay. Those with greater ability-to-pay should contribute a higher proportion of their income than those with lower incomes.
• Cross-subsidies (from the healthy to the ill and from the wealthy to the poor) in the overall health system should be promoted. This implies that there should be cross-subsidies across different financing mechanisms.
• Financial resources should translate into universal access to health services. All individuals should be entitled to benefit from health services via one of the funding mechanisms in place, and the package of benefits to which they are entitled should be clear, known and accessible. There should not be substantial differences in the range and quality of health services that different groups have access to.

On the basis of these principles, and an extensive review of health care financing options (outlined in EQUINET discussion paper 27) we recommend that in Africa:
• Governments make explicit commitments to move away from out-of-pocket funding of public sector health services and pursue alternative financing approaches.
• We increase tax revenue for health through improved tax collection and more appropriate corporate and wealth taxation strategies.
• We increase the health sector’s share of government resources in line with the existing commitment of African Heads of States, made in Abuja in 2001, to a 15% share for health.
• There be unconditional cancellation of African governments’ external debt, so that debt servicing can be redirected to health care.
• We introduce or expand health insurance schemes as part of an overall financing system that allows for cross-subsidy and closely monitor their equity impacts.
• We exercise caution in relation to private insurance for formal sector workers, which has undermined system-wide cross-subsidies in countries such as South Africa and Zimbabwe.
• Ministries of Health lead and control decisions on the use of donor funds to ensure that they contribute to achieving national health priorities.
• We implement effective mechanisms for identifying and protecting the poor and other vulnerable groups, such as by ensuring that they are subsidised as members of health insurance and do access decent health services.
• We equitably allocate the funds for health to ensure universal access to services
• We carefully plan any new financing policy developments, to take into account the views of beneficiaries, gain support from the health staff responsible for their implementation and identify any other strategic action required to generate adequate political and popular support to sustain policy change. It is particularly important to recognise that health workers are often caught in the middle of these policy changes, managing patients without the resources to meet their needs and expectations.
• We monitor progress and build ‘early learning’ mechanisms to review and adapt policies as implementation proceeds.

These principles and recommendations are a signal of our recognition of a bottom line: no matter what our policy aspirations, the way we finance our health systems will fundamentally determine the way our health systems reflect our social goals and meet our social needs.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org. EQUINET work on fair financing is available at the EQUINET website at www.equinetafrica.org. Discussion paper 27 on health care financing in Africa can be found at http://www.equinetafrica.org/bibl/equinetpub.php

Spotlighting equity in health policy and practice in Malawi
REACH Trust, Malawi and the Equity and Access Sub Group, Malawi.

The forthcoming June (volume 16 (1)) issue of the Malawi Medical Journal is a special issue focussing on equity. This special edition of the Malawi Medical Journal attempts to capture, synthesise and present debates and action around ‘how to’ deliver on equitable health service delivery in Malawi. The papers are organised into four sections.

The journal isssue explores the research and advocacy partnerships needed to promote equity in health in Malawi. It presents various equity studies on how the health sector can reach poor women, men, girls and boys. These studies were commissioned by the Equity and Access Sub Group to inform the equity monitoring of the Essential Health Package (EHP). Although each paper deals with a different health issue, cross-comparison of the papers allows system-wide analysis. The studies point to the need to bring essential services much closer to the poor– not only in terms of geographical proximity, but also in terms of affordability, cultural acceptability, and epidemiological relevance. This recommendation is closely in line with Government policy to implement the EHP of basic services. Thus, the recommendation is not to change policy, but rather to ensure its’ more energetic and effective implementation The EHP – free basic services at the point of delivery – lays a strong foundation for equitable health service provision. More energetic delivery then means improving access, strengthening human resources in Malawi at community level (including investing in Health Surveillance Assistants) and addressing stock outs of essential drugs.

The journal captures different viewpoints and perspectives on equity. The
six articles in this section highlight the importance of viewing equity with a holistic lens. The articles clearly illustrate the need for insights on equity drawn through various methods that capture the perspectives of different players - health workers as well as community members for example. They also demonstrate that many disciplines and approaches need to collaborate to understand, document and take action on the different factors that shape equity or inequity in health services.

The journal gives information on staying up to date and presenting information on equity in different ways. This section contains policy briefings, themed abstracts and details of useful websites on equity and health, which readers can use to stay current with equity and health debates and priorities at a regional and global level. The policy briefings and abstracts produced by REACH Trust are included in this journal for dissemination purposes. They cover issues such as linking research policy and practice to improve equity in health care in Malawi and promoting poor women and men’s access to health services through developing partnerships with community groups in Lilongwe. The abstracts provide snapshots of research findings across a number of thematic sub-headings, including equity and gender perspectives on TB and HIV in Malawi, equity monitoring, equity perspectives on TB diagnosis and an equity lens on pathways to care for TB and HIV care and treatment.

For more information on this journal issue contract REACH trust Malawi directly or through admin@equinetafrica.org

Stopping the drain of Africa’s wealth a bottom line for Africa’s health
EQUINET Steering Committee, April 2007

At this year’s World Health Day the WHO will be launching its annual report which focuses on human resources for health. In Africa, as we have raised in previous editorials in this newsletter, we are experiencing a ‘global conveyor belt’ of health workers flowing from rural, primary health care level in the public sector to urban, private care; from poor to rich areas and countries in the region and from the continent, with its high health needs and under-resourced health services to developed, high income countries such as USA, Canada, UK and Australia. The loss of public investment and social resources in this outflow is significant and outweighs any returns in remittances or aid for education.

However health workers will certainly continue to go to where they can work in adequately resourced health services, in decent jobs and where they can secure their own family needs. This draws attention to the much wider question of how in Africa we secure the resources to retain and value our health workers, and more widely to meet our population health needs. The latest EQUINET discussion paper, written by Patrick Bond and produced jointly by EQUINET with the Centre for Economic Justice in southern Africa points to a South-North drain of African wealth that undermines the resources for health and development, and that increases our dependency on the global North, and our loss of health workers.

The 2005 Commission for Africa report leaves the impression of a continent receiving a vast inflow of aid, with rising foreign investment, sustainable debt payments and adequate remittances from the African diaspora to fund development. Our discussion paper tells a different story: of significant and dramatically rising flows of resources out of Africa northwards, draining the continent of the important resources needed to address its own development, including in health. The paper synthesizes data about the outflow of Africa’s wealth, to reveal factors behind the continent’s ongoing underdevelopment, as the basis for proposing policy measures to reverse these flows.

The statistics speak loudly of a continent being progressively dispossessed of its wealth, and thus the resources it needs to improve health and human development:

* A debt crisis with repayments in the 1980s and 1990s that were 4.2 times the original 1980 debt levels, and annual debt repayments equivalent to three times the inflow in loans and, in most African countries, far exceeding export earnings, leaving a net flow deficit of by 2000 of $6.2 billion.
* Unequal exchange in trade and trade liberalisation policies that have lowered rather than increased Africa’s industrial potential and exacted an estimated toll in sub-Saharan Africa of $272 billion over the past 20 years.
* Flows of private African finance that have shifted from a net inflow during the 1970s, to gradual outflows during the 1980s, to substantial outflows during the 1990s.
* Falling foreign direct investment (FDI) from roughly one third of FDI to third world countries in the 1970s to less than 5% by the 1990s, and a shift to highly risky speculative investment in stock and currency markets – with erratic and overall negative effects on African currencies and economies.

Africa is commonly and mistakenly represented as the (unworthy) recipient of a vast aid inflow. Aid flows in fact dropped 40% during the 1990s, and the phantom aid that flows back to the source countries in technical and administrative costs was estimated in one study to be $42 billion of the 2003 total official aid of $69 billion, leaving just $27 billion in ‘real’ aid to poor people.

There is also a perverse subsidy in the extent to which industrialised countries exploit the global stock of non renewable natural resources . This takes place through the extraction of minerals and natural resources from Africa by Northern investors with little investment in return and few royalties provided. It also takes place through use of global goods like the earth’s clean air. Forests in the South absorbing carbon from the atmosphere are estimated for example to provide Northern polluters an annual subsidy of $75 billion. A method for measuring resource depletion used by the World Bank suggests that a country’s potential GDP falls by 9% for every percentage point increase in a country’s dependency on resource extraction. This implies, for example, that Gabon’s people lost $2,241 each in 2000, based on oil company extraction of oil resources,

These outflows deplete the resources available for productive and human development. They are felt most heavily by women and poor communities, and undermine progress towards the achievement of human security for the majority of African people.

They imply that the first step to effect genuine growth and to deliver welfare and basic infrastructure is for African societies and policymakers to identify and prevent the vast and ongoing outflows of the continent’s existing and potential wealth.

Current global reform agendas do not address these outflows. While they point to debt and unfair trade, they do not seek to reverse the outflow of African wealth.

Campaigns to reverse resource flows and challenge perverse subsidies are emerging from grassroots struggles and progressive social movements, such as those in Africa that are resisting privatisation and commodification of basic services, pressuring for rights to generic anti-retroviral medicines and resisting encroachments on human development through trade and macroeconomic policies that intensify inequities.

These grassroots struggles can be consolidated by national governments and regional co-operation to improve disclosure of financial flows and apply policies within Africa to prevent the outflows and encourage the ‘stay’ of domestic investment resources. The paper points to some options - systemic default on debt repayments, strategies to enforce domestic reinvestment of pension, insurance and other institutional funds; national-scale regulation of financial transfers from offshore tax havens; clearer identification and renegotiation of tied or phantom aid; and improved calculation and negotiation around of the costs of FDI (not simply the benefits), including natural resource depletion, transfer pricing and profit/dividend outflows.

EQUINET welcomes the focus on this year’s World Health Day on one area through which Africa is bleeding- its loss of human resources. We would however urge that to deal with this effectively in the continent, and address the inequity globally in the resources needed for health and human development goals, we need to deepen the debate. In 1998 EQUINET highlighted that a critical dimension of equity is the power and ability people have to make choices over health inputs and their capacity to use these choices towards health. For Africa this must surely include bringing control over the resources for health and development back within the continent.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org . EQUINET work on economic policy and health is available at the EQUINET website at www.equinetafrica.org