The September 2011 UN High-Level Meeting on Non-Communicable Diseases (NCDs) has come and gone. The political declaration adopted by governments, is included in this newsletter. It points to the need for multi-sectoral public policies that create equitable health-promoting environments. It calls for action across government sectors and partnership across government, civil society and private sector to implement these policies. It mandates WHO to develop for consideration ‘voluntary global targets’ and indicators for monitoring by 2012, for accountability on the declaration. The Commonwealth issued a statement on 21st September welcoming the declaration as a commitment to deal with NCDs. Others, some included in this newsletter, raised concerns about the absence of clear commitments on funds or targets, such as on access to medicines or on regulations to curb trade in unhealthy products. Questions were raised on what can be achieved through a reliance on partnership and voluntary arrangements, with a call for stronger exercise of public health authority. The High level meeting on NCDs opened a window into the competing influences of politics, commerce, social movement and science on global health negotiations. While evidence of health need and feasible strategy is persuasive input to these competing influences, Thomas Gebauer asserts in this month’s editorial that ethical principles, such as solidarity, are fundamental to health, and must be applied in global negotiations that affect the human right to health.
Editorial
In view of the wealth existing in today's world, the prospect of Health for All must not be an illusion any longer. The world doesn’t lack the resources for health; it requires a fair use of what is available, in other words: the redistribution of wealth guided by the concept of solidarity. The world is awash in money. What is missing is the political will of those in power and – to challenge ourselves – the public pressure to make change happen.
The struggle for Health for all starts with challenging the prevailing neoliberal paradigm. It is well known that globalisation has widened health inequalities. However, more emphasis should be given to the fact that the transformation of health services into commodities, the linkage of access to health care to individual purchasing power and the dismantling of public health systems has only been possible in the context of a specific ideology - an ideology that has widely affected even those who are suffering the negative consequences of neo-liberalism, the global poor.
At the core of the neo-liberal ideology is a concept that replaces social values and institutions such as solidarity and common goods by self responsibility and individual entrepreneurship. “There is no such a thing as society”, Maggie Thatcher said in the early 80’s - paving the way for the cynical credo of neoliberal politics: If everyone takes care for him/herself, then ‘all’ are taken care of.
Although there is plenty of evidence that health is primarily a political matter determined by the social environment, neo-liberalism has succeeded in pushing the responsibility for health away from public and state institutions to private actors and individuals, including individuals perceived as business entrepreneurs in a liberalised market. Even spheres of societies that traditionally do not belong to the field of business, such as health, education and culture, have been increasingly penetrated by market values.
It was the French revolution – calling for Liberty, Equality and Fraternity – that came up with the first comprehensive list of Human Rights in 1789. ‘Fraternity’, the revolutionary agenda’s third pillar, may be equated with ‘solidarity’ in today’s discourse. It has been under permanent siege during the last decades. Millions of people have been excluded from health and social care as a consequence of neglecting the social principles that nurture the cohesion of society. Only by revitalising solidarity – both as an ethical principle and in its public institutions –can health inequalities be tackled and Health for all achieved. Indeed, there is such a thing as society.
It is a fact that there are always and everywhere people too poor to afford adequate health care out of pocket. Even in a perfect world, in which all the social determinants of health are respected, people will fall ill and will be in need of support. Therefore Health for all requires the presence of a permanent and institutionalised redistribution of wealth. Those who are in the position to pay more should also pay for those who are in need. This balancing is exactly meant with the principle of solidarity. It is perhaps the most important key to establishing an effective health care system.
In this context it doesn’t matter whether a system is tax-financed or based on the idea of social insurance schemes. Both are socially agreed funding schemes guaranteeing that even members who are not in a position to contribute a single shilling or cent financially to national budgets or social insurance will receive the same services as all the others members when they need them. While individual contributions (in terms of taxes or insurance contributions) are dependent on financial capacities, the entitlement to and claiming of services however, is only determined by needs.
It is preciously the principle of solidarity that disconnects access to health care from individual purchasing power: those who are wealthier support those who are poorer, younger, or elderly; and those who are economically active support those who are unemployed, retired and children.
Thus, the principle of solidarity goes far beyond what is usually meant when solidarity refers to empathy and charity. The principle refers rather to an institutionalised solidarity that organises a fair burden sharing. It is fundamental to the “social infrastructure” of societies. Like the hard infrastructure, like transportation, energy, administration, law enforcement, police, and so on, the social infrastructure also needs to be publically regulated and funded. The term social infrastructure stands for an ensemble of common goods, such as effective health care services, proper education systems, social protection schemes, food security, and so on. In other words, it covers social institutions that are essential for the social cohesion of societies that should therefore accessible for everybody, independent from an individual’s purchasing power.
In view of the global poverty affecting one third of the world’s population fiscal policy-making should again focus on the redistribution of wealth. At an International Conference on “Strengthen Local Campaigns for National and International Accountability for Health and Health Services” held in Johannesburg in March 2011 delegates in their statement also called for “the principles of social solidarity that are an accepted part of governance within many nations to be extended to the international level”. That sounds quite radical, but even the World Health Organisation (WHO) makes this argument. The World Health Report 2010 invites WHO member states to introduce new fiscal measures to enhance governmental revenue capacities. The report particularly points to the taxation of large and profitable companies as one of the key policy instruments to widen the fiscal space, as well as a levy on currency transactions and a financial transaction tax. The latter would only make sense if it is agreed internationally as a global resource to enable all states to adequately finance health services, including countries in the north facing persistent health sector cuts and sale of public health care services.
Health care systems based on the principle of solidarity still exist. In countries like my own, Germany, they form part of the foundations of the society. Most likely these systems can only be defended by extending them to the international level. In fighting back neo-liberal extremists who are persistently posing deadly threats to societies by dismissing solidarity institutions as a proof of “devilish socialism”, it is crucial to again struggle for solidarity. This struggle needs to be waged at national level, but it also includes an international dimension, such as in the call for an “International Fund for Health” that serves as an international equalisation payment scheme to balance existing financial gaps. For this, countries with higher incomes that can support those at lower incomes would be obliged to contribute to the health budgets of poorer countries. Taking the principle of solidarity forward internationally is not a question of money. It is rather a question of the political will to create a new international treaty regulating that richer countries with higher fiscal capacity are obliged to transfer funds to poorer countries, as long as these are lacking adequate fiscal capacity. It is this principle of solidarity that will realise Health for all and other social rights.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please see the EQUINET website at www.equinetafrica.org. or the MEDICO website at http://www.medico.de/en/healthfund
In 2007, the International Finance Corporation (IFC) of the World Bank Group released a report that observed that over half of health care funding in Africa comes from private sources and that there is considerable spending on private health care providers. It proposed that, if rapid economic growth in Africa is expanding the middle-class, it is also increasing the demand for private health care. The report encouraged investment in the private health sector as one of the top five areas for investment in Africa. Subsequently, the World Bank introduced the “Africa Health Fund”, supported by the IFC and the Gates Foundation, amongst others, to fund efforts to expand the private health sector in Africa.
Should development aid be used to support the growth of for-profit private providers and private health insurance, as the IFC suggests? Should African governments encourage growth of private for-profit health services? Is this as healthy a partnership as the World Bank and IFC would suggest?
These questions need to be answered in all countries in East and Southern Africa, as the private sector already exists, or is growing, in all. While the not-for-profit private sector, such as faith based services, has had a long presence and co-operation with governments in the region, growth in the private-for-profit sector appears to be a new trend.
There are many examples. In the hospital sector, the Indian hospital group, Fortis Healthcare, and African Medical Investments (which is based in the Isle of Wight in the UK) have initiated investments in high-end ‘boutique’ hospitals that target the high-income domestic, expatriate, diplomatic and medical tourism markets in Kenya, Mauritius, Mozambique and Tanzania, while South African private hospital groups are expanding into other African countries. The US-based hedge fund Harbinger Capital Partners has bought a controlling stake in African Medical Investments which aims to become a leading operator of high-end hospitals.
An alliance between two pharmaceutical manufacturers, the South African company, Aspen Pharmacare, and the multinational, GlaxoSmithKline, is leading expansion into many countries in the region. Private health funders are also spreading. The Tanzanian private health insurer, Strategis, is set to expand rapidly with the sponsorship of the “Health Insurance Fund”, supported by the Dutch Ministry of Development Cooperation. This fund provides a mix of public, donor and private funding to stimulate private health insurance companies as a critical step in creating demand for private health care provision. PharmAccess, a Dutch NGO appointed to manage the Fund, is developing models and contracts to facilitate private health insurance elsewhere in Africa. The “Investment Fund for Health in Africa” established in 2007, also from the Netherlands and with Pfizer amongst its shareholders, provides private equity to invest in private health care providers. In 2010, it purchased a 20% stake in a private insurance scheme, AAR East Africa, that is based in Kenya but operates in many other countries in the region.
Such initiatives bring immediate investment resources to the region, and provide services to some of the population However, the experience of South Africa, the country with the longest and most extensive experience of the formal private sector in the region, raises questions about the impact these sorts of activity have on the equity and sustainability of the wider health system.
In South Africa, after de-regulation of the private health sector in the late 1980s, there was the same growth of private health insurers and providers now being proposed in other parts of Africa. As McIntyre shows in EQUINET Discussion paper 84, this was accompanied by increasing costs of health insurance, rising fees charged by private providers (especially hospitals) and low and shrinking coverage of the population. In 1981 an average household with only one member working in the formal sector devoted just over 7% of its wages to medical scheme contributions for the family. By 2007 this stood at almost 30% of average wages. Monopolies emerged, as the same company involved in private hospitals would also buy into ambulance services and a range of other health care activities. Private beds consolidated over the years within three large private hospital groups. This limited the competition that was supposed to reduce costs and decreased, rather than increased, consumer choice. While this expansion was taking place the private sector also received various public subsidies. At the same time it attracted skilled health professionals trained at considerable public cost away from the public sector.
These trends have proved very difficult to reverse in the 2000s in South Africa, despite considerable efforts by government to re-regulate the sector. It has made it more difficult to develop policies to achieve universal coverage. The experience is a warning signal for other countries in the region of the political and economic costs of a private-for-profit health sector expanding in a relatively unregulated environment.
Governments and communities cannot be mere spectactors of these developments. They, together with external funders, should be asking questions before they open the door to such trends elsewhere in the region: Who will benefit from the expansion of the private for-profit sector? What consequences will the expansion have on health service prices, resources, services and coverage? Will it support national health policy goals? What regulations and capacities exist in the state to manage this process?
There is at present inadequate evidence to provide clear answers to these questions, not least because it is difficult to obtain financial and other information from the private sector. Given their duty to protect the health of the whole population, Ministries of Health should thus remain cautious about fostering the expansion of the for-profit private sector and entering into public-private partnerships without getting clear information about the effects on the equity and sustainability of the wider health system.
While arguments are being put forward about the investment and profit potential of the private health sector, Ministries of Health need to make clear to their government colleagues not only the advantages, but also the potential pitfalls of encouraging for-profit private sector expansion as part of their economic growth policies. The opportunity costs of supporting the for-private health sector as opposed to developing the public health system need to be made visible. If private investments in the health sector are proposed, it is a duty of the state to require prior independent health impact assessments, especially where public subsidies from government or development aid funds are involved. The assessments should cover issues such as the impact on health care coverage for low income groups, projections of costs and affordability, impacts on public sector resources, the viability of the entire health system, and so on.
Ministries of Health and the public cannot allow private sector expansion to take place in a vacuum. Government needs to develop comprehensive policies and a robust regulatory framework for the private sector that protects against the development of monopolies and unethical business practices and aligns investments to national policies and core social objectives, particularly for improving the coverage of appropriate, good quality services in rural areas and low-income populations. Health ministries need to ensure that they have departments and capacities to engage with the private sector and to carry out the basic functions of ‘due diligence,’ including co-ordination, monitoring, regulation, management, inspection and enforcement of sanctions.
And as a bottom line, if governments are to gain support for their efforts to manage the for-profit private sector in line with national goals, they must inject resources into the public health system so that it can provide an equitable, effective and good quality alternative to private care.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please read EQUINET Discussion paper 87 and other materials on the EQUINET website at www.equinetafrica.org and visit the Health Economics Unit website at http://heu-uct.org.za/
Many children across Malawi experience severe diarrhoea caused by a virus called rotavirus. Rotavirus kills more than 500 000 children under the age of five years around the world each year—almost 1 400 deaths each day—the vast majority of them in sub-Saharan Africa and South Asia. In Malawi alone, rotavirus was estimated by Ministry of Health in Malawi to be responsible for nearly 5 000 deaths every year. Rotavirus attacks our families and threatens our nation’s future by targeting our most precious resource—our children. It spreads through the faecal-oral route, via contact with contaminated hands, surfaces and objects, but is not easily eliminated by improved sanitation. Those with the diarrhoea require oral rehydration and if properly rehydrated have a good chance of recovery. Death is usually through dehydration. .
The tragedy is that much of this death and suffering could be prevented right now, if children in Malawi had the same access to life-saving vaccines as children in industrialised countries. In the United States, rotavirus vaccines have been widely available for five years. Before the vaccine was introduced over 2.7 million cases of rotavirus gastroenteritis occurred annually, 60,000 children were hospitalised and around 37 died from the results of the infection in the USA. After the vaccination programme was introduced these rates went down dramatically. In Malawi, where the need is much greater, this vaccination is not yet widely available for children.
Vaccines are one of the best long-term investments to prevent disease and give children a healthy start to life —a few shots or drops can protect a child for a lifetime. And they are one of the most cost effective interventions to prevent illness in a country like ours Malawi many competing health priorities. With rotavirus (A), existing oral vaccines have been shown to provide significant protection against the disease. It is estimated that broad access to rotavirus vaccines in low-income countries could save up to 225 000 children annually. In fact, the World Health Organization strongly recommends including the rotavirus vaccine in all immunisation programmes because of its potential life-saving impact. But even the most effective vaccines will only have an impact if they are made available to people who need them. Yet rotavirus vaccines have been too expensive for low income countries, where health resources are scarce, and external funders have been hesitant to support the vaccine until costs come down.
In June, there has been new cause for optimism. Children in African countries could finally access the same vaccines for rotavirus as children living in high income countries. On June 6, the GAVI [the Global Alliance for Vaccines and Immunisation], an international organisation that supports the rollout of vaccines to low-income countries, announced it had been offered a significant price reduction for rotavirus vaccines from a pharmaceutical company, reducing the cost by a third to US$2.50 a dose. By comparison, measles vaccine still costs a lot less, at 19 to 30 cents a dose. So the cost is still relatively high. GAVI, which supports vaccine programmes in Malawi, now plans to rapidly accelerate its financial support for rotavirus vaccines, to scale up access. Malawi was one of the handful of countries that hosted clinical trials demonstrating that rotavirus vaccines save lives. The country is now planning to roll out new vaccines for pneumonia later this year—with the potential to give children protection against another big childhood killer. These signs of leadership give cause for optimism in a situation where the longer we wait, the more lives are lost.
At the same time, if this is to be sustainable, costs must be brought down even further. There is report of new, more affordable rotavirus vaccines on the horizon that will sustain our efforts to save children’s lives for the long-term. When GAVI announced the price cut for the existing rotavirus vaccine, it disclosed that an Indian rotavirus vaccine candidate – which should be available around 2015 – will cost US$1 per dose. While manufacturers in other parts of the South like India are developing vaccines that will assist in improving access and affordability, we should also be asking what we are doing to expand capabilities for vaccine production in Africa. Vaccines alone will not eliminate rotavirus or solve all of our persistent health problems. We still need to focus on long-term challenges such as improving sanitation, adequate water and strengthening health systems, to prevent faecal borne disease, and ensuring wide knowledge on and access to oral rehydration to prevent child mortality from diarrhoea. But in my view, ensuring access to rotavirus vaccines is a simple prevention measure that we can and should take today.
An earlier version of this oped appeared in the Daily Times-Malawi 13 June 2011 and the New Era Press Namibia 2 June 2011. 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 please visit Health Rights and Education Programme (www.hrep.org.mw/) or EQUINET (www.equinetafrica.org).
The world has become a very small place for some. Globalisation and the movement of people and goods mean that it’s possible on the same day to wake up in Asia and go to sleep in America. Farm products grown in an Africa can be on shelves in Europe within days. Yet it can take the same time or longer for a woman from that African country to get to a hospital with a midwife to access maternal health services. Clearly, the benefits of the increasingly rapid movement of goods, services and information across countries are not obtained by all. How have women in low-income rural and urban communities in Africa experienced the impact of globalisation?
A workshop held in Nairobi in May 2011 reviewed this experience and the implications for research on globalisation and health in Africa. The workshop was convened as part of a research programme on globalization and women’s health in east and southern Africa co-ordinated by Karolinska Institute and TARSC. The research programme found, through analysis of the Millennium Development Goals (MDG) database, that African countries are becoming more integrated with world markets and that women’s occupational roles are changing, but with inadequate disaggregation of global databases like the MDG data to assess the impact of these changes on women’s health and nutrition. A review of literature on existing studies suggested however that while globalisation related economic and trade policies have provided urban employment and social opportunities for women, they have also been associated with time and resource burdens for them that have had negative consequences for their own and their families’ health and nutrition.
Examples of research presented at the workshop similarly suggested that women’s involvement in export oriented coffee production in Uganda and in urban export processing zone (EPZ) factories in Tanzania had brought improved incomes for the women workers, but with longer working hours and weaker social protection. Improved incomes in both groups had not translated to better nutrition or dietary outcomes compared to women working in non EPZ factories or in farms producing food for local markets. For countries seeking to make a link between economic activity and improved health outcomes, this lack of improvement from globalisation related changes is a problem, especially given the context of Sub-Saharan Africa having the highest level of maternal mortality globally, with 900 maternal deaths per 100,000 live births, a level well above the targets aimed for in the MDG commitments. While globalisation has been associated with information, research and technological advancements and a wider demand for equity and rights for women, delegates also heard evidence that it has been associated with commercialised health care and reduced public funding, creating barriers to use of health services by poor women. Further, recent features of global markets - the 2008 financial crisis and the increased price of food and fuel – were raised by delegates as likely to intensify food insecurity, particularly for those already vulnerable to nutritional stress. Poor women in urban areas are likely to suffer more due to reliance on food purchases. A new trend of purchases or long-term leases for agricultural land by foreign investors for food exports and bio-could further threaten the local agricultural systems that commonly involve small scale women farmers, widening inequities in nutrition, health and access to livelihoods.
In discussing this evidence, delegates to the meeting identified that research on globalisation and women’s health in Africa needs to address three broad gaps, if the interests of low-income African women are to be better reflected in economic policies associated with globalisation:
i. to bring local evidence and voice into global policy processes;
ii. to highlight gaps between global policy commitments and local realities; and
iii. to ask the “what if?” questions, to explore and inform alternatives that would be more health promoting for African women and their livelihoods, and countries.
There are many specific areas of research that emanate from these three areas. For example, in the first, evidence on the experience and effect of global processes - whether IMF conditionalities, land grabs, commercialisation of services or other areas - needs to reach and be made accessible to national level and to those negotiating in global forums. Delegates noted that there is already evidence at local and regional level that could be useful for this, if reviewed and appropriately organised. This includes bringing together evidence from evaluations of global programmes and transnational activities in the different countries of the region.
However delegates also called for a shift in agenda formulation, with locally driven evidence and perspectives having greater influence on international agendas. Examples were given of research that explores such alternatives. For example, IDRCs Ecosystem and Human Health Programmes has supported work in Malawi to assess the effects of local production of nitrogen containing legumes. This was found to have not only improved soil fertility and reduced reliance on imported chemicals, but to also have improved the quality of diets and nutritional outcomes. Delegates concurred that this type of work had the potential of building partnership across actors, disciplines and countries, including with affected communities, that would better connect local level initiatives and evidence with global level processes and policies. While globalisation has raised attention to the injustice of the huge inequalities in women’s health globally, responding to these injustices calls for responses that strengthen the organisation of ideas, evidence and practice from the community level and their influence at national level, as a basis for the engagement in global processes.
For further information on this issue please read the background papers at http://sjp.sagepub.com/content/38/4_suppl and the report of the meeting available in the annotated bibliography at http://tinyurl.com/6zeeod5 at www.equinetafrica.org. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
When Indonesia announced in late 2006 that it had stopped sharing H5N1 virus samples with the World Health Organisation (WHO) Global Influenza Surveillance Network (GISN) - the global alert mechanism for the emergence of influenza viruses with pandemic potential - it shone a torch on an area of global inequity. Developing countries had been freely providing samples to the GISN, but were then not able to afford the vaccines that pharmaceutical companies developed and patented using the same samples.
The sharing by countries of influenza virus samples is important for vaccine development, and for understanding how viruses are mutating. Developing countries have thus freely provided samples to the WHO. But when private pharmaceutical companies use the samples to develop and patent vaccines which the same developing countries cannot afford, this is unjust and undermines public health.
Dealing with epidemics like influenza is not simply a concern at national level. The increased movement of people across nations and continents has been accompanied by an increased risk of spread of diseases across borders, such as bird flu, swine flu, SARS and others. Dealing with these pandemics is a matter of global health security that calls for the sharing of technology, information and resources to detect and respond to epidemics, including through vaccines effective for the current virus strain. African countries, often lack the infrastructure, skilled personnel and laboratory facilities needed for detecting and managing epidemics. Africa only has 12 National Influenza Centres sampling people with influenza like illnesses. These NICs submit the virus samples to the global network, and they are used to produce to vaccines that contain the major virus strains predicted for that year. The global network provides the means for countries to share in the benefit of these viruses used for vaccines. But, as the 2006 Indonesia action exposed, the benefit is not shared.
In 2007, the World Health Assembly (WHA) requested the WHO Director-General (DG) to convene an intergovernmental meeting to review how to ensure timely sharing of influenza viruses with pandemic potential and equitable access to the benefits from this. By April 2011 the intergovernmental process had drafted a Framework for this, termed the “Standard Material Transfer Agreement” (SMTA), that has been tabled and agreed to at the just concluded WHA in May 2011. The Framework contains provisions governing the sharing of influenza viruses and the resulting benefits, and obliges the pharmaceutical industry and other entities that benefit from the WHO virus sharing scheme to share benefits. In the SMTA for entities outside the WHO network, the recipient of the virus has to commit to at least two options of benefit sharing, such as donating at least 10% percent of vaccine production to WHO, or reserving treatment courses of needed antiviral medicine for the pandemic at affordable price, or granting royalty-free licences to manufacturers in developing countries.
However the Framework does not make mandatory the commitments to share knowledge and technology with developing countries on vaccine production, and is silent on patent issues and availability of affordable vaccines in countries where there is no manufacturing capacity, as is the case in many African countries. So while the SMTA establishes the principle of equity, it doesn’t fully operationalise it.
There is some guidance in existing international instruments on this issue. The World Trade Organisation (WTO) Trade Related Aspects of Intellectual Property Rights (TRIPs) agreement makes clear, for example, that intellectual property (IP) should not compromise countries’ obligation to protect public health. IP should thus not be used to deny countries affordable and timely access to vaccines. The Convention on Biological Diversity (CBD) and its associated Nagoya protocol affirm that states have sovereign rights over their own biological resources and to the fair and equitable sharing of benefits arising from the use of their genetic resources. The Nagoya protocol goes further to provide more specific information on how this should be achieved through monetary and non monetary benefits. These are not yet provided for in the SMTA and there was some debate on mentioning the protocol in the SMTA. Although there is debate over whether the CBD, which deals with genetic resources that have functional units of heredity, applies to viruses, their intent sends a message on the principle that should guide countries in finalising the SMTA. Whether the Nagoya protocol is named or not, if WHO is a custodian of global health security, it should provide no less protection of benefit sharing than is evident in the CBD, and should further provide for the sort of innovative approaches that facilitate technology and capacity transfer between high and low income countries to operationalise benefits sharing.
When the May 2011 WHA considered the SMTA, it presented an important opportunity to redress an area of global inequity in health. The debate at the World Health Assembly (WHA) had many interventions, some of which wanted substantial changes. For example Australia and several other countries wanted to delete mention of the Nagoya protocol from the resolution, which the committee recommended. Jamaica wanted to add an obligation for WHO to facilitate access to vaccines and antivirals through stockpiling and affordable pricing. Bolivia proposed that patenting of influenza biological material is against public health interests. In general however countries did not change the text to allow the process to move forward, and Bolivia reserved its rights to seek a prohibition of the patenting of influenza biological materials outside WHO GISRS. The major preoccupation was with implementation. Many low and middle income countries (LMIC) were keen to see how the SMTA would be applied, and Kenya and Algeria urged other countries to support capacities and technology transfer for monitoring and dealing with pandemic disease.
The gathering of people from all corners of the world would seem to be a good reminder of ease with which pandemics could spread, although the environment at the WHA may be very different to that of the low income communities who may have least access to the resources to prevent or manage them. An effective response to the potential severity of a global pandemic calls for strong, and where needed, mandatory commitments, plans and actions to share knowledge, technology and know-how, to prevent IP barriers and to operationalise principles of equity in benefits sharing and access, so that the timely delivery of viral samples translates into the timely access to vaccines for those who need them.
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 please visit SEATINI (www.seatini.org) or EQUINET (www.equinetafrica.org).
We are living during a time of unprecedented threat and opportunity for the right to health. We are seeing cutbacks in the funding for prevention and treatment of HIV, retreats from commitments to ‘universal access’ to HIV and TB treatment, attacks on human rights and new threats to national and global health, including through climate change and food insecurity. At the same time there are new and better technologies available for health, new medicines and diagnostics for common diseases like tuberculosis, and an array of interventions that could improve health and reduce malnutrition. Some states, particularly South Africa and Brazil, are seriously seeking to improve health on the principle that health is a human right. But it is questionable whether they have the resources to do it. There are examples of growing global co-operation and legal agreement around social challenges, such as climate change, although not yet around the most immediate social challenges that face the poor. Activist movements exist around AIDS, health and around social justice.
The Commission on the Social Determinants of Health pointed to the demand for a response to this moment of contradiction between threat and opportunity from a leadership and governance that is driven by social justice. It stated: “In order to address health inequities, and inequitable conditions of daily living, it is necessary to address inequities – such as those between men and women – in the way society is organized. This requires a strong public sector that is committed, capable, and adequately financed. To achieve that requires more than strengthened government – it requires strengthened governance: legitimacy, space, and support for civil society, for an accountable private sector, and for people across society to agree public interests and reinvest in the value of collective action. In a globalized world, the need for governance dedicated to equity applies equally from the community level to global institutions.”
This is not a new call. It resonates with the recognition of the right to health as a human right found in the 1946 World Health Organisation Constitution, the 1966 International Covenant on Economic Social and Cultural Rights (ICESCR), the 1978 Alma Ata Declaration and the 2000 UN Committee on Economic, Social and Cultural Rights ‘General Comment 14’ on Article 12 of ICESCR. Increasingly it is also reflected in the incorporation of the right to health into the national constitutions of over seventy countries in the last decade.
Nevertheless good health and access to adequate health care services remains out of reach to billions of people. Nearly two billion people (a third of the world’s population) lack access to essential medicines and about 150 million people suffer financial catastrophe annually due to ill health, while the costs of care pushes 100 million below the poverty line.
The world is well aware of these facts. They are published by the WHO and others. When these facts are raised in international forums, it has led states to make bold promises….that they later do not keep. In Africa, 19 of the African countries who signed the 2001 Abuja Declaration to spend 15% of their government budget on health al¬locate less now than they did in 2001. Yet the WHO indicate that low-income countries could raise an additional US$ 15 billion a year for health from domestic sources by increasing health’s share of total government spending to 15%. Neither are high income countries meeting their promises. According to the ‘Africa Progress Report 2010’, published by a unique panel chaired by Kofi Annan, when the $25 billion Gleneagles commitment comes due at the end of 2011, the resources allocated by G8 countries will have fallen short by at least $9.8 billion. The panel calls this a “staggering shortfall.”
Does this mean that the right to health has no value? No. Has the right to health been sufficiently popularised or used? No. Are the state and United Nations institutions who have a duty to protect and realise the right to health fulfilling their obligations? No.
In the last decade AIDS activists have established in practice the principle that states must fund treatment as a right, with the organisation of resources globally to meet this obligation. Currently we are seeing a reversal of this basic entitlement, as the right to these resources are being challenged by arguments over cost effectiveness, a retreat from funding treatment in middle income countries, despite the fact that three quarters of the poorest people in the world live in middle income countries; and a claim that too much money is going to AIDS treatment, despite the fact that an estimated ten million people still need treatment globally. Some states in low income countries claim to have inadequate resources for health even while their political and economic elites grow visibly wealthier, and even states who have met the Abuja commitment try to fairly distribute unfairly inadequate amounts of money for health.
The Commission on the Social Determinants of Health called for conditions that would enable civil society to organize and act in a way that promotes and realises the political and social rights affecting health equity. It seems that we should go further than this, given the reversals in progress and growing inequalities in health. We need to see the level of activism by civil society as a key social determinant of health. The fight for health should be a central pillar of all movements for social justice and equality, not in the abstract, but for the specific goods, institutions, demands and resources that will realise the right to health.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.This is an edited extract of a speech given at the Southern African Regional Dialogue on Realising the Right to Health in March 2011. For more information on the issues raised in this op-ed and for this and other presentations made at the conference see: www.section27.org.za.
Grace was born in a family of 9 children. She was still in school when her mother became ill, so she dropped out to care for her. She married when she was young. “God blessed us with 2 children, both girls. Then my two children and my husband died of AIDS. I too have HIV and will never marry again”, she says. When her husband died she had no support for her life as their property was taken by her late husband’s relatives. She was left with nothing and helpless. She did not want to do commercial sex work, but she couldn’t see another option, and it gave her a means to earn enough to live a poor, risky and insecure daily life in Lilongwe.
This is not an unusual story. For some even younger than Grace, the AIDS epidemic has increased the risk of sexual, physical and emotional harm and neglect. Young women and children who have been deprived of care and support are particularly susceptible to working in the commercial sex industry. They face risk environments for HIV transmission for themselves and their clients, as well as of violence and other forms of abuse.
Today the story, at least for Grace, is different. She describes the changes she has brought in her own life and in her community. She herself has a more secure and healthy life. She also talks about commercial sex workers that have now accessed loans and are moving out of bars and running small businesses. Others have gone back to school. A meeting of women involved in commercial sex work raises rights and decisions, where to get counselling, testing and treatment for HIV, how to get greater control over their sexual activities and fertility, and how to build skills for other forms of work.
Grace points to the lever for this health affirming change - theatre.
“In 2007 some of us in commercial sex work trained on legislative theatre. Theatre for a Change contributed to the transformation of my life.”
Theatre for Change in Malawi equips socially and economically marginalised communities with the communications skills, knowledge and awareness to transform their lives and the lives of others personally, socially and professionally. In Malawi, it works with groups including commercial sex workers to reduce the risk of HIV. It involves women from the core group of former commercial sex workers who work as peer facilitators among younger people getting involved in sex work. Through the theatre and by performing their stories to a variety of audiences, the women access a voice and a platform to raise concerns and open debate. The process known as Legislative Theatre. The performances involve the audiences in coming up with solutions to the issues these women face, in the process changing attitudes and catalysing change in both the women themselves, their communities and even in policy makers when they are involved. The theatre work is supported by other programmes to provide access to female and male condoms, to HIV testing and counselling, and to relevant health services, including antiretroviral treatment. These services are available, but their uptake has been blocked by barriers like stigma. This process provides a vehicle for raising the health, gender and sexual rights and responsibilities of sex workers and their clients.
As Grace comments: “Now I know my rights and no one can violate my rights. I have self esteem and I am able to make decisions about my own body.”
It is already known that it is more effective to send former commercial sex workers to mobilise and reach out to others, as much as positive peer pressure from men has influenced other men to go for testing and counselling. For the women who have been involved in commercial sex work, the theatre work has helped to reach other commercial sex workers, especially adolescents. It has led to greater openness on health problems and changed attitudes towards commercial sex workers, including amongst the health workers who used to stigmatise commercial sex workers.
Those involved learn while they teach. They are trained in psychosocial issues and counselling to support their interactions with people of different ages, gender, place and occupation. They also build a more affirmative view of themselves, from being victims of economic insecurity and social stigma to people who plan and set goals for their own and their family lives.
Grace sums it up: “Everyday of my life brings an opportunity for a new beginning…I waste not a moment mourning yesterday’s misfortunes, defeats and challenges. These have been my stepping stones."
While antiretrovirals provide a therapy for the physical effects of HIV and AIDS, it seems that theatre can also be a powerful and equally necessary therapy for its social effects.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed, a film and further information on the Theatre for a Change programme visit www.tfacafrica.com/What-we-do/TfaC-in-Malawi/Sex-worker-programme
In this issue of the newsletter one author claims that this may be a year of a ‘perfect storm’ in health, where increased knowledge, widening health priorities, new institutional coalitions, economic challenges and innovations coalesce to create new ways of doing things. Some of these new approaches could advance health equity. For example in this newsletter there are contributions that call for a shift in focus from intellectual property as a stimulus for innovation in health technology to innovative policies for equity in research and development; from aid effectiveness to development effectiveness; or from downstream medical interventions to more upstream measures addressing the population-level determinants of ill health. Debates at the recent WHO Executive Board on reform of the organisation raised issues of equity in its leadership, organisation and funding. At the recently held World Social Forum, an ‘African Consensus’ presented alternative thinking about the continent and its economic and social development to the rapid liberalization and privatization policies of the ‘Washington Consensus’. Bona Chitah's editorial suggests that translating new thinking into health equity outcomes calls for feasible technical options, but more deeply demands an ethical foundation that is clear, shared and strong enough to navigate and sustain implementation, whatever the tide.
Much attention has recently been given to raising an adequate level of resources for health, especially to achieve goals of universal coverage. But if these resources are to reach those who need them, we also need to allocate resources fairly. This is particularly important given the very different access different social groups have to health care. In spite of the recognition by many countries for needs based resource allocation, including my own country, Zambia, our experience suggests that we still face many obstacles to put this intention into practice.
Data in Zambia shows, for instance, that although the allocation formula was radically revised with policy support in 2004/5 to incorporate deprivation and population weights, the new formula has still not been fully implemented. We realize that applying a formula to redistribute resources on the basis of need is not just a technical issue, but has significant political implications. We found in our research in 2007 and 2010 that applying a formula that takes deprivation into account in Zambia implies a loss of over 30% of revenue for the wealthiest districts, if immediately implemented. This raised considerable resistance towards an immediate implementation of the revised formula from key stakeholders such as district health management teams, as well as from the political leadership in the affected districts.
Allocating a fair share of health care resources to those with greatest health need is not only an ethical issue. It also makes public health sense to reduce the burden of disease, improve the uptake of health care and reduce avoidable inequalities in health. It makes economic sense in terms of poverty reduction and improved productivity, Needs based allocation of resources combines with other elements of priority setting in health, including the setting of basic entitlements and ensuring the effectiveness of health interventions. So why have we faltered in achieving this goal?
A common explanation is that the available resources are too limited to allocate equitably. How do you distribute an unfair total amount fairly? Prior work in EQUINET has shown that it is easier to reallocate new resources equitably when budgets are increasing than to redistribute static or shrinking budgets. In 1995 to 2006 in Zambia, according to the Ministry of Health, the total health expenditure per capita ranged from $17.50 in 1999 to $58.00 in 2006, but the government share was only between 8 – 14 per cent of this. The resource allocation formula was applied only to the recurrent budget, and between 2004 and 2009, the per capita recurrent budgets to districts ranged between only US$1.50 and US$ 4.14. How much impact can be achieved on inequalities in access and coverage health when such limited resources are being reallocated? So even though fair resource allocation is a demand that arises from the scarcity of health care resources, it is itself limited by that scarcity. Breaking this vicious cycle would be important for equity.
It is thus a problem that the significant resources that come from external funders are not themselves subject to a needs based resource allocation formula. National Health Accounts data in Zambia show that 44% of health finances are spent on district health services comprising the district health management offices, district hospitals and health centres, and 20% on provincial and tertiary facilities. Of these expenditures, the share of external funding was 42%, and funding earmarked for HIV/AIDS made up almost 25% of this. These funds are disbursed as vertical funding for specific targeted programmes and purposes. The funds are distributed primarily to achieve geographical coverage, with less concern for equity, as has been the case for Prevention of Mother to Child Transmission and general ante-retroviral treatment programmes that command significant resources.
While the adequacy of funds available for reallocation and the segmentation of external funds may weaken resource allocation, there is a deeper issue: Priority setting - and thus allocation- has not been strongly grounded in ethical values or social norms. It makes a difference whether financing decisions, including those related to the allocation of resources, are based on the pursuit of equity and social justice, on utilitarian issues of efficiency, including economic efficiency, or on an egalitarian liberalism that aims for steadily improving coverage, complemented by individual actions to enhance uptake.
The lack of a shared ethical premise supporting resource allocation may be the most significant constraint to advancing the fair allocation of resources. Experiences of resource allocation in Zambia suggest that reforms aimed at enhancing fairness in resource allocation falter more easily when they are not protected, or demanded, by a strong expression of social norms and values. It could thus be the key factor leading to uncertainty, and sometimes failure to implement resource allocation in a consistent and committed way for the effective strengthening of the health system in low resource settings. So while we build the technical measures and institutional capacities to more fairly allocate the resources for health, we also need to ensure that the ethical foundation it is based on is clear, shared and strong enough to sustain implementation on the face of the other blocks we face.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed, and reports on equity in resource allocation please visit the EQUINET website at www.equinetafrica.org.