Women’s concerns in access to care, treatment and support
by Emma Bell, The International Community of Women Living with HIV/AIDS (ICW)

Research has consistently shown that gender inequalities and gender stereotypes restrict people’s access to health services. The same is true of treatment for HIV and related problems. Testimonies from women gathered by the International Community of Women Living with HIV/AIDS (ICW) shows the many ways in which this continues to take place, even as access to treatment expands.

HIV-related stigma and discrimination and gender inequalities are rife and when, for example, a woman has to ask relatives for permission to access services her safety and confidentiality are jeopardised. Violence and sexual coercion in the first place put women at risk from HIV infection. An HIV positive diagnosis can lead to increased levels of abuse, violence and abandonment and also lead to a further lack of self-confidence all of which undermine women’s ability to look after their health and assert their rights. When services are centrally located in major urban areas or when they charge fees for service, women are even less likely to access them. In fact even when ART is free women have found that costs associated with travel and treatment for related health problems puts the chance of leading a healthy life with HIV out of their reach.

A further concern arises when women access ARVs and their families do not. This may happen either due to a lack of ART provision for families or a reluctance on the part of family members to be tested. This puts the women who are being treated under severe pressure, through coercion or guilt, to share their treatment. "Most of us as women living with HIV and who are using ARVs we face a common problem that our husbands or partners tend to force us to give them our ARVs dose while he has not tested for HIV and doesn’t know his CD4 counts. They do not want to go for testing while they show all HIV symptoms. Even if you refuse he will find where you keep your medicine and steal them." (ICW members, Tanzania, 2005). Further, if family members are not accessing treatment then the burden to care for them as their health worsens generally falls on women.

Gender and HIV-related stigma and discrimination are also reflected in the health services. Our members have reported that health care workers:
• are often indiscreet and disrespectful;
• put conditionalties on treatment access, for example, making women go on contraceptives;
• fail to understand the context within which women have to put into action advice and treatments given, for example, advice against breast-feeding maybe ignored because of the associated stigma;
• lack specialist knowledge and services about treatment issues for women; and
• do not provide suitable monitoring and follow-up care of treatment and side-effects.
These latter two conditions are worsened in resource poor settings. Women report that they feel better able to deal with a positive diagnosis when health care workers are respectful of women and their rights, refer them to sources of care and support and understand the specific problems they face in terms health; and how they can act on the advice and treatment given them.

"We have been having some changes and interruptions in our treatment regimes because many times when we go for ARVs clinic we are being asked for some money so we tend to miss the dose even for a week or month till we get some money to pay for that service. Another regime is lack of enough food especially to us women who are under treatment. The consequences were; not finishing my dose which caused infections, staying without a dose till the clinic day and lie to the service provider that I have finished my dose, fighting with my husband or even chasing me out of the house when I refuse giving him my dose."
(ICW members, Tanzania, 2005)

Too often information is not tailored to cover the range of concerns that HIV positive have regarding care, treatment and support. Information given may be pushing a government or company line, be written in English and not local languages or may use medical language and dense text. The information may only be available in health centres and not distributed to places where women can access it during their daily routines. It may only be available in written form causing problems for women that are not literacte. The scarcity of relevant information is made worse by the lack of research on the gender-related impact of treatment for AIDS, or on related issues like its interaction with social and clinical factors such as hormonal contraceptives and violence in the family.

That is why ICW calls for knowledge and information tailored to the specific needs of women, delivered in a way that understands that women may not chance upon it on a table in a waiting room at the hospital. Support groups are already doing a wonderful job in this regard. We also call for women-specific clinical and social research that does not just treat participants as research subjects from which information can be extracted, but empowers them to participate in research in ways that enable them to gain skills and to use the information to advocate for change in their communities and countries.

Finally, there are a growing number of HIV positive women who are treatment activists. We feel frustrated when we constantly hear policy-makers tell us that we, as women treatment activists, we do not have the skills to engage with them. We would rather ask whether those in policy positions have the skills to engage with us in a way that is respectful and meaningful. With the challenges we face in reaching universal access, surely it is time that we all challenged our notions of where true expertise lies?

The International Community of Women Living with HIV/AIDS (ICW), set up in 1992, is an international network with over 5000 HIV positive women members worldwide. This article is based on their testimonies. “ACTS” refers to HIV positive women's ability to gain consistent access to all available care, treatment and support services.

Please send feedback or queries on the issues raised in this briefing to ICW http://www.icw.org/tiki-view_articles.php or to the EQUINET secretariat at TARSC, email admin@equinetafrica.org . EQUINET work on access to treatment is available at the EQUINET website at www.equinetafrica.org

From 3 by 5 to universal access to treatment: opportunities for equity?

Sally Theobald, Ireen Makwiza REACH Trust, Malawi; Erik Schouten, Ministry of Health, Malawi and Management Sciences for Health; Andrew Agabu, Andrina Mwansambo, National AIDS Commission, Malawi.

Why the move to universal access when we haven’t yet met the 3 by 5 target? What does universal access actually mean? Does this new focus on universal access offer an opportunity for advocacy for equity?

The focus on universal access has its roots in the Special Session of the UN General Assembly (UNGASS) declaration in 2001 and was further reinforced by discussion at the International AIDS Conference in Bangkok in 2004 and the G8 Summit in Gleneagles, Scotland, 2005. The onus is for countries to define – through consultative processes – what ‘universal’ access means rather than working to global targets and put together plans and processes to meet universal access. These country consultative processes should in theory feed into regional consultation processes. For southern and east Africa, these will be held in Zimbabwe from 7-10 March, 2006 and will, in turn, shape the Africa Wide consultation 4-6 May, 2006 and the Global Steering Committee.

While there are sceptics, this may be seen as an opportunity to raise the profile of equity concerns. EQUINET’s work on antiretroviral therapy (ART) in the context of health systems reported on the EQUINET website (www.equinetafrica.org) raises two overarching and inter-related equity challenges:

1. How can we address barriers to access to quality treatment and care – by gender, age, socio-economic status and geographical coverage?

2. How can we ensure that ART delivery strengthens rather than undermines the broader public health system?

Countries have been asked to consider main barriers to scaling up which will be fed to the Global Steering Committee for action. In Malawi, for example, initial barriers highlighted include:

* Constraints to ensuring adequate sustained financing, and therefore to planning ahead, for scaled up AIDS responses:
This calls for sustainable and responsive funding for the provision of ART and for the strengthening of public health systems. This is critical to ensure that we continue to be able to provide ART to those in need. The current Global Fund for AIDS TB and Malaria process of proposal writing for 5 year programmes and resubmitting after 2 years is problematic, as it can result in decision making delays and risks of interrupted supplies of ART, HIV test kits and other supplies.

* Too few trained human resources, and health and social systems constraints:
We need to build and sustain a healthy and motivated workforce to provide ART and to meet the broader health needs of our citizens. This means investing in training and developing supportive working environments to retain our workers and address the brain drain. However, despite our best efforts the numbers of professional cadres will not be adequate by 2010. We also need to think creatively about who constitutes ‘human resources for health’, and how to deliver services through building partnerships with lay health workers, NGOs, private sector providers and community based organisations. Such partnerships and decentralisation of health provision will enhance the access of poor women and men to HIV and AIDS Treatment and Care.

* Barriers to reliable access to commodities and low-cost technologies (e.g. condoms, injecting equipment, medicines and diagnostics):
There is need for use of TRIPs flexibilities, and for pharmaceutical companies to not only reduce the cost of drugs but also ensure long-term fair access to patient-friendly ART regimens for adults and children. Diagnosis and treatment of paediatric AIDS is made difficult due to the unavailability of simple and affordable technology for diagnosing HIV in children, and the lack of paediatric formula. The current first line regimen for adults is based on fixed dose combinations (FDCs) and with the advantage that patients only have to take 2 tablets a day. Scaling up programmes in resource poor environments relies heavily on these simplified regimens which ease the supply chain and instructions to patients on adherence. If the next generation of regimens is not available as FDCs (our current second line regimen consists of 7 tablets per day) the scale up of ART will be heavily compromised.

* Stigma and discrimination, inequity, gender discrimination and insufficient promotion of HIV-related human rights:
We need to be active in addressing stigma and ensuring that gender equity and rights based approaches underpin action. In Malawi we have a policy on equity and ART. The focus on universal access provides an opportunity to advocate to implement this and monitor progress.

These challenges to universal access resonate clearly with EQUINET’s equity focus and work. Make sure your voice is heard in these consultation processes at country, regional and global level. You can also join an e-mail based consultation with civil society organisations and networks to provide direct input into a Global Steering Committee on Universal Access which is currently being hosted by ICASO. Send your feedback to: universalaccess@icaso.org The ICASO press release for more information on the consultation process is available at:

Please send feedback or queries on the issues raised in this editorial or requests for further information on EQUINET and REACH Trust’s work on equity and health systems strengthening in ART outreach to admin@equinetafrica.org

A call for your input! Concerted action for health equity in east and southern Africa
Steering Committee, Regional Network for Equity in Health in east and southern Africa (EQUINET)

How can we attract health workers to stay within our public health services?

How many countries in our region meet the Abuja target of 15% of government spending on health?

What does an African debt burden of $8.6 billion a year mean for health services?

How many countries in our region include the right health in the constitution?

How can the cost of health for the poorest communities be reduced?

What does it mean to have a ‘people centred’ health system?

The EQUINET newsletter is over five years old and has in its lifetime covered a spectrum of issues affecting health equity in our region, and raised some of the questions above. In 2005 our editorials ranged from access to treatment to the outflow of resources from Africa. The spectrum of challenges to health equity are clearly wide, and involve many different people, communities, disciplines and actors. We hope that the newsletter has been informative and useful and will continue to be so. We’d greatly welcome your ideas and information on how to improve it.

In 2006 we are also asking for you to play a more active role! EQUINET will, with your support, be carrying out a regional equity analysis in 2006, to profile the issues, evidence, experiences and options for action to strengthen health equity, through a regional equity analysis. The adoption in 2005 of the SADC Health protocol gives us a policy framework for this. Within this context, we will over the course of 2006 draw together YOUR perspectives, evidence, experiences, and views on how to advance health equity at local, national and regional level.

From the work we have done in EQUINET, including the values and perspectives communicated through the last five years of this newsletter, we have identified some priority areas that we will focus on. People in the region have major health concerns relating to access to incomes, food, employment, healthy living conditions and community environments. These require action from all sectors, and not just the health sector. There is a common concern that to advance health across all sectors and all social groups, we also need to revitalize and build comprehensive, universal and integrated national health systems that address these concerns and that provide access to health care for all. While many features of health systems have been raised, there are some that have been most commonly identified as a priority for health equity that we will give more focus to in 2006.

These are
i. building people-centred health systems that organise, empower, value and entitle communities;
ii. promoting increased fair, sustainable and equitable financing for health at national, regional and global level;
iii. ensuring adequate, well-trained, equitably distributed and motivated health workers; and
iv. backing national policies with fair global policy, including just trade, reversing unfair flows of resources and having the national and regional policy flexibility to exercise policies that improve health.

What policies, programmes and obstacles exist in these areas in our region?

Which have been more successful in overcoming differences in health across social groups and ensuring access to health care for all?

What opportunities and challenges do we face in implementing these policies and programmes?

We invite you to contribute to the dialogue, learning and analysis that we will build in these areas, through your expertise and experience, positive examples and case studies, evidence and data, and photographs. Email us on admin@equinetafrica.org with any information, published papers or pictures of the work you or others are doing in these priority areas. Through the newsletter we will share this information more widely. We will also feed it into the regional equity analysis.

We also invite you to be involved in the research, student grants, training, dialogue forums, exchange visits and other areas of work that we will be carrying out with you in 2006 to inform and strengthen learning and action on health equity. Our website (www.equinetafrica.org) provides up to date information on these activities.

We look forward to working with you in 2006!

Health on the road to the WTO's Hong Kong Ministerial Conference: Deception and exploitation and leading the fight against improved public health
Riaz Tayob

The current WTO negotiations, headed for the next trade ministers meeting in Hong Kong in December, look set for more protection of corporate rights and a further erosion of health rights in the General Agreement on Trade in Services (GATS) and the Trade Related Intellectual Property Rights Agreement (TRIPs). Outcomes in these discussions depend on a breakthrough in the agricultural negotiations.

While health is a basic human right, the protection of this right still has little recognition in the global trade agenda. The formal recognition of public health interests is in fact subjugated to the interests of corporate profit, with the protection of these corporate interests by rich countries.

While the TRIPs agreement allows violations of patent rights for public non-commercial use, compulsory licensing and parallel importation, these rights are not exercised because political pressure is brought to bear on countries that try to use them. TRIPs are creating a false scarcity of access to pharmaceutical drugs. Developing country governments and civil society campaigned at the 2001 Doha, Qatar World Trade Organisation (WTO) Ministerial Conference to improve access to drugs. This ended with a statement of ministers (restating the rights contained in the 1995 agreement) allowing countries to use flexibilities in the agreement to legally bypass patent rights.

Since achieving this confirmation of rights, global public health has suffered a series of defeats. Flexibilities are still not being used because unseen threats are made against countries that try to use their rights. The practical import of these deceptively generous rights in TRIPS is nullified, while rich countries are still able to exercise them (such as when the US accessed patented drugs to cope with the threat of a terrorist anthrax attack).

Even when flexibilities are exercised, African countries still have a problem that compulsory licensing under TRIPs can be used to produce mainly for local consumption. Countries with low or no local production capacity, cannot access branded drugs because of price. They cannot import generic drugs produced under compulsory licenses in other countries because other countries must comply with the local consumption regulations where up to 49% of production can be exported. Before the 2003 Cancun Ministerial, a settlement was reached allowing countries with limited local production capacity a waiver to import these drugs, but the waiver agreement is so onerous as to be useless. It has not been used once since coming into effect – not even by developed countries who can also take advantage of this flexibility to export drugs to poorer parts of the world.

The WTO Secretariat - supposedly merely international civil servants - also changed the signed text of the waiver, by including a footnote and asterisk after the signature. (The footnote refers to a document that was not part of the agreement, called the Chairman's text, which carries language about sustainable development and the fundamental rights to food, productive assets, development, health, education, economic, social and cultural autonomy, and self-determination but insists that signatories must resort to market mechanisms to claim these rights.) The US insists this footnote should guide the interpretation of the waiver, while developing countries regard it as irrelevant. The WTO Secretariat has refused to remove the asterisk and the footnote, despite the millions of lives affected by its addition.

Africa is pushing for a useable settlement in current negotiations, seeking to amend the TRIPs agreement and remove the onerous conditions in the waiver – so they can access low cost drugs. This has been summarily rejected by the US which wishes to retain current arrangements to protect profits and divert cheaper drugs into their markets. The EU is playing a brokering role, with the same ends as the US, but minimising the ambitions of the Africans in a more diplomatic way.

And with no progress on TRIPs, rich countries are making more demands on developing countries. The draft text on services for the Hong Kong Ministerial negotiations disregards developing countries submissions on domestic regulation and reflects the rich country proposals. It promotes the “list it or lose it” approach to regulations, requiring countries to list restrictive regulations or face losing them if challenged at the WTO. Developing countries have opposed the deception that the draft text reflects a possible consensus position: these objections have been “noted”, but not reflected in the text.

Regulatory measures are major impediments to international services trade. The GATS agreement – which regulates professional health services, health care services and health insurance – places disciplines on the state’s ability to regulate the service sector. Only “necessary” regulations can be validly imposed, with GATS demanding that ‘necessity’ be determined by the WTO and not by nations themselves – effectively outsourcing government regulatory power to the WTO's Dispute Settlement Body in Geneva. Therefore, GATS will seriously limit the ability of states to manage destructive competition and create adequate economies of scale. They will undermine the flexibility to use subsidies to the poor and cross-subsidisation. For poor countries, these commitments are effectively permanent because reversing commitments requires the payment of compensation that poor countries can ill-afford.

To add insult to injury, the EU demands countries in the south liberalise service sectors while giving European civil society “assurance” that their public services will not be put on the table. The EU says there is a crisis in the services talks with too few offers of liberalisation on the table from developing countries. Developing countries contend that offers from the rich countries do not match their export interests, so they cannot take the blame for the lack of progress in negotiations. To improve the liberalisation offers on the table, the EU proposes changes in the GATS negotiations process. Instead of countries volunteering a list of sectors the EU is demanding that target benchmarks be set for liberalisation of sub-sectors. Qualitatively, the EU wants: limits removed with respect to consumption of services abroad; increased access to cross border trade and commercial presence; removal of foreign equity ownership; and the reduction of discriminatory economic needs tests. Developing countries have rejected this aggressive pursuit of GATS.

The most important matter in the WTO remains agriculture, which could unblock all the other negotiations. Rich country subsidies allow produce to be sold at prices below the cost of production. These subsidies (to the tune of US$ 1 billion per day) play havoc with international commodity prices and undermine the export market interests of developing countries. Compounding this are demands for reduced import tariffs in developing countries. The subsidy cuts offered by the EU and US will have little or no impact and leave us far from an international trading system that promotes the type of food sovereignty needed for improved food security and nutrition outlined in earlier EQUINET newsletters.

The current WTO negotiations expose the extent to which proposals from the rich countries will seriously undermine advances in public health. The trade, political and other pressures brought to bear indicate that below a veneer of ‘democratic functioning’ the discussion on global trade continues to be held within institutional arrangements and processes that protect excesses of wealth and hide the exploitation of the poorest nations in the world.

* Riaz Tayob is from SEATINI and represents EQUINET's theme work on trade and health.

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

Statement by Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, on World AIDS Day, December 1, 2005

There are many occasions during the course of the year to pronounce about the pandemic. On the occasion of this World AIDS Day, I’d like to resist the temptation to run with hyperbole. Rather, I’d like to put two specific proposals which may seem obvious, but which speak, I believe, to the heart of the struggle against the virus.

The first involves dollars. The Global Fund to Fight AIDS, Tuberculosis and Malaria --- the best financial vehicle by far to help break the back of the pandemic --- is in terrible trouble. It is over three billion dollars short for 2006 and 2007, and that shortfall will doom millions to death in the following years unless something drastic is done, and fast.

What has happened was completely unexpected. The G8 leaders met at Gleneagles in July, and emerged with ringing promises of financial assistance for Africa. The first test of those promises came just eight weeks later, in early September, at the replenishment conference for the Global Fund. The G8 flunked the test. The assumption was that the Global Fund would go right over the top given the rhetoric of the Gleneagles Summit, but instead, having requested $7.1 billion, the Global Fund fell billions short.

It’s fair to say that everyone was stunned. It took only eight short weeks for the G8’s signed agreement to fall apart.

I’ve just spent the last three days in Rwanda at the regional conference of the Global Fund for East Africa and the Indian Ocean. It’s absolutely astonishing to see how determined the countries are to achieve the goal of universal treatment by 2010, but they’re frightened by the prospect of not having sustainable resources. They know they can’t interrupt treatment once it’s started, but what guarantee do they have, under present circumstances, that the G8 will be by their side as promised?

All they can count on, for certain, is betrayal.

That must somehow be reversed. The year 2005 showed that treatment is possible in great numbers, and there is a strong sense that if the momentum can be sustained, the back of the pandemic can be broken. But that will depend on a continuing, reliable flow of resources. It depends on the commitments of the G8 being honoured. With the loss of honour goes the loss of life.

However, in addition to keeping the pressure on governments, we need a new source of dollars. That source must be the private sector. It was always hoped -- indeed, even expected -- that private sector money from major multinational corporations would help to keep the Global Fund going. It hasn’t happened. The contributions are negligible. It’s as though most of the private sector doesn’t know the Global Fund exists.

I want to suggest that companies contribute 0.7% of pre-tax profits annually to the Global Fund. To maintain the symmetry with governments and the Millennium Development Goals, they should phase the money in and reach the full target by 2015. Which corporations? Pretty obviously, I think, the big multinational corporations that have exacted such huge wealth from Africa’s mineral, diamond, oil and other resources over the decades, and certainly the pharmaceutical industry, which resisted the lowering of drug prices for an unconscionable length of time.

But there may be an even better and fairer way to select the corporate contributors. The Global Business Coalition on HIV/AIDS has a membership of some two hundred multinational corporations. Many of these corporations deal admirably with their workforces, providing antiretroviral drugs to their workers where necessary, and sometimes to the workers’ partners and children. Others of these corporations make in-kind contributions, or investments in research and training centres. But the true expression of corporate social responsibility would be a 0.7% contribution to the Global Fund. If the principle spread, the dollars would mount unto the billions.

There’s no reason to feel cynical about such a proposition. People mocked when Gordon Brown talked of his International Finance Facility, but now it’s well and truly launched. People mocked when France advanced the idea of a tax on airline travel to fund development, but now President Chirac seems determined to proceed. There’s room for every genuine initiative.

This effort would show the world that the pandemic can be beaten.

Now allow me to switch gears and deal with a particular aspect of children and AIDS which reveals an appalling double standard, and must be dealt with. In fact, it should have been dealt with several years ago.

The overwhelming majority of HIV-positive children are infected by the virus during and following the birthing process. Children infected in early infancy usually die before the age of two. There are more than half a million deaths of children from AIDS every year.

In many countries, primarily in Africa, there are programs in place called PMTCT, Prevention of Mother-to-Child Transmission. Unfortunately, most of these are merely pilot programs: fewer than ten per cent of HIV- positive pregnant women have access to PMTCT. That, in itself, is scandalous.

In most countries the PMTCT program uses what is called single-dose nevirapine … one tablet of that drug to the mother during labour and a liquid equivalent of the drug for the child within 48 hours of birth. Incredibly enough, the transmission is cut by close to 50 per cent! Half the babies who would otherwise be born positive are born negative.

That, of course, is wonderful. But compare it with North America (or anywhere in the western world). North American hospitals do not use the drug nevirapine; they use full antiretroviral triple-dose combination therapy from approximately 28 weeks through to the end of the pregnancy. The result? The transmission rate drops to between one and two per cent!!

Why do we tolerate one regimen for Africa (second-rate) and another for the rich nations (first rate)? Why do we tolerate the carnage of African children, and save the life of every western child? Is it possible to do full therapy in Africa rather than single dose nevirapine? Of course it is. Doctors Without Borders does it in Uganda; Partners in Health does it in Rwanda; Saint Egidio does it in Mozambique. In fact, Rwanda is introducing a formal protocol to make sure that full therapy is provided in every setting where PMTCT is available. They are the first country to do so.

It leaves the mind reeling to think of the millions of children who should be alive and aren’t alive, simply because the world imposes such an obscene division between rich and poor. That’s about to change, but why does it always come after an horrific toll is taken?

There is another aspect of saving children’s lives that is much neglected and much rationalized. Even when transmission is prevented during pregnancy and birth, the virus can still be passed through breast milk. Therefore, we require safe solutions to infant feeding, including secure supplies of formula where feasible, with careful instruction about clean bottles and preparation, and all of it provided free: there’s just no possibility of rural village women in Africa being able to pay for breast milk substitutes.

Research available so far indicates that that, too, must become public policy wherever possible. And where it’s not possible or safe, exclusive breast-feeding for six months is undoubtedly the best course. It’s worth noting that it took almost a decade to finally develop antiretroviral drug preparations for children with AIDS. The time has come to reduce, dramatically, the numbers of children who begin their lives infected.

On this World AIDS Day, 2005, I have the deep impression that if only we could galvanize the world, we’d subdue this pandemic. We’re terrific when it comes to studies and documentation. Reports like the Epidemic Update issued by UNAIDS last week are models of statistical compilation, containing pockets of fascinating material. But the report itself acknowledges that real progress against the pandemic is hard to find.

We need a superhuman effort from every corner of the international community. We’re not getting it. At the present rate, we’ll have a cumulative total of one hundred million deaths and infections by the year 2012. We call ourselves an advanced civilization.

Equity in the distribution of health personnel in southern Africa: Report of regional meeting, 18-20 August 2005, Johannesburg

The EQUINET regional meeting on Human Resources for Health August 19-20 2005 in Johannesburg South Africa discussed and debated Human Resources for Health (HRH) research and policy with a view to improving the equitable distribution of HRH within southern Africa. By the end of the deliberations, the delegates from government, non government, health worker, national, regional and international level at the meeting highlighted key areas of shared perspective on HRH.

The delegates noted an HRH crisis in east and southern Africa that has become more marked with the inadequate resourcing of the health sectors under economic reforms. The migration of HRH from the region to high income countries and the outflows of health workers from primary and district levels of health systems and from the public to private sectors leaves many low income communities with high health need with inadequate personnel for their health care services. This is a perverse outflow of public resources that undermines equity and the health system response to the major public health challenges in the region.

The multisectoral nature of policy implementation on HRH within government, and the international pull factors for migration of HRH were noted. Following the example of some countries in the region it was proposed that HRH be taken up as an issue for government as a whole and not just for the health sector, led by the highest level of government. At the same time Ministries of Health need the institutional latitude to facilitate training and strengthen retention of health workers. Constructing an appropriate policy framework given diverse contextual imperatives implies building a portfolio of policy measures and building policy implementation capacities.

Acting on HRH requires new resources, and, as raised by the African Ministers at the World Health Assembly in 2004 and again in 2005, delegates proposed international action and global transfers to address migration of and reinvestment in HRH.

It was proposed that HRH issues be addressed within the context of building and strengthening the public health sectors in the region. Towards this three areas of focus were identified for action:

- Valuing health workers so that they are retained within national health systems. This includes reviewing and implementing policies on non-financial incentives for HRH such as career paths, housing, working conditions, management systems and communication. To support this delegates proposed greater investment in training in HRH supervision, in management and communication systems, HIS and HRH, and measures to support health workers own health.

- Promoting relevant production of HRH, particularly in terms of the health personnel for district and primary care levels, and drawing on experience in the region on training of auxiliaries. For equitable distribution and retention the delegates noted the importance of appropriate selection of students and the need to locate training within career paths and incentives that recognise the HRH trained within the public health sector.

- Responding to migration, which requires closing the evidence gap with respect to migration (levels, flows and causes), financial flows, costs (benefits, losses) and return intentions and mapping the effectiveness of current policies. Delegates noted that migration represents a perverse subsidy calling for international policy responses that provide for reparation.

* This is the consensus statement from a report of a regional meeting on 'Equity in the Distribution of Health Personnel in southern Africa', held 18 to 20 August 2005, Johannesburg, South Africa. For the full report please visit http://www.equinetafrica.org/bibl/docs/REP082005hres.pdf

The Global Forum for Health Research Conference: “Poverty, equity and health research”
Di McIntyre


The Global Forum’s annual conference was held in Mumbai, India from 12-16 September 2005, and focused on “poverty, equity and health research”. EQUINET was extremely well represented, with four papers presented, three in full plenary sessions, on EQUINET research in the area of: participation and health, ART, fair financing and policy analysis. The papers presented by the EQUINET conference participants can be found on the Equinet website.

Forum 9 was attended by delegates from around the globe; one of the great attractions of the Global Forum conferences is that it includes participants from a wide range of research disciplines, policy-makers and civil society organisations. The conference had seven main themes: poverty; equity; innovation; neglected diseases and conditions; policies, systems and priorities; research capacity strengthening; and reproduction and human development. Some of the issues discussed and conclusions arising from the two core themes of poverty and equity are summarised below.

Poverty theme

The key role of poverty in contributing to ill health, and the lack of access to health services for the poorest were highlighted in a number of presentations. There was also an emphasis on how out-of-pocket payments for health care leads to further impoverishment for vulnerable households.

One of the most interesting ‘debates’ at the conference related to whether or not the Mexican PROGRESA (now called Opportunades) program has been successful or not. This program involves monthly payments to poor households on condition that the household attempts to improve their education, health and nutritional status.

For example, a household will receive up to US$28 per month per child if the child attends 85% or more of classes, and up to US$12 per month per family in ‘food transfers’ if each child receives 2-4 health checkups per year, each adult receives one health checkup per year and pregnant women receive seven pre-and post-natal checkups.

Findings from evaluations of this program, undertaken in two different sets of villages, were presented in two different sessions and contained divergent results. The one study, undertaken by the World Bank and IMF, claimed very positive results of the program with a very high proportion of beneficiaries being in the poorest section of the population and improvements in health status and educational enrolment, as well as poverty reduction, being attributed to the program.

The other study, undertaken by a team of local researchers in one of the poorest areas of Mexico, found less positive outcomes. In particular, they highlighted that although the program was targeted at the poor, many poor households were not being reached. Very importantly, the program appears to be creating conflicts and “destroying the social fabric” of communities. There appear to be conflicts between those who are benefiting from the program and those who are not, despite being “equally poor”, and there is resentment at the paternalistic monitoring of family education and health choices. Unfortunately, no opportunity was presented to debate these studies or the PROGRESA program in detail. Nevertheless, these presentations highlighted the need to carefully monitor poverty reduction programs and to identify unexpected negative impacts.

One of the key recommendations arising from this theme was that mechanisms of accurately and comprehensively identifying and protecting the poor are urgently needed.

Equity theme

Much of the research presented at the conference again highlighted the extent of inequities at household, community, national and global levels and the effects of inequities on vulnerability and risk of infection, disease and injury; access to care, treatment interventions and health outcomes. Unlike many other conferences which focus almost exclusively on inequities on the basis of socio-economic status, considerable emphasis was placed on gender inequities and inequities related to disability at Forum 9. While this was very positive, it was noticeable that the gender and disability sessions were more poorly attended and it was noted that inequities related to ‘race’, ethnicity, age, language and cultural affiliation received very little attention. There was also quite limited discussion on how to successfully address inequities.

One of the particularly interesting series of papers presented at the conference, which might provide insights on fair financing approaches to be considered in the African context, related to the EQUITAP project. This project has undertaken an extensive analysis of equity in health care financing in a large number of Asian countries. The results very clearly demonstrate that countries, such as Hong Kong, Malaysia and Sri Lanka, which have strong public health systems with general tax revenue being the major source of finance in the health sector are the most equitable. Health systems that have universal health insurance systems, such as Thailand, also fare quite well. The EQUITAP project has also analysed the level of catastrophic out-of-pocket payments in Asian countries. The findings from the EQUITAP and other research projects all highlighted the need to move away from out-of-pocket payments as a health care financing mechanism and to increase tax and insurance funding for health services.

Other observations

In the closing plenary, there was a general sense that many interesting issues had been raised and that there had been valuable engagements between participants. A number of suggestions were made on how to improve on these engagements in future, including:

- Greater care should be taken in the language that we use, to enable communication between different researchers and between researchers and policy-makers. Sometimes unnecessary jargon is used, but more concerning is that certain terms (e.g. equity) are commonly used but may have a number of different interpretations depending on the underlying ideological perspective. In order to ensure effective communication, it is important that everyone clarify their specific definition or interpretation of key terms.
- It is critical to pay greater attention to the context within which particular research has been undertaken, both in interpreting the findings but also in assessing the generalisability of findings.
- Forums such as this should create opportunities for more deliberately structured and challenging debate. Many participants regarded the lack of explicit debate on contradictory research findings, as highlighted above in the case of the PROGRESA program, in order to better understand what works and what does not, and why, as a missed opportunity.
- There was a perceived need to invest more energy in trying to consolidate and synthesise existing knowledge to a greater extent. In particular, there is a need to disseminate information on positive experiences and success stories.

The next Global Forum conference will be held in Cairo, Egypt from 29 October to 2 November 2006 and will focus on “Combating disease and promoting health”.

* Di McIntyre is with the Health Economics Unit, University of Cape Town.

* Please send comments to admin@equinetafrica.org

Supporting the Retention of HRH: SADC Policy Context
Lucy Gilson and Ermin Erasmus

An EQUINET partner, the Centre for Health Policy at Wits University, has released a report examining policies in the SADC region on the retention of human resources for health. This report has been prepared for the Health Systems Trust (HST), South Africa and the Regional Network for Equity in Health in Southern Africa (EQUINET). It presents a review of issues in the regional policy context that are of relevance to the retention of human resources for the health sector (HRH) within the region, based on a rapid appraisal in selected countries and at regional level.

This work specifically focussed on the actions needed to stem the flow of international migration by encouraging the retention of health staff within countries. A particular concern raised across countries is staff retention in the public and rural services that preferentially serve the poorest populations. Importantly, policy documents and national respondents see the problems of retaining staff in these locations (the push factors underlying migration) as linked to the factors that undermine motivation and productivity. Policies to address retention issues (and so encourage health workers to stick and stay in country settings) are, thus, also likely to address poor motivation and weak productivity. In addition, these three sets of problems often go hand in hand with poor health worker attitudes and behaviours towards patients. So tackling these problems may have double benefits for health system performance – contributing to adequate availability of competent staff, as well as enhanced staff responsiveness to patients.

The report presents the findings of this work in sections 3-5 covering:

- Review of current international and regional HRH policy initiatives of relevance to the Eastern and Southern Africa region;

- Review of national level policy environments, with specific consideration of Malawi, South Africa and Tanzania;

- Implications for the future role of EQUINET in supporting implementation of HRH policy initiatives within the region.

In summary, the report notes that:

- encouraging HRH retention requires a complex package of actions/ /working through different entry points, rather than single policy actions;

- implementation of any HRH retention policy package is challenging because of the need to coordinate efforts across a wide range of governmental actors as well as get the support of a range of external actors;

- regional co-operation to support country level action to encourage retention appears to be, as yet, little developed, although recent discussions within the African Union and SADC, provide possible bases for such co-operation;

- current international initiatives may provide regional opportunities for addressing HRH problems (as a core constraint on health system development), but also hold the danger of over-burdening health systems, and in particular leadership and management within them.

In supporting initiatives to promote HRH retention within the region we suggest that EQUINET could, in broad terms, engage with others in providing a focal point for regional networking in support of HRH policy action. Such networking could, more specifically, focus on two sets of activities (see section 5 for details).

First, analytical work could fill current gaps by supporting cross-country analysis of the implementation of financial incentives, developing ideas and proposals around how to strengthen non-financial incentives and monitoring the impact at country level of externally driven initiatives on HR issues or initiatives (such as those for HIV/AIDS) likely to have impact on HR.

Second, dialogue and engagement with key actors (such as parliamentarians, senior health and other civil servants, professional groupings) could be supported by the development of policy briefs on key issues and collaboration with WHO AFRO, SADC, NEPAD and the AU.

* The report, which is available from http://www.equinetafrica.org/bibl/page.php?record=594, was presented at a "Policy and research meeting on equity in the distribution of health personnel in southern Africa" in August. The meeting:

- provided an update and recap on major policy issues and positions on HRH in east and southern Africa at the country and regional level;
- presented brief summaries of the work that has been done under auspices of EQUINET;
- identified policy positions and issues that require further research;
- explored capacity building and policy intervention within the region;
- identified priority issues in order to deliver clear agendas for action; and
- identified some key collaborations to assist in taking the work forward effectively.

The meeting report will be available on the EQUINET website at the end of September.

Alternative world health report launched in Cuenca and London
David McCoy and Mike Rowson

The conception and birth of the Global Health Watch

Five years ago, about 1500 people from 80 countries met in Bangladesh at the first Peoples Health Assembly. The Assembly was organised as a counter-balance to the official World Health Assembly convened every year by World Health Organisation, and represented a protest against the failure to achieve health for all by the year 2000.

The Assembly gave renewed expression to social objectives such as fairness and the universal right to health care, as well as to the public health principle that in addition to providing health care, health systems and health professionals must act to abolish poverty and work towards people having access to education, nutrition, water, sanitation and peace.

It also gave birth to the Peoples Health Movement – a network of individuals and organisations from all regions of the world, formed with the understanding that the principles of the Charter would only be achieved through social mobilisation and political engagement. The Global Health Watch, an alternative world health report from the perspective of civil society, was designed as an instrument to support advocacy and mobilisation. Amongst its aims is to provide a platform that will embrace the science and politics of development, and thereby, simultaneously involve academics, health practitioners, parliamentarians, journalists and civil society in improving health and equity.

More than 120 people – researchers, health workers, non-government policy analysts and campaigners - and 70 non-government organisations contributed to the report. The connection of the Watch to the Peoples Health Movement and a wide range of NGOs will hopefully ensure that it doesn’t end up as another report gathering dust – disengaged from the vehicles that can help translate analysis and recommendations into actual action. Already a number of NGOs have volunteered to host launches of the Watch in other countries, including Malaysia, South Africa, Ireland, Egypt, Germany, Holland, and the US.


The Watch is not designed to report on the state of health and poverty – it is not about the size of the HIV pandemic, or the number of children who die every second; or the declining life expectancy in Africa. The aim is to provide a report on what is being done about improving health by reporting on the actions, policies and programmes of organisations charged with improving health. This idea of “watching” the performance of key institutions can also be viewed as a contribution to democratic deficits that exist at many levels of decision-making and the erosion of public accountability that has accompanied globalisation and the concentration of wealth and power.

Global political and economic institutions

According to the Universal Declaration on Human Rights, people do not just have a right to an adequate standard of living and medical care – they also have a right to live in a social and international order in which the rights to medical care can be realised. However, this right is continually violated. According to the World Commission on the Social Dimension of Globalisation, “none of the existing global institutions provide adequate democratic oversight of global markets, or redress basic inequalities between countries”.

The Watch questions the success story painted by proponents of the current form of globalization, pointing to increases in poverty in Africa, eastern Europe, central Asia and Latin America. Producers in developing countries have often been undermined by increased global competition from powerful nations after trade liberalisation. In Mexico, for example, the liberalisation of the corn sector under the North American Free Trade Agreement, led to a flood of imports from the United States, where agribusiness is massively subsidised. Mexican corn production stagnated whilst prices declined. Small farmers became much poorer and some 700,000 agricultural jobs disappeared over the same period. Rural poverty rates rose to over 70%, the minimum wage lost over 75% of its purchasing power, and infant mortality rates amongst the poor increased.

To change this will require a shift away from the dominant human rights discourse which focuses on the obligations of national governments towards their own citizens, towards more of a focus on a) the obligations of governments to the citizens of other countries; and b) the obligations of non-government actors, as well as the rules by which the world economy is controlled and governed. Furthermore, whilst some countries have social contracts, progressive taxation systems and laws and regulations to manage the human consequences of market failures at the national level, there is no ‘global social contract’ to manage the failures of globalization.

World Health Organisation (WHO)

A key chapter in the report is dedicated to WHO. The report argues that WHO is insufficiently resourced, inadequately empowered, undermined by national political agendas and handicapped by internal management problems. WHO does many things well and repeatedly demonstrates the need for a multilateral agency charged with protecting and promoting health, but the Watch calls for better funding and improvements in WHO’s operating environment. The report also notes that the proliferation of public private initiatives, vertical programmes and the insidious influence of the World Bank has resulted in WHO being further undermined as the leading global health agency.

But we need, for example, a WHO that can challenge and aspire to block trade and economic agreements that threaten to harm health and human rights. As a starting point, the Watch calls upon WHO to convene a delegation of public health and trade experts to attend the trade talks in Hong Kong this year, mandated with the role of providing public health advice to Ministries of trade and finance. But this simple request is unlikely to be granted without public lobbying. At the most recent Executive Board meeting of WHO, a mild resolution put forward by developing countries requesting WHO to conduct a more active analysis on the impact of trade on health was blocked by the US and other countries – illustrating the impotence of WHO in tackling the more fundamental determinants of health.

Other recommendations aimed at WHO include:

Steering the global health ship

- Substantially increase funding for WHO with more proportionately devoted to its core budget with fewer strings attached;
- Open a debate on WHO’s key roles to avoid mission-creep and to develop consensus within and beyond the organization;
- Strengthen WHO’s role at country level and give it a mandate to help governments co-ordinate global, bilateral and international NGO initiatives to improve health.

An organization of the people not just of governments
- Expand current efforts to reach out to civil society, especially in the developing world;
- Ensure that public-interest civil society organizations are differentiated from those acting as a front for commercial interests;
- Improve the nature of the WHO leadership elections – possible solutions include a wider franchise, perhaps of international public health experts and civil society organizations. Candidates should be required to publish a manifesto and debate their vision for the organization publicly.

Improve the management of the organization
- Improve the mix of the professional staff, ensuring that there are more social scientists, economists, public policy specialists, lawyers and pharmacists. More representation from developing countries should be coupled with stronger regional offices run by experienced professionals.

The corporate sector

Of the 100 largest economic entities in the world, 51 are businesses; and the combined sales of the top 20 businesses are 18 times the combined income of the poorest 25% of the world’s population. Transnational corporations wield immense power through their wealth, control of resources and influence on governments and key decision-making bodies, with profound consequences for health and development.

The price of medicines and the radical changes to the way we construct patents; the resistance to making the required changes to address climate change; widespread labour exploitation and occupational health hazards; the dumping of cheap, subsidised food in Africa; the corrupt trade in weapons; the unchecked pollution of many extractive industries; and the unhealthy changes in food eating practices are just some examples described in the report, of the causal relationships that exist between profit-seeking corporate activity and the state of global health.

While commercial activity and free enterprise in themselves should not come under attack, the deterioration of democratic control and oversight over corporate actions and power must be highlighted. The imbalance between corporate freedom and social obligations is unhealthy, and health professionals need to assert their public health authority to limit the negative consequences of corporate actions, and ensure proper regulatory frameworks.

The attention paid to the corporate sector also leads us to shift thinking away from an exclusive focus on poverty towards an equally necessary focus on wealth, and in particular one what many would call obscene wealth. One of the demands we make is for the establishment of an international tax authority to help recover the conservatively estimated US$255 billion that is lost annually through tax avoidance.

This is an amount of money, in spite of the low tax rates, that would fund comprehensive and functional health care systems in every poor country. Public-private partnerships and corporate social responsibility programmes are great, but the Watch calls for the greater use of legitimate, fair and non-punitive instruments of public policy to ensure the universal provision of health care and social security, and the redistribution that is required to reverse the politically unsustainable deepening of global disparities.

Health systems

The chapter on health systems sets a very different agenda from the one currently popular with donors, where the emphasis is on fragmented, vertical health programmes usually focussed on one or two diseases, or on particular selected interventions. The Watch describes how Ministries of Health in poor countries operate in a policy circus, pulled in a hundred different directions by different programmes, donors and agencies, undermining coherent and integrated health systems development. In many instances, these agencies also contribute to an internal ‘brain drain’ – sucking many of the most skilled professionals out of public health care systems.

In the poorer countries, this has come on top of economic crises, structural adjustment programmes and neoliberal reforms that have decimated public health care systems and extended the commercialisation of health care to the detriment of equity, accessibility and efficiency.

The Watch presents new evidence which suggests that higher levels of private finance and provision lead to worse health outcomes, and explains how private financing and provision leads to a commercialisation of health care systems which widens health care inequities, lowers access to care for the poor, causes inefficiencies and deteriorates levels of trust and ethics.

Unless a common vision of health care systems development is established, we will not achieve the health-related Millennium Development Goals. The Watch therefore calls for the adoption of a 10-point agenda to repair and develop health care systems (more detail on the recommendations is available from both the Watch itself and the accompanying advocacy document, Global Health Action):

1. Provide adequate funding for health care systems;
2. Take better care of public sector workers;
3. Ensure that public financing and provision underpin health care systems;
4. Abolish user fees that push people into poverty;
5. Adopt new health systems indicators and targets that incentivize countries to improve the health system rather than simply tackle specific diseases;
6. Reverse the commercialization of health care systems by using regulatory and legislative instruments; and search for ways in which the private sector’s resources can be harnessed for the public good;
7. Strengthen health management and adopt the District Health System as the model for organising health care systems;
8. Improve donor assistance within the health sector;
9. Promote community empowerment to improve the accountability of the health system;
10. Promote trust and ethical behaviour to combat the corrosive effects of commercialization.

At the moment international health agencies consistently stress the importance of strengthening health care systems – but with little debate or discussion as to what this actually means. This is one area where WHO can really play a positive role and demonstrate health sector leadership.

Global Health Watch 2

Planning for the second edition of the Watch has begun. But between now and then, the challenge will be to actively mobilise the broader health community around the Watch and the advocacy agenda that accompanies it.

At the launch of the report in London, NHS organisations and professional associations were asked to think of institutional responses to the global health crises by:
- Developing long-term ‘partnerships’ with counterparts in poor countries - involving support, the transfer of material resources, skills and technology – and also providing a mechanism by which health workers in the NHS can learn and understand the impact of UK actions and policies on global health);
- Daring to put aside a proportion of money to promote global health until such time that we have a mechanism to recompense poor countries for training so many of our health workers;
- Implementing fair trade and ethical purchasing policies within our own organizations; and
- Campaigning for change. Medact, which was established specifically as a membership organization for health workers to promote global health, provide one concrete vehicle by which individual health workers can work together to lever change.

In southern Africa, the health and development community should consider ways in which the Watch can be used as a tool to strengthen and develop a progressive global public health movement and greater public accountability.

* David McCoy and Mike Rowson are managing editors of GHW

* Please send comments to admin@equinetafrica.org

Impact of Adjustment Policies on Vulnerability of Women and Children to HIV/AIDS in Sub-Saharan Africa
Roberto De Vogli and Gretchen L. Birbeck

The social and economic impact of the adjustment programmes of the International Monetary Fund (IMF) and the World Bank in developing countries has been a source of heated debate over the last two decades. Research on the effects of these policies has led to contradictory conclusions.

A number of World Bank evaluations indicate that 'adjuster countries' generally succeed in improving health, education, and social welfare programmes compared to 'non adjusters' (1-3). Based on such studies, the World Bank concludes that adjustment programmes do not necessarily adversely affect vulnerable populations. Furthermore, the World Bank believes that reforms that include these reforms are necessary for poverty eradication in developing countries.

On the other hand, publications from UNICEF and from representatives of academic institutions and non-governmental organizations (NGOs) indicate that adjustment policies may be particularly harmful for the most vulnerable populations. In "Adjustment with a human face", UNICEF reports studies from several developing countries which indicate that adjustment policies have negatively affected the health status of women and children (4).

Evidence suggests that the adjustment programmes may also create conditions favouring societal vulnerability to HIV/AIDS (5). Unfortunately, no study, to date, has systematically evaluated the relationship between IMF/World Bank economic reforms and the vulnerability of women and children to HIV/AIDS.

This paper reviews what is known regarding the social and economic consequences of adjustment policies on maternal and child welfare and explores the potential impact such consequences may have on the vulnerability of women and children to HIV/AIDS. We approach the impact of macroeconomic adjustment policies from a conceptual perspective. Our theoretical framework illustrates how adjustment policies may influence the predisposing factors for impoverishment of women and exposure of children to HIV/AIDS in sub-Saharan Africa.

The underlying assumption is not that adjustment is the only cause of vulnerability of women and children to HIV/AIDS. Antecedent predisposing factors, such as poverty and inequality, are responsible for the vulnerability of women and children to HIV/AIDS in the first place. However, adjustment policies may further contribute to a socioeconomic environment that facilitates the exposure of women and children to HIV/AIDS, especially when their implementation is not accompanied by specific measures protecting the most vulnerable populations.

AIDS in sub-Saharan Africa directly and indirectly devastates the lives of millions of women and children. According to the joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization, 19.2 million women and 3.2 million children aged less than 15 years are living with HIV/AIDS in the world. Almost two-thirds of them reside in sub-Saharan Africa. In 2003, over one million women and approximately 610,000 children died from AIDS.

Socioeconomic conditions of women and children are determined by a series of hierarchical factors that interact with one another at different levels of their ecosystem. These factors correspond to the household level (i.e. income of the family), the meso level (i.e. food prices, real wages, employment opportunities), and the macro level (i.e. economic policies, health policies, social welfare systems). The latter level is particularly important: macroeconomic changes modify the meso-economic conditions that, in turn, are transmitted down to the household level. Macroeconomic measures, such as adjustment policies, may have an impact not only on macroeconomic indicators, such as gross domestic product (GDP) growth and the external debt rate, but also on social indicators, such as access of women and children to shelter, food, healthcare, and education. Since poor access to basic human needs may facilitate the exposure of children to HIV/AIDS, economic policies at the macro level may ultimately be related to the socioeconomic conditions that reduce or facilitate the spread of HIV/ AIDS among infants and youths.

Economic reforms that decrease access to basic needs for poor households will eventually result in increased exposure of women and children to HIV/AIDS. Conversely, economic growth that leads to increased access to basic goods and services for the most vulnerable families may significantly reduce their exposure to the infection.

Since 1980, most sub-Saharan African countries entered into one or more adjustment programme(s) of the IMF/ World Bank. Many of these programmes have not been implemented as prescribed by the World Bank and IMF, but as implemented, these policies have not produced the expected results in terms of economic growth and reduction of unsustainable debt. A World Bank study of 26 African countries that implemented adjustment policies concluded that six countries had a large improvement in macroeconomic indicators, nine had a small improvement, and 11 had a deterioration (3). Moreover, Africa's external debt increased from US$ 120 billion in 1980 to US$ 340 billion in 1995 (14).

Adjustment policies mainly consist of currency devaluation and financial liberalization; privatization of government corporations; trade liberalization (including import liberalization and export promotion); elimination or reduction of subsidies for agriculture and food staples; and reductions in government spending (including expenditure for health, education, and social services).

Analyses of the effects of currency devaluation on prices for basic items, such as food, housing, and transportation, lead to controversial conclusions. Prices for basic commodities rise after the adoption of the adjustment policies because currency devaluation increases the cost of imports. In Zambia, devaluation increased the cost of bread from 12 kwacha a loaf in 1990 to 350 kwacha in 1993 (21). In Senegal, after currency devaluation, inflation rates dramatically increased especially for daily food and health products (22). In Kenya, the real price for maize rose by 29% between 1982 and 1983 (23). In Tanzania, commodity prices skyrocketed as a result of devaluation (24).

Despite these results, there is also evidence that currency devaluation may be an appropriate solution to prevent a further collapse of a failing economy (13). A study conducted in cocoa-growing areas of Ghana concluded that even the poorest smallholders benefited from the improved producer prices resulting from devaluation (25).

If currency devaluation produces mixed effects, removal of food subsidies has a more direct impact on access to food and basic commodities, especially among low income groups. In Zambia, after the removal of subsidies in 1985, the price of maize meal rose by 50% (26). In Zimbabwe, after eliminating food subsidies, the cost of living for lower-income urban families rose by 45% between mid-1991 and mid-1992. The increased cost of food items results in a sharp reduction of low-income household expenditure on other basic commodities.

Sharp increases in the cost of living and impoverishment of women not only increase the vulnerability of infants to HIV/AIDS, but also have a negative impact on vulnerable young people. Children of poor mothers are more likely to be exposed to predisposing factors for HIV (10). Socioeconomic constraints force these children to leave school and search work to support their families. Children may also be abandoned. Youths and children living in impoverished families are more likely to live and work on the street, where they may be forced into prostitution to exchange sex for money, goods, food, or shelter (31).

Privatization results in significant job losses in the public sector without necessarily increasing employment in the private sector (34-36). To improve efficiency and keep production costs low, public enterprises reduce costs of labour by freezing wages and reducing employment.

This results in a decline of real wages or an increase in unemployment, especially among low-income workers. During the 1980s, average real wages declined in 26 of 28 African countries (34). In Ghana, between 1984 and 1991, after privatization of the 42 largest state enterprises, more than 150,000 workers lost their jobs (31).

These cutbacks in public-sector employment disproportionately affect women (4,37,38) who traditionally hold positions, such as clerical workers, cleaners, nurses, or teachers. In Ghana, the least skilled women working in the public sector lost job protection, security, and benefits as a consequence of policies aimed at increasing efficiency, while others lost employment altogether (39). Privatization not only affects women in urban areas, but also impacts those in rural areas since informal land privatization is linked to a reduction in access of women to subsistence food production (40).

Unemployment, low wages, and job insecurity caused by privatization not only increase women's adoption of survival strategies, including prostitution, but also modify existing gender-related relationships. Employed women tend to be more empowered by having more opportunities for education, more experience in public life, more self-confidence and self-esteem, all basic prerequisites for negotiating safe sex with male partners (41). Conversely, unemployment, job insecurity, and reduced purchasing power increase the exposure of women to sexual harassment and sexual abuse, especially among those working in low-earning jobs (42).

Reduced employment opportunities resulting from privatization may also increase the proportion of African children forced to live on the street or work to support their families (43). In Zambia, due to privatization and retrenchment of government employees, 72,000 people lost their jobs and child labour increased nine folds among females aged 12-14-years (44).

In regions where a significant proportion of population live in miserable conditions, indiscriminate cost-recovery measures disproportionately affect those who cannot afford to pay user-charges. The World Bank and other organizations which support the implementation of user-fees for health services insist that even poor households are willing to pay for higher quality, more reliable health services. In a household survey conducted in Rwanda, most respondents, regardless of income, indicated a preference for higher fees to assure the availability of medications (59).

However, populations living on less than a dollar per day can rarely afford to pay user-fees and their inability to pay may negate their 'willingness' to pay (60). The literature repeatedly shows that introducing user-charges at STI clinics result in a dramatic drop in women's use of services (61-64). Access to free STI treatment and condoms increase their use (65-66), and the introduction of user-charges creates an obstacle to HIV-preventive behavioural practices among women. Women and youth without access to AIDS education, HIV screening, STI treatment, and reproductive health services have little control over their AIDS-related risk factors. Untreated STIs increase the risks of HIV transmission (67) as shown in Uganda where over 90% of new HIV infections were attributable to other STIs (68). The introduction of user fees for health clinics is likely to increase the number of untreated STIs consequently producing high HIV susceptibility in women (66). These HIV-infected women infect their children through vertical transmission of the virus.

Following the prescriptions for structural adjustment and stabilization policies, many sub-Saharan African countries reduced public expenditure on education and introduced school fees limiting access to education, especially among those children who cannot afford to pay such charges (4,36). The introduction of school fees causes a dramatic fall in primary school enrollment rates and increases the number of children who drop out of school. Sub-Saharan Africa has the lowest primary school enrollment ratio in the world. This ratio fell from 77.1% in 1980 to an estimated 66.7% in 1990 (69).

Certain components of adjustment reforms, such as currency devaluation and trade liberalization, may produce mixed effects on the vulnerability of women and children to HIV/AIDS. Other reforms, such as financial liberalization, removal of food subsidies, and introduction of user fees for healthcare and education have a negative impact on the spread of the epidemic among poor women and children. In most cases, adjustment policies create synergies making it extremely difficult to identify their net social effects. Clearly, there is, currently, no single study capable of demonstrating a causal link between adjustment policies and the exposure of women and children to HIV/AIDS. However, this analysis provides some evidence that adjustment policies may inadvertently facilitate societal conditions that increase the vulnerability of women and children to HIV/AIDS in sub-Saharan Africa.

It must also be acknowledged that the World Bank is, at present, the largest single investor in health in sub- Saharan Africa. Such investment may reduce the HIV epidemic through some mechanisms. However, the unintended consequences of adjustment policies may have greater negative effects on the same health outcome.

Given the potential for adjustment policies to exacerbate the AIDS pandemic among women and children, there is an urgent need to either demonstrate that such measures are not harmful to maternal and child welfare or to modify policies. The present buffering mechanisms designed to protect the most vulnerable segments of the population during macroeconomic stabilization and structural adjustment are not sufficient. The IMF and the World Bank need to provide adequate scientific evidence demonstrating the effectiveness of their policies. Failure to do so may undermine their international credibility and further exacerbate the already tragic social conditions of marginalized women and children at risk of HIV/AIDS in the developing world.

* This article is composed of extracts from the original review paper, done with permission of the author. For the full paper and list of references visit http://www.phishare.org/documents/icddrb/3205/

* Roberto De Vogli is with the Department of Epidemiology and Public Health, University College of London. Gretchen L. Birbeck is with the African Studies Center and Departments of Neurology and Epidemiology, Michigan State University.

* Please send comments to admin@equinetafrica.org