Aids: A moral issue for as long as it is defined by inequalities
Sanjay Basu

The World Health Organization (WHO) recently released the first set of comprehensive data comparing the prevalence of HIV/AIDS in poor countries with the rates of antiretroviral (anti-HIV) drug access in those nations. The data are striking and disheartening, yet have received little press coverage. Indeed, at the time of their release, some American newspapers ran editorials indicating that antiretroviral access has received "too much attention".

Two problems are implicit in such a contention. The first is political. AIDS is very much a symptom - albeit the most extreme symptom - of the large diseases of inequality and poverty that result not only in HIV, but also in hunger, hemorrhagic fever and housing problems. The same credit and political obstacles that have led to gender discrimination in housing and employment have led women into prostitution and relationships based on sexual dominance [1, 2]. The same structural adjustment programs and neoliberal economic policies that have crashed farming sectors and forced thousands into migration are the same policies that have led migrants to the barracks of minefields to live with depression, alcoholism and the subsequent solicitation of prostitutes [3-5]. And so to address AIDS appropriately would be to appreciate that it does not simply receive "too much attention", but that the attention it receives should be drawn towards its base - and this includes the inequalities in healthcare access that are symbolized by antiretroviral access disputes.

The second problem with the new popular line of thought on antiretrovirals is a statistical problem. The recently-released WHO data are striking but perhaps not surprising. If "too much attention" has been focused on drug access, then why are only six-tenths of a percent of the 1.6 million infected people in Tanzania able to access antiretroviral medications? Why are only 1.5% of the 2.4 million in Mozambique and the Congo able to gain such access? In a country like Zimbabwe, where one of every four adults is infected, only one of every fifth can access an antiretroviral medication. As one scrolls through the WHO's data, the numbers of infected persons continue to be expressed in seven digits, while the percent of those gaining access to antiretrovirals continues into smaller and smaller decimal ranges.

* Please click on the link to read the full article.

Further details: /newsletter/id/30690
Equinet Newsletter 45: November 2004: Scarcity and loss of health personnel

EQUINET NEWS IS THE ELECTRONIC MAILING LIST OF THE NETWORK FOR EQUITY IN HEALTH IN SOUTHERN AFRICA (EQUINET) http://www.equinetafrica.org/ EQUINET NEWS is a newsletter designed to keep you informed about materials on the Internet on equity and health in southern Africa, focusing primarily on EQUINET's principal themes. The newsletter also includes news about Equinet activities, policy debates or theme work to keep you updated on work taking place. Further information on the materials in these briefings is available from TARSC (email: admin@equinetafrica.org).

Can we better support parliaments to turn protocols into practice for equity in health in southern Africa?
EQUINET Secretariat, TARSC

The SADC Health Protocol came into force at the 2004 SADC Mauritius Summit and now applies across the region. It outlines the priorities and mechanisms for regional co-operation in health. We look forward to the protocol being raised and discussed within the parliaments of the region to see how far we are making progress in the regional priorities and approaches signed on to by the heads of state in Mauritius.

Why should parliaments be important to struggles for equity in health? Parliaments are a watchdog of public policy and consolidate this policy in law. In their legislative role they are able to transform social norms and values into binding legal entitlements. Their oversight role on the budget and on the actions of the executive provides an important opportunity to ensure that these legal entitlements are realized in practice. For example parliaments are an important watchdog of the government Abuja summit commitment that at least 15% of government budgets are invested in the public health sector. They can give voice through various processes of debate, inquiry, public hearings and consultation to public views, including the views of those areas and groups where such voice may be weaker or less articulate.

In an EQUINET, GEGA and SADC Parliamentary Forum regional meeting in South Africa in August 2003, it was recognized that parliaments are uniquely placed to build alliances with the Executive branch of government, across political parties, between different portfolio committees and with civil society, health sector and other agencies at national and regional level in support of health equity. (The report of this meeting is found at www.equinetafrica.org) The parliamentary reforms taking place in the region provide an enabling environment for this. At the August 2003 regional conference, delegates agreed that the establishment of parliamentary committees on health provided a forum for deeper review, policy monitoring and analysis, and noted that a range of health related activities were already taking place. These committees have held public hearings on laws and policies, visited and investigated conditions in the health system, held systematic hearings on the national budget and its consistency with national health policies and promoted public awareness on key areas of social norms and action in health, such as HIV and AIDS. In Zambia, South Africa and Zimbabwe, for example, with support from institutions in EQUINET and GEGA, parliamentary committees on health have analysed and made input on equity issues in the health budget and have visited districts to follow up on the equity issues raised. In Tanzania the parliament has established a parliamentary forum on AIDS at which key issues such as equity in access to Antiretroviral treatment have been debated. In Malawi parliaments have raised and promoted debate on issues of migration of health personnel and on the quality of health services at the district level.

In June 2004, during the EQUINET regional conference on equity in health, parliamentary committees and organisations working on health equity agreed that these critical areas of work needed more consistent regional exchange of information and good practice, support and activity. They would also benefit from longer term co-operation with state, academic and civil society institutions working on health equity. How can this be achieved? Is a more regular forum of health committees needed, within the SADC framework? How can the current work and institutional partnerships with parliaments be better networked and more consistently supported to ensure greater exchange of information, learning and good practice? These issues were raised as matters of concern to organisations like EQUINET working with parliaments and we invite readers and institutions working with parliaments to give feedback to these queries. What experiences exist in the region of work with parliamentarians on equity in health? How can we better strengthen and support such parliamentary roles, particularly if we are to achieve our goals of equity and social justice in health, and the policy commitments expressed in the SADC Health Protocol?

This briefing is produced by the EQUINET secretariat at TARSC. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat email admin@equinetafrica.org . Reports cited are available as a downloadable pdf file from our website at www.equinetafrica.org

NGO study examines state budgets for HIV/AIDS in African and Latin American countries
Alison Hickey, AIDS Budget Unit, IDASA, South Africa

A new report on the funding by nine African and Latin American countries on HIV/AIDS has found that countries must do more to ensure a comprehensive response to the epidemic—incorporating prevention, treatment, care and support. The study, undertaken by NGO research institutes in each country, was jointly coordinated by Idasa in South Africa and Fundar in Mexico.

The study, entitled Funding the Fight: Budgeting for HIV/AIDS in Developing Countries will be discussed by researchers during a one-day meeting taking place in Johannesburg this week. This research project makes a remarkable contribution to the field of HIV/AIDS resource-tracking, in that comparable budget analysis studies were undertaken by civil society organisations.

The study found that while many countries have developed national strategic plans and programmes, these were poorly costed and budgeted. It also found that the tracking of resources allocated towards HIV/AIDS in national budgets was hindered by weak or absent links between allocations and their intended objectives and outputs. Governments have inadequate systems in place to track the allocation of resources for HIV/AIDS.

Yet the research yielded a number of important findings. In Africa most countries, until recently, have focused on prevention more than treatment. This despite the fact that WHO/UNAIDS estimates that 3.8 million Africans are in need of treatment, while only 150 000 people are currently receiving the life-prolonging drugs. The study notes the boost to HIV/AIDS spending following the recent announcement and launch of ARV treatment programmes in South Africa, Mozambique, Kenya and Namibia. However the researchers caution that even though governments may increase their allocations to provide treatment, this programme may be undermined if more money is not made available to strengthen the health system overall.

In the Latin American countries, where HIV/AIDS prevalence is below 1%, the bulk of government spending on HIV/AIDS is earmarked for providing antiretroviral treatment. In Argentina 90%, in Chile 80%, Ecuador 74% and Nicaragua 54% of the national AIDS budget is committed to providing treatment and care and support, with less resources available for prevention. The researchers warn that treatment alone may not be enough to curb the epidemic and that the governments of Latin America need to increase their allocations and commitment to prevention.

The Report points out that all the African countries are falling below the 15% target agreed upon by Governments at an OAU Summit in Abuja in 2001. Amongst the African countries, the health allocations as a share of total government expenditure range from 6% in Kenya to approximately 15% in Mozambique. South Africa’s allocation is estimated to be just under 12%. Health budgets in the Latin American countries, with the exception of Nicaragua, were primarily financed through state revenue, whereas in the African countries, except South Africa, they tend to rely primarily on donor funds.

While it is difficult to isolate specific HIV/AIDS allocations from the overall health budget, the report finds HIV/AIDS earmarked funds consume less then 4% of health budgets in the Latin American countries included in the study, ranging in 2002, from under 1% in Chile to 3.5% in Argentina. In Africa, the priority accorded to HIV/AIDS programmes in health budgets varied significantly—from 1.6% in Mozambique, to 11.4% in Kenya in 2002. In South Africa the HIV/AIDS allocations have climbed steadily from 0.67% of the consolidated national and provincial health budget in 2000/1, to 3.86% in 2004/5. HIV/AIDS-specific allocations made up 0.49% of South Africa’s overall national budget in 2004/5.

An important finding from the Report is that the increasing allocations being made to HIV/AIDS may be squeezing out other health priorities. In all countries the researchers observed that while HIV/AIDS allocations have been increasing, this has not been matched by a commensurate increase in allocations to the health sector overall. Without adequate attention to strengthen and support overall health infrastructure, facilities and medical personnel, HIV/AIDS programmes will be undermined, and simultaneously the health care delivery will strain under the burden of HIV/AIDS.

The report urges African countries to increase their own financial commitments to HIV/AIDS interventions. It points out that with the exception of South Africa, most African countries rely to a great extent on donor funding. Greater commitment of state funds is essential to the longevity of scaled-up programmes, particularly treatment.

The report has been able to yield very valuable findings, and the researchers are calling for budget reforms and greater transparency of government allocations for, and actual spending on, HIV/AIDS. This information will enable civil society and citizens to better understand and monitor how much is being spent on HIV/AIDS, for what programmes, and in what regions and provinces. Effective government responses to AIDS require us to know where the money is coming from, where it is going, and how well it is being spent.

For more information contact: Alison Hickey, Manager, AIDS Budget Unit, Idasa. Cell: 083 280 2759; Teresa Guthrie, Project Co-ordinator, AIDS Budget Unit, Idasa. Cell: 082 872 4694. To order a hard copy of the report, contact: nomzi@idasact.org.za A full electronic version will be available October 2004: www.idasa.org.za

EQUINET is currently carrying out work in line with the SADC Business Plan on HIV and AIDS on monitoring, protomting good practice, supporting research and sharing information on health systems and equity issues in treatment access. More information on this programme is available from the EQUINET secretariat at TARSC, email admin@equinetafrica.org.

Support 100% Multilateral Debt Cancellation
A sign-on letter and action alert from Physicians for Human Rights

The debt relief movement is poised for a historic day this October 1st when G-7 finance ministers discuss 100% multilateral debt cancellation for impoverished countries. Debt cancellation would free up significant funds for development, including fighting AIDS and strengthening health systems. You can help make this happen.

If you are a health professional, please lend your name to an international health professional sign on letter that will reach all G-7 finance ministers and presidents/prime ministers before this important meeting. This letter is copied below. If you would like to add your name, please respond by September 20th to aidsact@phrusa.org with your full name, degree, affiliation, and state/country.

International Health Professional Sign-on Letter

September, 2004

Dear G-7 Presidents and Prime Ministers:

We write to you as health professionals from diverse countries in Africa, Asia, Latin America and the Caribbean, North America, Europe, and Australia who strongly support debt cancellation for poor countries. Debt cancellation is a prescription urgently needed to help heal seriously ailing health systems – some of which cannot even provide minimal care – in many of the countries in which we live and work.

Debt cancellation would free large sums of money, funds that should be used to build stronger and more equitable health systems, which are desperately needed if the fight against AIDS and other killer diseases is ever to be won. Right now we are losing that fight. AIDS alone kills about 3 million people per year, as another 5 million people becoming infected with HIV annually. At the end of June 2004, fewer than 10% of people in developing countries in urgent need of AIDS treatment were receiving it. In light of the health crises that many of our countries face, debt cancellation is necessary on human rights and humanitarian grounds. We therefore urge you to endorse 100% multilateral debt cancellation for impoverished countries when the issue is discussed at the meeting of G-7 finance ministers this October 1.

We know that poor countries need this debt relief urgently. African countries alone are collectively spending about $15 billion per year servicing their debts to wealthy creditors, including multilateral institutions. The fifteen focus countries of the U.S. President’s Emergency Plan for AIDS Relief spent $10.3 billion servicing their debts in 2001; this is more than the $9 billion these countries are scheduled to receive over the Emergency Plan’s entire five years. The World Bank, IMF, and regional development banks are typically the largest creditors of the most impoverished nations.

Relief from debt could be instrumental in enabling countries to meet AIDS treatment targets, as well as other health goals. Your governments all support the World Health Organization’s (WHO’s) 3 by 5 initiative, which aims to get 3 million people in developing and middle-income countries on AIDS treatment by the end of 2005. Yet treatment goals cannot be achieved without health workers. And as so many of us know through our own experiences, many countries, particularly in Africa, have nowhere near the necessary numbers of health personnel. For example, WHO and the World Bank have reported that Tanzania and Chad, both countries that would benefit greatly from debt cancellation, require their health workforces to triple and quadruple in size, respectively, to achieve the Millennium Development Goals.

The connection between suffering health systems and the debt payments that limit funds available to them is palpable. To a significant degree, the severe shortage of health workers in Africa is a symptom of acute underinvestment in health systems, many of which suffer from too few staff, too few supplies, and too few drugs. This underinvestment is a central cause of the migration of health professionals to wealthy nations, where health systems are stronger and pay is better. Creating the conditions that will enable health professionals to remain in their home countries and allow them to provide the best care possible for their patients will cost money. Health care workers will continue to leave if they are unable to meet the charge of our professions: serving our patients. Our colleagues will continue to emigrate so long as they do not have medicines for their patients, or functioning equipment, or proper supervision. And they will continue to leave so long as they cannot support their families or be confident of their own safety. They need fair salaries, equipment to protect themselves from occupational infections of HIV and other diseases, and psychosocial support to help cope with the constant death and stressors they face.

Full multilateral debt cancellation for impoverished nations could go a long way towards meeting people’s right to the highest attainable standard of health. Indeed, debt relief that countries have received under the Heavily Indebted Poor Countries (HIPC) initiative has already begun to do so. In Malawi, savings from debt relief have paid for extra staff and support in primary health centres, nurse training, and improving the supply of essential drugs in health facilities. In Mozambique, debt relief funds helped increase the number of children receiving immunizations for tetanus, whooping cough, and diphtheria. Debt relief savings have also helped fund primary health care in Uganda, including salaries of health care workers, while countries including Uganda and Cameroon have used debt relief savings to help finance HIV/AIDS programs.

Debt cancellation is an excellent investment not only in people’s health, but also in countries’ economic well-being. Increased spending by impoverished countries in health, education, and other fields that promote human development, which will result from debt cancellation, goes hand-in-hand with economic growth. As WHO’s Commission on Macroeconomics and Health has highlighted, investments in health will increase worker productivity, creating economic gains that would far exceed the initial cost to creditors of debt relief. Debt cancellation will help put countries that are economically marginalized and heavily dependent on foreign aid onto paths towards economic autonomy and integration in the world economy. By contrast, without debt cancellation and other investments to reverse the spread of and treat people with HIV/AIDS, decreased worker productivity will make countries increasingly dependent on foreign assistance and unable to participate in the global economy.

We therefore urge you to support 100% multilateral debt cancellation for impoverished countries, including HIPC countries and as well as non-HIPC countries that are in need of this relief. We hope that your finance ministers will announce your governments’ support for such an initiative at their October 1 meeting. And we encourage you to work with countries whose debts are cancelled to ensure that their savings from debt payments are used on poverty reduction and human development. Countries can establish mechanisms to ensure that savings from debt services payments are used to reduce poverty and to promote human development. Uganda has established a Poverty Action Fund into which savings from debt relief are channelled, and which includes a series of procedures to ensure that the debt relief savings are well spent. Other countries, including Tanzania and Malawi, have established similar mechanisms.

We also encourage you to work towards a permanent solution to the debt of impoverished countries – including for countries that do not receive 100% multilateral debt cancellation and for any new debt assumed by those countries whose debts are cancelled – by creating a new understanding of what level of debt countries are expected to repay. In particular, we urge you to announce that from this time forward, countries will be neither obliged nor expected to make debt payments that would compromise their ability to meet their people’s basic needs or otherwise fulfill their people’s human rights.

We are health professionals. Our job is to heal. So it pains us to see debt payments siphoning away funds that could go far towards enabling our colleagues and ourselves do our jobs and meet the needs of the patients we serve. We fervently hope that you will help enable us to be the healers that we were trained to be.

[If you would like to add your name, please respond by September 20th to aidsact@phrusa.org with your full name, degree, affiliation, and state/country.]

Removing user fees for primary care: necessary but not enough by itself
Lucy Gilson and Di McIntyre, EQUINET Theme co-ordinators, Fair Financing

User fees are once again a hot topic of policy debate. This time the question is whether to remove primary care fees. At its conference in June this year, EQUINET took a clear position on the issue. We called for these fees to be removed. But we also stated that this action is not a cure-all for the problems facing health systems in Africa. User fee removal must be accompanied by actions that increase overall national resources for public sector health services and that deal with international conditions and policies that undermine this.

The two reasons why primary care fees must go are that:
- They contribute to the unaffordable cost burdens imposed on poor households;
- They signal to poor households that society does not care about them.

Fees at primary care are relatively low. Even so, there is widespread evidence to show that fees encourage self-treatment (using herbs or poor quality medicine bought in unregulated market places), deter people from taking full doses (so increasing the chances of drug resistance), and act as a barrier to early, or even any, use of health facilities. In these ways the small level of fees can increase the costs poor people bear when ill. So even though fees represent a smaller proportion of the total costs of accessing health care than transport or lost income, they contribute to levels of cost burden that can, in some instances, impoverish poor households. At one level, impoverishment results from selling key assets, cutting down on other necessary expenditures, or borrowing, often at exorbitant interest rates, to pay for health care. At another level, charging fees adds cost to the other immense barriers of accessing care, such as distance and abusive treatment. It signals to poor people that they are not valued or cared for by society.

However, removing primary care fees is not enough by itself to tackle the range of existing health care challenges in Africa. Other actions are also required.

First, the levels of funding available for health care must be increased. At least 15% of government budgets should be invested in the public health sector, as committed by African governments in Abuja. Only one country in southern Africa, Mozambique, is currently reported to be achieving this. This will support the sustained quality increases necessary to improve health system performance, as well as allowing the system to respond effectively to the utilization increases likely to result from fee removal.

Linked to this African country debt should be cancelled. The EQUINET June 2004 Conference called for international action to remove the debt burdens imposed on African countries, and for national action to increase the level of government funding to health systems. These changes in financing also need to be underpinned by changes in terms of trade for African countries that result in huge resource outflows from Africa, including market barriers in industrialized countries to trade in food products and the poaching of health personnel.

Second, the removal of fees must be undertaken in a way that actively strengthens the health system.

In particular, the responses of health workers and managers must be deliberately managed to avoid negative impacts on morale and performance. As front-line providers and managers are the point at which patients meet the health system, their morale and performance has a direct influence over how patients experience health care, and how policies are implemented. In South Africa, while the removal of fees had a powerful positive effect on health outcomes, health workers said they were not adequately informed or involved, and were thus unprepared for the resulting increases in utilization. This can lead to unnecessary tensions at primary care level, and patients complaining that health workers treat them badly. In countries where fees have been retained, they have allowed managers and local communities some control over the decision of how to use the revenue. In others they have been used to fund agreed incentives for staff. These issues need to be managed and alternative ways found of providing for local resource control and staff incentives to avoid demoralisation.

Experience from a wide range of policy actions indicates that managing this policy change must involve:

1. Giving a specific government unit the task of implementing fee removal in ways that strengthen the health system;
2. An effective public relations campaign to communicate the change with the general public, and to signal that removal of fees is about valuing patients and providers;
3. Ensuring that the policy goals are clearly explained to managers and health workers to promote support for the policy at all levels of the health system;
4. Preparatory planning to ensure adequate levels of drug and staff availability to cope with the likelihood of initial utilization increases -
and longer-term planning for how to tackle wider drug and staffing, including motivation, problems;
5. Establishing new, manager-controlled funds at local level that allow management freedom on small-scale spending decisions;
6. Clear communication with health workers and managers about what and when actions will be taken - through meetings, supervision visits, special information letters;
7. Expect that there will be unanticipated problems with implementation, and so set up monitoring systems that provide a basis for identifying what other actions need to be taken: monitoring utilization trends, including the relative use of preventive versus curative care, and giving health workers and managers opportunities to feed back on health facility experiences.

Tackling the human resource barriers to effective fee removal will inevitably require the wider action that is necessary to address the overall human resource crisis in Africa. On this issue EQUINET has called for human resource policies and measures at national, regional and international level that promote the retention and improved working conditions of health personnel in public sector health systems, backed by compensation for regressive south-north subsidies incurred through health personnel migration. An editorial later this year will provide more detail on this.

User fee removal clearly provides an opportunity to begin to address the needs of poor people. However, their removal is not enough by itself. EQUINET calls for this to be backed at national level by increased public financing for health and at international level by a cancellation of debt. In addition, user fee removal must be implemented in ways that strengthen the health system. User fees were actively promoted internationally during periods of efficiency and market led health sector reforms that produced a huge cost to equity in health in southern Africa. User fee removal must be underpinned by actions at international and national levels that provide for the resources to achieve human rights to health and health equity goals.

* Information on EQUINET work on fair financing is available on the EQUINET website at www.equinetafrica.org EQUINET welcomes feedback to its editorials, suggestions, information and follow up enquiries to the EQUINET secretariat at TARSC, email admin@equinetafrica.org

Access to Food: a fundamental basis for health
Editorial by the EQUINET steering committee and secretariat

Cereal production in Southern Africa has remained stagnant for over a decade since 1990 at 22 million MT, despite a growth in population of 60 million in the period. This fact highlighted at the SADC Heads of state summit on food security brought sharp attention to unacceptable and mounting shortfalls in food security in the region. Rates of childhood stunting in Africa are predicted to increase to above 25 percent by 2015, more than double the Millennium Development Goal (MDG) for that year. Only 3 out 10 African countries have experienced an improved maternal nutritional status in the last decade.

The EQUINET steering committee highlighted at the June 2004 regional conference its agreement with SADC heads of state that food security and food sovereignty are now an important focus to achieve wider goals of health equity and social justice in the region. The gross statistics were further debated as they mask the fact that it is the lowest income rural and urban communities, women and children who are most at risk of food insecurity and its consequences.

Mary Materu, from the Centre for Counselling, Nutrition and Health Care (COUNSENUTH), Tanzania highlighted the massive inequity of the fact that “when the world is producing enough food to feed everybody, more than 800 million people, most in developing countries, do not have enough food to cover their nutritional needs.”

Mickey Chopra, from the University of the Western Cape School of Public Health, highlighted the wider fallout from this deprivation of the right to food: “Adequate food and nutrition is a basic right. The deprivation of this right has immense consequences for addressing inequities across the region. Poor nutritional status stunts educational development as well as increasing the risk of acquiring, and the severity of, infectious diseases (including HIV/AIDS). The lack of household food security has led to increased vulnerability, especially of women, to diseases such as HIV. If the huge cost of burden of disease suffered by the poorest is to be tackled addressing lack of household food security and malnutrition is essential.”

This deprivation arises from a combination of increasing food prices and falling food production. These immediate causes are driven by macro level factors such as trade relations, domestic food and agricultural polices and micro level factors such as intrahousehold food distribution, gender roles and caring practices.

The EQUINET steering committee noted that the current food insecurity cannot be traced purely to drought or to AIDS. “The 2002/3 food crisis in Southern Africa was more widespread and impacted much more severely on households than could be predicted from rainfall patterns. The destructive effect of AIDS on household labour and incomes clearly compounded other threats to food security, such as inequities in access to productive resources and to market access, particularly for women.”

Current trade policies were identified as having a profound and negative impact on food security in Africa. Chopra highlighted how OECD subsidies to agriculture between 2000 and 2002 of about US$250billion placed protectionist barriers against food imports from Africa, undermining returns from production and thus effectively suppressing production. Kenya, for example, more than doubled production of processed milk between 1980 and 1990. When subsidised milk powder imports could be sold more cheaply than Kenyan processed milk, imports soared, increasing from 48 tonnes in 1990 to 2 500 tonnes in 1998 and domestic production of processed milk plummeted by almost 70 percent. Kenya's ability as a nation to diversify into processing was undermined. More importantly small producers bore the brunt of this decline in demand for local milk. At national level production for export has led to decreasing land areas planted with food crops for domestic consumption. Domestic food production has also been weakened by falling investment in agricultural research.

These trade and economic barriers, harming small producers and thus women farmers, worsen the impacts of HIV/AIDS on household-level labour, assets and skills, on burdens of care and household productive capacities that have set up a vicious interaction between malnutrition and HIV. Mary Materu of COUNSENUTH further highlighted the need for improved nutrition to be supported by access to education, water and sanitation.

This understanding of the immediate and underlying factors driving food insecurity and malnutrition underlined the view at the EQUINET conference that addressing food security and nutrition called for action across a wide range of sectors. At global level it was clear that Millennium Development Goals that call for improved nutrition cannot co-exist with trade policies that undermine the production basis for achieving the goals in the most vulnerable regions of the world. At regional and national level Chopra presented evidence to show that improved food security calls for more equitable access to land, improved investment in small holder farming, and increased access by women farmers to production inputs.

Dr Erika Malekia of the Southern African Development Community (SADC) echoed this call for “an integrated plan of action, focused on addressing inequalities in areas such as land distribution, gender equity.”

The conference delegates resolved to advocate for trade and agricultural policies that ensure food sovereignty and household food security through land redistribution and investment in small holder farming in ways that promote gender equity and sustainable food production. EQUINET will be following up on this resolution in a more focused future programme of work on food security and health equity. The conference suggested that EQUINET support for SADC regional strategies for food security should include two critical components, particularly if equity issues are to be addressed. The first is to strengthen and inform from a health perspective the challenges to trade policies that undermine national food production. The second is to inform and strengthen the health dimensions of policies and programmes that support land redistribution, smallholder production and increased access by women smallholder farmers to production inputs.

The EQUINET Conference abstract book and resolutions are available on the EQUINET website at www.equinetafrica.org and the conference report will be posted on this site in the coming month. EQUINET welcomes feedback to its editorials, suggestions, information and follow up enquiries to the EQUINET secretariat at TARSC, email admin@equinetafrica.org

Reclaiming the state: Advancing people's health, challenging injustice
Facts, figures and quotes from the Equinet Conference, Durban, South Africa 8-9 June 2004

* “Equity in health implies addressing differences in health status that are unnecessary, avoidable and unfair. Equity in health implies directing more resources for health to those with greater health need. Equity in health means having the power to influence decisions over how resources for health are shared and allocated.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.

* “In the highly unequal societies of southern Africa, our health challenges demand health systems that assertively redistribute the resources for health and policies that reflect values of equity, solidarity and universality. This can be achieved through rising investment through the state and public sector.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.

* “The gains of neoliberal globalisation?
- 4% GDP lost in unfair terms of trade 1970-1990
- Africa's FDI share from MNC investment 25% in 1970's, 5% in 1990s.
- Income gap richest to poorest 53x in 1960 and 121x in 2000
- 185 million people out of work
- 55 million people live on <$1 a day
- Southern outflows increased.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.

* “Despite a hostile global environment, which has the potential to subjugate us to political and economic imperatives not of our choosing, we can and must mobilize collective action to chart and implement our positive vision and policies on the equitable health systems that we want.” - From a presentation 'Reclaiming the state: Advancing people's health, challenging injustice'.

* “ Impact of malnutrition on development:
- [A study of the long term impacts of the 1982-84 Zimbabwe drought on 665 children]…resulted in a loss of stature of 2.3 centimeters, 0.4 grades of schooling, and a delay in starting school of 3.7 months.
- [It is estimated] that this loss of stature, schooling and potential work experience results in a loss of lifetime earnings of at least 7 - 12%.” - From a presentation on 'Household Food Security, Nutrition and Equity.'

* “Only 3 out of 10 African countries show a decrease in severe maternal nutritional status in the last decade.” - From a presentation on 'Household Food Security, Nutrition and Equity.'

* “31 countries in Africa do not meet the 'Health for All' standard of a minimum of one doctor per 5000 people.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.

“External debt of the USA is $2.2 trillion - almost the same as the $2.5 trillion owed by the entire developing world…Every American citizen owes the rest of the world $7,333 while every citizen of all the developing countries only owes the rest of the world $500.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.

* “Estimating the cost of training a GP in the SADC Region to be $US60 000, then it can be assumed that there is a reverse subsidy from the developing world of $500m per annum for health personnel alone.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.

* “UNCTAD estimates that US$184,000 is saved in training costs per professional and that US saved US$3.86 billion as a result of importing 21 000 Nigerian doctors.” - From a presentation 'Health Personnel in Southern Africa Confronting Maldistribution and the Brain Drain'.

* “Things are pretty bad here you know. South Africa is not the Tropicana Hotel [in Durban, where the conference took place]. Since independence the rich have been getting richer and the poor poorer.” - Trevor Ngwane, Anti-Privatisation Forum, commenting in a parallel workshop session.

* “The green rooms [negotiating forums at the World Trade Organisation criticised for their lack of transparency] are basically where the bully countries call in the smaller countries, beat them up and then send them home with a message to their mothers.” - Riaz Tayob, SEATINI, replying to a question on a presentation on global trade and health.

Reclaiming the State: Advancing Peoples Health, challenging Injustice
Resolutions of the Third Southern African Conference on Equity in Health, Durban, South Africa, June 8 and 9, 2004


* The 1997 Kasane meeting on Equity in Health that confirmed the commitment to equity in health at all levels in southern Africa; the 1999 Southern African Development Community (SADC) Protocol on Health, the 2003 Maseru Declaration on HIV and AIDS and the resolutions of the SADC Heads of States Summit on food security held in Tanzania, 2004;
* The formation of EQUINET and our work since 1998 in support of these commitments, to strengthen the understanding of, the evidence for, advocacy of and implementation of this policy commitment to equity and social justice;
* Our conception of equity and social justice in health, which aims to address unfair differences in health and in access to health care through the redistribution of the societal resources for health, including the power to claim and the capabilities to use these resources;
* The widening constituency we are building for equity and social justice in health amongst governments, parliamentarians, health professionals, trade unions and other organs of civil society, researchers and communities at national and regional level;
* The challenges posed by neoliberal globalisation to our values of equity and social justice, to government ability and flexibility to implement the public policies that we choose and to the public sector health and essential services and that are critical for our health;

The June 2004 EQUINET conference in Durban South Africa affirmed that we stand for:

* Equity and social justice in health;
* Public interests over commercial interests in health;
* International and global relations that promote equity, social justice, people's health and public interests;
* Increased unconditional resource flows from the North and fairer terms of trade;
* Reduction and where possible restitution of flows of resources from South to North;
* A conception of human rights that affirms the agency of communities in claiming social and economic entitlements, the primacy of vulnerable groups and that captures African traditions of communitarianism;
* Equitable health systems that provide healthcare for all and redistribute and direct resources towards those with greatest needs;
* Rising investments in the state and public sector in health;
* Health (care) systems which promote collective, population oriented strategies for health and comprehensive primary health care;
* Trade and agricultural policies that ensure food sovereignty and household food security through land redistribution and investment in small holder farming in ways that promote gender equity and sustainable food production;
* At least 15% of government budgets invested in the public health sector, as committed in Abuja, together with debt cancellation;
* Progressive tax-based funding of health systems;
* Fair financing for health, in which the rich contribute a greater share of their income to health than the poor, with strengthened cross subsidies for solidarity and risk pooling;
* Equitable and affordable access to generic drugs, with application of essential drug policies across all health providers;
* Ethical and equitable human resource policies at national, regional and international level, backed by compensation for regressive south-north subsidies incurred through health personnel migration;
* Equitable public health and multisectoral responses to HIV and AIDS for prevention and health promotion, treatment and care and to mitigate the impact of the epidemic, particularly within and for young people and vulnerable groups;
*The expansion of access to anti-retroviral therapy for people living with AIDS in Southern Africa as an urgent priority, through funding and approaches that strengthen, and do not compromise, our public health services and systems;
* Democratic and accountable states, with full authority to exercise policy measures necessary to protect the health of people;
* Powerful and effective participatory and representative mechanisms at all levels of our health and social sectors and in the state more generally;
* Effective and accountable mechanisms for public and stakeholder contribution to decision making in health;
* Regional integration and co-operation within Africa to strengthen democratic states, advance the health of people and challenge injustices to health;
* Values based leadership across organisations working to promote equity in health.

The conference set out a programme of work and action for EQUINET and its partners to implement these goals.

* * Visit the Values, Policies and Rights, Health equity in economic and trade policies, Poverty and health, Human Resources, Resource allocation and health financing, Equity and HIV/AIDS and Governance and participation in health sections of the newsletter for more details about papers presented at the conference. The full abstract book and other conference documents will be available on the EQUINET website (www.equinetafrica.org) by the end of this month. Please send all comments to admin@equinetafrica.org

Restoring a socially-conscious state
Abstract of Equinet conference keynote address, Adebayo Olukoshi, Director, CODESRIA, Dakar Senegal

Historically, the state has played an important role as a social actor. Indeed, the social function of the state was as critical to the constitution of the social contract as the quest for a secured territorial framework within which individuals and groups could exercise their livelihoods. The high point of the development of the social state came in the period after the Second World War with the growth and spread of different variants of social democracy and welfare states.

Not surprisingly, African states at independence were invested with broad-ranging social responsibilities which they pursued with varying degrees of success. However; the onset of the African economic crises in the period from the early 1980s onwards and the rise on a global scale of the forces of neo-liberalism encapsulated the confluence of factors that culminated in the retrenchment of the social state - including from an institutional and expenditure point of view - and the enthronement of a narrow, market-based logic in the provision of social services - including, among other things, the pursuit of cost recovery, the imposing of user fees, the promotion of privatisation, and the employment of new public sector management strategies in the social sectors.

At the same time, the social sectors, including especially the health system, were to suffer a serious erosion of capacity that was connected to the drain of talents, the degradation of the infrastructure of service, and the collapse of professionalism. Perhaps much more serious is the decoupling of social policy from macro-economic policy-making and its treatment as a residual category to which targeting strategies such as safety nets, various programmes for the alleviation of the social effects of economic structural adjustment and a plethora of poverty reduction strategies would be applied. It is suggested that this decoupling of social and macro-economic policy making is at the root of the expansion of the boundaries of exclusion that defines the structural roots of injustice in the social sectors generally and the health sector in particular.

The prospects for the restoration of a socially-conscious state will depend on the capacity of governments to adopt an approach in which social policy is treated as an integral part of macro-economic strategies for growth and development.

* Adebayo Olukoshi, Professor of International Economic Relations and currently the Executive Secretary of the pan-African Council for the Development of Social Science Research in Africa (CODESRIA) which is headquartered in Dakar, Senegal. He has previously served as Director of Research at the Nigerian Institute of International Affairs, Lagos, Nigeria and as a Senior Fellow/Research Programme Coordinator at the Nordic Africa Institute, Uppsala, Sweden. His current research interests centre around the politics of reform and transition in African politics, economy and society.