Will we have more control over the resources we need for health?
Rene Loewenson, EQUINET Secretariat, June 2005

The massive inequalities in the distribution of resources for health globally will be brought increasingly into focus in the coming months, with the upcoming G8 meeting and the UN review of the Millenium development goals. With it will grow debates on the interpretation of the causes of and remedies for these inequalities, particularly for Africa. If we are to apply values of fairness and equity to this situation there is no doubt that global funds for health must flow southwards to African communities and public sector health services. As the editorial below by Vandana Shiva indicates, the situation calls for more however - it calls for social and economic justice. We must confront the deliberate policies that lead to net resource outflows from poor communities, underfunded public sector services and countries in Africa. EQUINET training, meetings and research in the coming months will focus on options for confronting these outflows in relation to health workers, health finances and trade policies. Please contact us at admin@equinetafrica.org if you would like to know more about any of these areas of work or visit our website at www.equinetafrica.org.

EQUINET in 1998 identified, as part of the understanding of equity in health, the importance of the relative control and authority that different people, communities and countries have over how the resources for health are distributed. At the end of the year, after the G8, after the UN Summit and after the WTO Hong Kong Ministerial, we will be asking ourselves - are African households, African public health planners and African countries more or less in control of the resources for health, including those we produce, but no longer consume, in Africa?

How To End Poverty: Making Poverty History And The History Of Poverty
Vandana Shiva
Source: www.zmag.org

The cover story of the Time Magazine of March 14, 2005 was dedicated to the theme, "How to End Poverty". It was based on an essay by Jeffrey Sachs "The End of Poverty", from his book with the same title. The photos accompanying the essay are homeless children, scavengers in garbage dumps, heroin addicts. These are images of disposable people, people whose lives, resources, livelihoods have been snatched from them by a brutal, unjust, excluding process which generates poverty for the majority and prosperity for a few.

Garbage is the waste of a throwaway society - ecological societies have never had garbage. Homeless children are the consequences of impoverishment of communities and families who have lost their resources and livelihoods. These are images of the perversion and externalities of a non-sustainable, unjust, inequitable economic growth model.

In "Staying Alive, I had referred to a book entitled "Poverty: the Wealth of the People" in which an African writer draws a distinction between poverty as subsistence, and misery as deprivation. It is useful to separate a cultural conception of simple, sustainable living as poverty from the material experience of poverty that is a result of dispossession and deprivation.

Culturally perceived poverty need not be real material poverty: sustenance economies, which satisfy basic needs through self-provisioning, are not poor in the sense of being deprived. Yet the ideology of development declares them so because they do not participate overwhelmingly in the market economy, and do not consume commodities produced for and distributed through the market even though they might be satisfying those needs through self-provisioning mechanisms.

People are perceived as poor if they eat millets (grown by women) rather than commercially produced and distributed processed junk foods sold by global agri-business. They are seen as poor if they live in self-built housing made form ecologically adapted natural material like bamboo and mud rather than in cement houses. They are seen as poor if they wear handmade garments of natural fibre rather than synthetics.

Sustenance, as culturally perceived poverty, does not necessarily imply a low physical quality of life. On the contrary, because sustenance economies contribute to the growth of nature's economy and the social economy, they ensure a high quality of life measure in terms of right to food and water, sustainability of livelihoods, and robust social and cultural identity and meaning.

On the other hand, the poverty of the 1 billion hungry and the 1 billion malnutritioned people who are victims of obesity suffer from both cultural and material poverty. A system that creates denial and disease, while accumulating trillions of dollars of super profits for agribusiness, is a system for creating poverty for people. Poverty is a final state, not an initial state of an economic paradigm, which destroys ecological and social systems for maintaining life, health and sustenance of the planet and people.

And economic poverty is only one form of poverty. Cultural poverty, social poverty, ethical poverty, ecological poverty, spiritual poverty are other forms of poverty more prevalent in the so called rich North than in the so called poor South. And those other poverties cannot be overcome by dollars. They need compassion and justice, caring and sharing.

Ending poverty requires knowing how poverty is created. However, Jeffrey Sachs views poverty as the original sin. As he declares:

A few generations ago, almost everybody was poor. The Industrial Revolution led to new riches, but much of the world was left far behind.

This is totally false history of poverty, and cannot be the basis of making poverty history. Jeffrey Sachs has got it wrong. The poor are not those who were left behind, they are the ones who were pushed out and excluded from access to their own wealth and resources.

The "poor are not poor because they are lazy or their governments are corrupt". They are poor because their wealth has been appropriated and wealth creating capacity destroyed. The riches accumulated by Europe were based on riches appropriated from Asia, Africa and Latin America. Without the destruction of India's rich textile industry, without the take over of the spice trade, without the genocide of the native American tribes, without the Africa's slavery, the industrial revolution would not have led to new riches for Europe or the U.S. It was the violent take over of Third World resources and Third World markets that created wealth in the North - but it simultaneously created poverty in the South.

Two economic myths facilitate a separation between two intimately linked processes: the growth of affluence and the growth of poverty. Firstly, growth is viewed only as growth of capital. What goes unperceived is the destruction in nature and in people's sustenance economy that this growth creates. The two simultaneously created 'externalities' of growth - environmental destruction and poverty creation - are then casually linked, not to the processes of growth, but to each other. Poverty, it is stated, causes environmental destruction. The disease is then offered as a cure: growth will solve the problems of poverty and environmental crisis it has given rise to in the first place. This is the message of Jeffrey Sachs analysis.

The second myth that separates affluence from poverty, is the assumption that if you produce what you consume, you do not produce. This is the basis on which the production boundary is drawn for national accounting that measures economic growth. Both myths contribute to the mystification of growth and consumerism, but they also hide the real processes that create poverty.

First, the market economy dominated by capital is not the only economy, development has, however, been based on the growth of the market economy. The invisible costs of development have been the destruction of two other economies: nature's processes and people's survival. The ignorance or neglect of these two vital economies is the reason why development has posed a threat of ecological destruction and a threat to human survival, both of which, however, have remained 'hidden negative externalities' of the development process.

Instead of being seen as results of exclusion, they are presented as "those left behind". Instead of being viewed as those who suffer the worst burden of unjust growth in the form of poverty, they are false presented as those not touched by growth. This false separation of processes that create affluence from those that create poverty is at the core of Jeffrey Sachs analysis. His recipes will therefore aggravated and deepen poverty instead of ending it.

Trade and exchange of goods and services have always existed in human societies, but these were subjected to nature's and people's economies. The elevation of the domain of the market and man-made capital to the position of the highest organizing principle for societies has led to the neglect and destruction of the other two organizing principles - ecology and survival - which maintain and sustain life in nature and society.

Modern economies and concepts of development cover only a negligible part of the history of human interaction with nature. For centuries, principles of sustenance have given human societies the material basis of survival by deriving livelihoods directly from nature through self-provisioning mechanisms. Limits in nature have been respected and have guided the limits of human consumption. In most countries of the South large numbers of people continue to derive their sustenance in the survival economy which remains invisible to market-oriented development.

All people in all societies depend on nature's economy for survival. When the organizing principle for society's relationship with nature is sustenance, nature exists as a commons. It becomes a resource when profits and accumulation become the organizing principle for society's relationship with nature is sustenance, nature exists as a commons. It becomes a resource when profits and accumulation become the organizing principles and create an imperative for the exploitation of resources for the market.

Without clean water, fertile soils and crop and plant genetic diversity, human survival is not possible. These commons have been destroyed by economic development, resulting in the creation of a new contradiction between the economy of natural processes and the survival economy, because those people deprived of their traditional land and means of survival by development are forced to survive on an increasingly eroded nature.

People do not die for lack of incomes. They die for lack of access to resources. Here too Jeffrey Sacks is wrong when he says, "In a world of plenty, 1 billion people are so poor, their lives are in danger". The indigenous people in the Amazon, the mountain communities in the Himalaya, peasants whose land has not been appropriated and whose water and biodiversity has not been destroyed by debt creating industrial agriculture are ecologically rich, even though they do not earn a dollar a day.

On the other hand, even at five dollars a day, people are poor if they have to buy their basic needs at high prices. Indian peasants who have been made poor and pushed into debt over the past decade to create markets for costly seeds and agrichemicals through economic globalisation are ending their lives in thousands.

When seeds are patented and peasants will pay $1 trillion in royalties, they will be $1 trillion poorer. Patents on medicines increase costs of AIDS drugs from $200 to $20,000, and Cancer drugs from $2,400 to $36,000 for a year's treatment. When water is privatized, and global corporations make $1 trillion from commodification of water, the poor are poorer by $1 trillion.

The movements against economic globalisation and maldevelopment are movements to end poverty by ending the exclusions, injustices and ecological non-sustainability that are the root causes of poverty.

The $50 billion of "aid" North to South is a tenth of $500 billion flow South to North as interest payments and other unjust mechanisms in the global economy imposed by World Bank, IMF. With privatization of essential services and an unfair globalisation imposed through W.T.O, the poor are being made poorer.

Indian peasants are loosing $26 billion annually just in falling farm prices because of dumping and trade liberalization. As a result of unfair, unjust globalisation, which is leading to corporate, take over of food and water. More than $5 trillion will be transferred from poor people to rich countries just for food and water. The poor are financing the rich. If we are serious about ending poverty, we have to be serious about ending the unjust and violent systems for wealth creation which create poverty by robbing the poor of their resources, livelihoods and incomes.

Jeffrey Sachs deliberately ignores this "taking", and only addresses "giving", which is a mere 0.1% of the "taking" by the North. Ending poverty is more a matter of taking less than giving an insignificant amount more. Making poverty history needs getting the history of poverty right And Sachs has got it completely wrong.

Women and HIV/AIDS in Africa

* Text of a speech by Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, delivered at the University of Pennsylvania's Summit on Global Issues in Women's Health, Philadelphia, April 26, 2005

I well realize that this is a conference on women's global health, and everything I'm about to say will apply to that generic definition. But the more I thought of the subject matter, the more I want to use HIV/AIDS in Africa as a surrogate for every international issue of women's health, partly because it's what I know best; partly because it's an accurate reflection of reality.

I've been in the Envoy role for four years. Things are changing in an incremental, if painfully glacial way. It's now possible to feel merely catastrophic rather than apocalyptic. Initiatives on treatment, resources, training, capacity, infrastructure and prevention are underway. But one factor is largely impervious to change: the situation of women. On the ground, where it counts, where the wily words confront reality, the lives of women are as mercilessly desperate as they have always been in the last twenty plus years of the pandemic.

Just a few weeks ago, I was in Zambia, visiting a district well outside of Lusaka. We were taken to a rural village to see an "income generating project" run by a group of Women Living With AIDS. They were gathered under a large banner proclaiming their identity, some fifteen or twenty women, all living with the virus, all looking after orphans. They were standing proudly beside the income generating project ... a bountiful cabbage patch. After they had spoken volubly and eloquently about their needs and the needs of their children (as always, hunger led the litany), I asked about the cabbages. I assumed it supplemented their diet? Yes, they chorused. And you sell the surplus at market? An energetic nodding of heads. And I take it you make a profit? Yes again. What do you do with the profit? And this time there was an almost quizzical response as if to say what kind of ridiculous question is that ... surely you knew the answer before you asked: "We buy coffins of course; we never have enough coffins".

It's at moments like that when I feel the world has gone mad. That's no existential spasm on my part. I simply don't know how otherwise to characterize what we're doing to half of humankind.

I want to remind you that it took until the Bangkok AIDS conference in 2004 - more than twenty years into the pandemic - before the definitive report from UNAIDS disaggregated the statistics and commented, extensively, upon the devastating vulnerability of women. The phrase "AIDS has a woman's face" actually gained currency at the AIDS conference in Barcelona two years earlier, in 2002, and even then it was years late. Perhaps we should stop using it now as though it has a revelatory dimension. The women of Africa have always known whose face it is that's withered and aching from the virus.

I want to remind you that when the Millennium Development Goals were launched, there was no goal on sexual and reproductive health. How was that possible? Everyone is now scrambling to find a way to make sexual and reproductive health fit comfortably into HIV/AIDS or women's empowerment or maternal mortality. But it surely should have had a category, a goal, of its own. Interestingly, the primacy of women is rescued (albeit there's still no goal) in the Millennium Project document, authored by Jeffrey Sachs.

And while mentioning maternal mortality, allow me to point out that this issue has been haunting the lives of women for generations. I can remember back in the late 90s, when I was overseeing the publication of State of the World's Children for UNICEF, and we did a major piece on maternal mortality and realized that the same number of annual deaths - between 500 and 600 hundred thousand - had not changed for twenty years. And now it's thirty years. You can bet that if there was something called paternal mortality, the numbers wouldn't be frozen in time for three decades.

I want to remind you that within the UN system, there's something called the Task Force on Women and AIDS in Southern Africa. Permit me to tell you how it came about, and where it appears to be headed ... and I beg you to see this as descriptive rather than self-indulgent.

In January of 2003, I traveled with the Executive Director of the World Food Programme, James Morris, to four African countries beset by a combination of famine and AIDS: Zimbabwe, Zambia, Malawi and Lesotho. We had surmised, at the outset, that we would be dealing primarily with drought and erratic rainfall, but in the field it became apparent that to a devastating extent, agricultural productivity and household food security were being clobbered by AIDS. We were shocked by the human toll, the numbers of orphans, and the pervasive death amongst the female population. In fact, so distressed were we about the decimation of women, that we appealed to the Secretary-General of the United Nations to personally intervene.

And he did. He summoned a high level meeting on the 38th floor of the UN Secretariat, with TV conferencing outreach to James Morris in Rome and to the various UN agencies in Geneva, and after several agitated interventions, the Secretary-General struck a Task Force on Gender and AIDS in Southern Africa, to be chaired by Carol Bellamy of UNICEF.

If memory serves me, Carol Bellamy determined to focus on seven of the highest prevalence rate countries: studies were done, recommendations were made, costs of implementation were estimated, monographs were published. And here's what festers in the craw: the funding for implementation is not yet available. The needs and rights of women never command singular urgency.

There's an odd footnote to this. Within the last two months, a number of senior students at the University of Toronto Law School, compiled papers dealing with potential legal interventions on a number of issues related to HIV/AIDS in Africa. One of the issues was, predictably, gender. Not a single student, over the course of several weeks, whether on the internet or wider personal reading, came across the Secretary-General's Task Force (although one student said that she had a vague recollection that such a thing existed). The Task Force findings are clearly not something the UN promotes with messianic fervour.

I want to remind you that as recently as March, there was tabled, internationally, the Commission on Africa, chaired by Prime Minister Tony Blair ... indeed established by Tony Blair. It has received nothing but accolades, particularly for the analysis and recommendations on Official Development Assistance, on trade and on debt. The tributes are deserved. The document goes further down a progressive road than any other contemporary international compilation.

With one exception. I want it to be known - because it's not known - that the one aspect of this prestigious report which fails, lamentably, is the way in which it deals with women. There is the occasional obligatory paragraph which signals that the Commission recognizes that there are two sexes in the world, but by and large, given that women are absolutely central to the very integrity and survival of the African continent, they are dealt with as they are always dealt with in these auspicious studies: at the margins, in passing, pro forma. And it's not just HIV/AIDS; it's everything, from trade to agriculture to conflict to peace-building.

Maybe we should have guessed what was coming when there were only three women appointed out of seventeen commissioners. They had the whole world to choose from, and they could find only three women ... it doesn't even begin to meet the Beijing minimum target of thirty percent. We're not just climbing uphill; we might as well be facing the Himalayas.

I want to remind you, finally, of the arrangements we've made within the United Nations itself. HIV/AIDS is the worst plague this world is facing; it wrecks havoc on women and girls, and within the multilateral system, best-placed to confront the pandemic, we have absolutely no agency of power to promote women's development, to offer advice and technical assistance to governments on their behalf, and to oversee programmes, as well as representing the rights of women. We have no agency of authority to intervene on behalf of half the human race. Despite the mantra of 'Women's Rights are Human Rights', intoned at the International Conference on Human Rights in Vienna in 1993; despite the pugnacious assertion of the rights of women advanced at the Cairo International conference in 1994; despite the Beijing Conference on women in 1995; despite the existence of the Convention on the Elimination of Discrimination against Women, now ratified by over 150 countries; we have only UNIFEM, the UN Development Fund for Women, with an annual core budget in the vicinity of $20 million dollars, to represent the women of the world. There are several UNICEF offices in individual developing countries where the annual budget is greater than that of UNIFEM.

More, UNIFEM isn't even a free-standing entity. It's a department of the UNDP (the United Nations Development Programme). Its Executive Director ranks lower in grade than over a dozen of her colleagues within UNDP, and lower in rank than the vast majority of the Secretary-General's Special Representatives.

More still, because UNIFEM is so marginalized, there's nobody to represent women adequately on the group of co-sponsors convened by UNAIDS. You see, UNAIDS is a coordinating body: it coordinates the AIDS activities of UNICEF, UNDP, the World Bank, UNESCO, UNFPA, WHO, UNDCP (the Drug Agency), ILO and WFP. UNIFEM asked to be a co-sponsor, but it was denied that privilege.

So who, I ask, speaks for women at the heart of the pandemic? Well, UNFPA in part. And UNICEF, in part (a smaller part). And ostensibly UNDP (although from my observations in the field, "ostensible" is the operative word).

Let me be clear: what we have here is the most ferocious assault ever made by a communicable disease on women's health, and there is just no concerted coalition of forces to go to the barricades on women's behalf. We do have the Global Coalition on Women and AIDS, launched almost by way of desperation, by some international women leaders ... like Mary Robinson, like Geeta Rao Gupta, but they're struggling for significant sustainable funding, and their presence on the ground is inevitably peripheral.

I was listening to the presentations at the dinner last night, and thinking to myself, when in heaven's name does it end? Obstetric fistula causes such awful misery, and isn't it symptomatic that one of the largest - perhaps the largest -contributions to addressing this appalling condition has come not from a government but from Oprah Winfrey?

I was noting, just in the last 48 hours, that Save the Children in the UK has released a report pointing out that fully half of the three hundred thousand child soldiers in the world are girls. And if that isn't a maiming of health - in this case emotional and psychological health - then I don't know what is. And perhaps you notice the rancid irony: women have achieved parity on the receiving end of conflict and AIDS, but nowhere else.

Female genital mutilation, the contagion of violence against women, sexual violence in particular, rape as a weapon of war - Rwanda, Darfur, Northern Uganda, Eastern Congo - marital rape, child defilement, as it is called in Zambia, sexual trafficking, maternal mortality, early marriage ... I pause to point out that studies now show that in parts of Africa, the prevalence rates of HIV in marriage are often higher than they are for sexually active single women in the surrounding community; who would have thought that possible? ...

The overall subject matters you're tackling at this conference strike to the heart of the human condition. All my adult life I have accepted the feminist analysis of male power and authority. But perhaps because of an acute naiveté, I never imagined that the analysis would be overwhelmed by the objective historical realities. Of course the women's movement has had great successes, but the contemporary global struggle to secure women's health seems to me to be a challenge of almost insuperable dimension.

And because I believe that, and because I see the evidence month after month, week after week, day after day, in the unremitting carnage of women and AIDS - God it tears the heart from the body ... I just don't know how to convey it ... these young young women, who crave so desperately to live, who suddenly face a pox, a scourge which tears their life from them before they have a life ... who can't even get treatment because the men are first in line, or the treatment rolls out at such a paralytic snail's pace ... who are part of the 90% of pregnant women who have no access to the prevention of Mother to Child Transmission and so their infants are born positive ... who carry the entire burden of care even while they're sick, tending to the family, carrying the water, tilling the fields, looking after the orphans .... the women who lose their property, and have no inheritance rights, and no legal or jurisprudential infrastructure which will guarantee those rights .... no criminal code which will stop the violence ... because I have observed all of that, and have observed it for four years, and am driven to distraction by the recognition that it will continue, I want a kind of revolution in the world's response, not another stab at institutional reform, but a virtual revolution.

Let me, therefore, put before the conference, two quite pragmatic responses which will make a world of difference to women, and then a much more fundamental proposal.

Many at the conference will not know this, but the Kingdom of Swaziland recently made history when it received from the Global Fund on AIDS, Tuberculosis and Malaria, money to pay a stipend - modest of course, but of huge impact - to ten thousand caregivers, looking after orphans, the vast majority being women. The Swaziland National AIDS Commission (that may not be the precise name), reeling from the exploding orphan population, made the proposal for payment to the Global Fund, and it swept through the review process with nary a word. The amount is roughly $30/month, or a dollar a day .... not a lot to be sure, but clearly enough to make a great difference.

My recommendation is that this conference orchestrate the writing of a letter, to be signed by people like Mary Robinson, Geeta Rao Gupta, and prominent women from academia, and have that letter sent to every African Head of State and Minister of Health, urging them to ask for compensation for caregivers, using the Swaziland precedent.

And the second pragmatic proposal? I would recommend, with every fibre of persuasion at my command, that the conference collaborate directly with the International Partnership on Microbicides, whose remarkably effective Executive Director, Dr. Zeda Rosenberg, will be here on campus on Thursday. She will tell you what she needs and how to go about getting it. The prospect of a microbicide, in the form of a gel or cream or ring, which will prevent infection, while permitting conception - the partner need not even know of its presence - can save the lives of millions of women. The head of UNAIDS, Dr. Peter Piot, who will be known to many of you, recently suggested that the discovery of a microbicide may be only three to four years off. That's almost miraculous: short of a vaccine - and we must never stop the indefatigable hunt for a vaccine - a microbicide can transform the lives of women, and dramatically reduce their disproportionate vulnerability. What's needed is science and money. You can help with both.

On the more fundamental front, I want to suggest that the process of UN reform, now urgently underway, be confronted with arguments that spare no impatience.

I have heard the President of Botswana use the word extermination when he described what the country is battling. I have heard the Prime Minister of Lesotho use the word annihilation when he described what the country is battling. I sat with the President of Zambia and members of his cabinet not long ago, when he used the word holocaust to describe what the country is battling.

The words are true; there's no hyperbole. The words apply, overwhelmingly, to women. That being the case, there has to be a proportionate response. It seems to me that the response should proceed on two simultaneous fronts.

First, let me say that I was thrilled by the suggestion from Mary Robinson, and others, that Penn State act as a kind of coordinator for the surprising numbers of initiatives, unrelated one to the other, occurring under the auspices of many universities. The practice of twinning, the practice of using various Faculties as training centres, the practice of American and Canadian universities bridging the gap in capacity until the developing country can take over ... all of that is to the good, and it needs coordination. But there's more, I would submit, for you to do. Within multilateralism, that is within the UN system, wherein lies the best hope for leadership, there must be a change in the representation of women. There must emerge, for Women's Global Health, and certainly for HIV/AIDS, an agency, an organization, a powerful Think Tank, whatever the entity --- it can start on the outside, and then claim equal presence amongst the co-sponsors of UNAIDS, and thrust its advocacy upon the Secretariat, the Agencies, the member states, in unprecedented volume and urgency. Nor does this entity confine itself solely to women's global health, although that is the entry point. It insists on the 50% rule ... just start your evidence-gathering by identifying the numbers of senior women, agency by agency, secretariat department by secretariat department, diplomatic mission by diplomatic mission, and when you've recovered from the shock of learning that the multilateral citadel knows nothing of affirmative action, then begin your unrelenting advocacy. This must become a movement for social change. It needs leadership. Why not this University, why not this conference? And let me emphasize; there's nothing limiting about this concept. We're looking towards the day when governments are finally made to understand that women constitute half of everything that affects humankind, and must therefore be engaged in absolutely everything. Why would it not be possible to build a movement, committed to the rights of women, in the first instance amongst nursing and medical faculties across the world, and take the world by storm? You have resources, knowledge and influence available to no others. The terrible problem is that you've never marshalled your collective capacities.

Second, a similar movement must be directed, I would submit, to Africa itself. I'm hesitant here, because there are enough neo-colonial impulses around without my being presumptuous in making recommendations for Africa, and indeed for women. But I must bring myself to say what I know to be true: the African leadership, at the highest level, is not engaged when it comes to women's health. There's so much lip service; there's so much patronizing gobble-de-gook. The political leadership of Africa has to be lobbied with an almost maniacal intensity on the issues of this conference, or nothing will change for women.

That, too, will take a monumental effort. In my fantasies, I see a group of African women, moving country to country, President to President, identifying violations of women's health specific to that country, and demanding a change so profound that it shakes to the root the gender relationships of the society. I know that African women leaders like Wangari Matthai and Graça Machel and many prominent cabinet ministers, committed activists and professionals think in those terms; what is needed is a massive outpouring of international support from their sisters and brothers on the planet.

I'm 67 years old. I'm a man. I've spent time in politics, diplomacy and multilateralism. I know a little of how this man's world works, but I still find much of it inexplicable. I don't really care anymore about whom I might offend or what line I cross: that's what's useful about inching into one's dotage.

I know only that this world is off its rocker when it comes to women. I must admit that I live in such a state of perpetual rage at what I see happening to women in the pandemic, that I would like to throttle those responsible, those who've waited so unendurably long to act, those who can find infinite resources for war but never sufficient resources to ameliorate the human condition.

I'm excited of course about the Millennium Development Goals, and I'm equally excited that with the leadership of the British, this next G8 Summit in the summer might just possibly spawn a breakthrough. And there are countless numbers of people working to that end.

But I have to say that I can't get the images of women I've met, unbearably ill, out of my mind. And I don't have it in me either to forgive or to forget. I have it in me only to join with all of you in the greatest liberation struggle there is: the struggle on behalf of the women of the world.

Equity in Health Research and the “10/90 Gap” in Africa: The role of The African Health Research Forum
William M Macharia

Before the Commission on Health Research for Development report (1990) was the International Health meeting at Alma-Ata in 1978 when the existence of major health inequalities experienced by populations living in the developing world were exposed. It was in Alma-Ata where the concept of Primary Health Care for developing countries was proposed as a means of delivering health to all by the year 2000 – now long past.

To give credit where it is due, there were some tangible gains over the years that followed, as demonstrated by improved child and infant mortality rates, higher primary immunization rates, better education of the girl child and higher life expectancy. But poverty levels escalated over the years while the effects of HIV/AIDS turned into a third world health nightmare even as health sector structural adjustment programs ensured access to health care was virtually denied to the most poor thereby reversing the earlier positive trends.

In its landmark report of 1990, “Health Research: Essential Link to Equity in Development”, the Commission on Health Research for Development revealed the major discrepancies that existed in the global distribution of financial resources for health research. An estimated 80% of the global population living in the developing world were found to shoulder 95% of the global disease burden using only 5% of global investments for health research. At the national level, the health sector remained a low priority area to which only 0.1-3% of the GDP was allocated in the annual budgets. Health research was ranked even lower with less than 0.5% of the budget, if any. As a result, about 90% of all national health research funds were from development partners who ended up dictating research agendas in recipient countries. This health and research resources allocation imbalance at national and global levels has not changed much over the years with less than 10% of global spending on health research today still being devoted to diseases or conditions that account for 90% of the global disease burden – the 10/90 Gap (10/90 report 2001/02).

Given this scenario, it was no wonder that the health research agenda in nearly all developing countries, Africa included, was found to be dictated by development partners – “he who pays the piper calls the tune”. In order to positively influence their relationship with development partners, as correctly recommended by the CHRD, developing countries were requested to direct more of their resources into both health and research. The Commission then called on countries to allocate a minimum of 2% of their national health expenditures to research and for all internationally funded health programs to earmark 5% of budgets for health research support.

Credited to the CHRD report, a number of important global initiatives have been put in place since its release. The Commission for Health research and Development (COHRED) was, for example, established in 1993 to promote the concept of Essential National Health Research (ENHR). Also, implementation of the recommendations of an Ad-Hoc committee on health research which were published in 1996 led to the establishment of the Global Forum for Health Research in 1998 with the mandate of monitoring progress of health research in developing countries as well as tracking financial flows to redress existing disparities.

Following its establishment, the Forum has hosted regular annual Global Forum meetings and sustained release of widely disseminated update reports, “The 10/90 Report on Health Research”. The best remembered of all the Forum meetings is probably the International Conference 2000 (IC2000) held at the Shangli-La Hotel in Bangkok. It was at this conference that nations undertook to “take stock” of their accomplishments since the release of the CHRD report a decade earlier.

Findings of an African consultative process that involved 300 key informants from 110 institutions in 18 African countries that took place in preparation of the IC 2000 meeting were disheartening. With very few exceptions like South Africa, health research financing in Africa continued to be characterized by low global expeditures and insignificant national investments. Many countries had still not adopted the concept of Essential National Health Research (ENHR) though promising trends were evident where the concept had been grasped and implemented. In such countries, a “bottom-up” consultative process had been adopted by stakeholders in prioritization of national health problems thus creating a better sense of problem ownership by communities.

Success was however curtailed by inadequate program funding and poor national health research systems. It was also obvious from these consultations that health research was far from being recognized as an effective tool for health action, partly because quality research output and utilization remained low. Collaboration among various stakeholders like researchers, research institutions, institutions of higher learning, service delivery organizations, policy makers and external development partners remained below expectation in nearly all countries visited.

Despite the importance of equity in health care provision and research featuring prominently in both the Alma-Ata and CHRD recommendations, hardly any gains were evident on the ground. Encouragingly however, a number of countries were found to have policies or plans to put some in place. Major disparities in access to health care remain between the rich and the poor, urban and rural, between genders, along age ranges and ethnic lines.

Subsidies allocated to the poor, for example, continued to benefit the rich while marginalized populations were further relegated to the periphery of health care provision. Research on equity in health remained extremely low though necessary for igniting debates on the need for equitable distribution of resources for health. Among other recommendations, participants in the Africa consultative process strongly recommended “that equity be brought to the surface and that research guides the process of not only identifying the disparities but also proposes appropriate responses and helps to monitor progress towards equity”

The Bangkok IC 2000 meeting identified three key challenges for Africa: building appropriate capacities to undertake research, development of effective national research systems and creation of research enabling environments. Establishment of an African Forum to advocate for more attention to research as an essential tool for development was highly recommended as an important point of starting to address the challenges. Besides articulating the African voice on research, it would also catalyze building of coalitions, South-South and North-South linkages, effective regional and global networking as well as acting as a broker for resources for health research.

The African Health Research Forum was launched in November, 2002 at the Global Health Research Forum meeting in Arusha, Tanzania as the result of efforts of a regional steering committee appointed at the IC 2000 meeting. Over the last three years, the Forum has undertaken a regional survey on health research networks, hosted consensus building meetings with representatives of 15 key research networks and other major stakeholders and participated in discussions hosted by WHO/AFRO, NEPAD, and Private-Public Partnership Initiatives among others. The Forum has also been invited to sit in the WHO/AFRO and East Africa Health Research Advisory Council and hopes to continue seeking invitations to other similar regional and sub-regional health research committees in furtherance of the execution of its mandate.

Among other initiatives so far undertaken by the Forum is a Health Research Leadership Training program being pilot-tested with two Anglophone and two Francophone countries. Like the establishment of a regional forum, nurturing of leadership in health research was identified as another crucial tool for advancing health knowledge production and utilization in Africa. This IDRC funded initiative is a collaboration between African Health Research Forum (AfHRF) and the Canadian Global Coalition for Health Research which targets training of mid-career level epidemiologists, social scientists, policy makers and community health care workers using a “team-training” concept. The teams would then be expected to act as national focal points in the advocacy for generation and use of research knowledge for improvement of their people’s health. Although the training is primarily through individual and group learning, two week “institutes” are organized once a year to expose the groups to prominent regional health research leaders and other resource persons as part of the learning process.

Learning emphasis for the teams focuses on the importance of equity, ethics, methodology, team play, management and governance in research. AfHRF is therefore in a unique position not only to advocate for more attention on the hitherto forgotten important area of equity in health research but to also bargain for more national, regional and global health resources to be directed to benefit the more disadvantaged in society. An example of such avenues was the release and dissemination of an AfHRF and the WHO Africa Advisory Committee on Health Research (AACHR) crafted “Voice on Health Research” at the Mexico Health Ministers Summit and the 2004 Global Forum Meeting. Given the emerging important roles that NEPAD initiatives and the United Nations Millennium Health Development Goals are likely to play in the future in Africa, AfHRF will aspire to maintain close links with them with a view to advancing the shared visions of health research stakeholders in Africa.

* Prof William M Macharia (MBChB.,MMed,MSc) is with the African Health Research Forum.

* Please send comments to editor@equinetafrica.org

Abuja 2005: Civil society demands on health and the decisions taken be the AU


Statement by CSOs at the Fourth Ordinary African Union Summit of the Heads of States, 24-31st January 2005, Abuja, Nigeria

Signed by the African Network for the Campaign on Education for All (ANCEFA), African Womens Development and Communications Network (FEMNET), African Centre for Democracy and Human Rights (ACDHR), Center for Democracy and Development (CDD),
Pan African Movement (PAM), Pan African Development Education and Advocacy Programme(PADEAP), West African Students Union (WASU), Womens Rights Advancement and Protection Alternatives (WRAPA), Development Network of Indigenous Voluntary Agencies (DENIVA), Fahamu, ActionAid International, Oxfam GB


The fourth Ordinary African Union Summit of the Heads of States takes place at a time when the consequences of poorly financed and collapsing public health services across the continent can only be described as a public health emergency. Returning to Abuja where four years ago they committed themselves to accelerate the fight against HIV/AIDS, Tuberculosis and other related infectious diseases, it is clear that key obstacles continue to prevent hundreds of millions of Africans from realising the right to health. African Governments and the African Union must reinvigorate the fight against the violation of HIV/AIDS and health related rights.


- African Governments must commit to increasing GDP allocation for health by three per cent each year in order to reach the 2001 Abuja Summit commitments of 15%.
- African government should ensure that treatment of AIDS and infectious diseases is provided free, reaches vulnerable groups and in an accountable manner.
- African Governments, who have to yet ratify the AU Protocol on the Rights of Women, must do so. It is a major instrument in securing the right to health for Africa’s women and girls.
- The African Union Commission must lead on lobbying the G8 in 2005 for debt cancellation and measures from industrialised countries to compensate for the brain drain of African health workers.
- The African Union Commission must lead on lobbying the G8 in 2005 for debt cancellation and securing measures from industrialised countries to compensate for the brain drain of African health workers.
- African Governments must mandate the African Union Commission to champion for enabling laws and policies in member states and a coordinated global advocacy approach towards the WTO Hong Kong Inter-ministerial in December 2005.

Situational analysis

Across our continent the health status of women remains precarious and in many instances, worsening, not only because of HIV but also because of the many unacceptable inequalities that exist in women’s health, the limited choices that are made available to women and finally, the lack of accountability for their health.
- Pascal Mocumbi, Prime Minister, Mozambique, 2003.

The majority of Africa’s 800 million citizens continue to remain locked out of health facilities across the continent. By the time the Summit opens, Africa will have lost 20 million people to the plague of AIDS. Behind them, they would have left 12 million orphans to fend for themselves. While our leaders meet, outside the doors of the Abuja International Conference Centre, 80% of the 40 million people currently living with HIV/AIDs across the world will be struggling to fight a debilitating disease that in some parts of the industrialised world is no longer a killer disease. 55% of these will be women.

By the time the Summit opens on the 24th January, 90 million African women and girls will have been forcibly circumcised or had their genitals mutilated. Between the opening and the closing Summit ceremonies, 77,000 women and girls will have undergone unsafe abortions in countries where restrictive abortion policies ensure that no standards can be maintained or monitored. As a result of this and other factors, a staggering 47/48 sub-Saharan African countries will not meet the goal of reducing maternal mortality and one in ten babies will not survive child birth due to poor and inadequate health infrastructure in Africa.

Yet, this is sadly no longer news in a continent numbed by the domestic stories of neglect, blocked access to life-saving drugs and poverty. What could be news is the scaling up of international and African public resources into expanding access to health-care services.

Expand public financing for health and education

When African Heads of States met in Abuja in April 2001, they correctly declared HIV/AIDS, Tuberculosis (TB), and other related infectious diseases (ORID) as a state of emergency. Recalling and reaffirming their commitment to all relevant decisions, declarations and resolutions in the area of health and development and on HIV/AIDS, particularly the "Lomé Declaration on HIV/AIDS in Africa" (July 2000) and the "Decision on the adoption of the International Partnership against HIV/AIDS" (Algiers 1999) they stated;
“WE COMMIT OURSELVES to take all necessary measures to ensure that the needed resources are made available from all sources and that they are efficiently and effectively utilized. In addition, WE PLEDGE to set a target of allocating at least 15% of our annual budget to the improvement of the health sector.”

Now known as the “Abuja 15% commitment” this target was seen as a critical contribution to the fight against HIVAIDS and other diseases. Shockingly, despite this public commitment, four years on many countries continue to spend less than 10% of the revenue on health. African Governments must commit in this Summit to increasing GDP allocation for health by three per cent each year in order to reach the 2001 Abuja Summit commitments of 15%.

New research published by the Global Campaign for Education and endorsed by UNAIDS, shows that a complete primary education makes a strong and direct impact on HIV infection rates, especially among young women. Girls with a complete primary education are 2.2 times less likely to contract HIV than those with some or no primary education. Education equips young people to understand and apply facts and gives them the status, clout and confidence to avoid unsafe and exploitative relationships. Investing in free primary education for everyone but especially for girls, is one of the most effective and urgently needed measures to fight the epidemic. Investing in secondary education would bring additional benefits. Consequently, the AU needs to give priority to free, universal and compulsory basic education with gender equity, both in its own strategies for development and poverty reduction, as well as in its dialogue with forums such as the G8.

Debt cancellation is pre-requisite for progress

The heavy external debt burden …continues to mortgage African economies and cast a shadow over our People’s’ future. To date, the proposed remedies are ad hoc.
- Secretary General of the Organisation of African Unity, July 2002

A comprehensive AIDS plan for Africa would cost US$10 billion per year, yet African nations spend one and a half times this amount in debt servicing. In many countries, more is spent on debt servicing than on education and health or is received in aid grants and foreign direct investment. For the same money, the global fund against HIV/AIDS, Malaria and Tuberculosis could stop these diseases and provide Anti-Retrovirals (ARVs) for the three million people living with HIV in all developing countries not just Africa.

This absurdity can only be seen from the experience of one country. Tanzania for instance, currently pays US$39 million dollars per annum in debt servicing while receiving only US$27 million in aid. It is revealing to recall that after the second world war, Germany was considered to be harshly penalised for having reparations set at 7% of its exports, yet in 2005 Tanzania is supposed to “adjust” and grow with debt servicing set at 60% of its exports.

Yet, this Summit occurs at a time when momentum has built once more around the necessity for debt cancellation. Several G8 countries have bi-laterally cancelled debts owed by African countries. In February 2005, the G7 Finance Ministers will consider proposals to underwrite debt cancellation by committing additional bi-lateral financing or by re-valuing IMF gold reserves. The benefits of this would be immense. Debt cancellation would enable countries like Ethiopia to expand access by doubling its expenditure on health and thus reaching beyond the 60% who are currently reached by health services.

There is precedence in Africa for successful re-channeling of debt relief into basic social services. At least six countries in Africa offer insight into the possibilities debt cancellation could create. In Benin for example, 54% of HIPIC relief monies was channeled into improving health programmes by recruiting health staff for rural clinics, implementing HIV/AIDS and anti-malarial programmes and improving access to safe water and increasing immunisation. Malawi has been able to allocate a 30% cut in debt servicing per year to enhance their HIV/AIDs health care system. US$1.3 million of debt relief money has been critical to resourcing Uganda’s National HIV/AIDS plan. Cameroon was able to launch a comprehensive national HIV/AIDS strategic plan funded to the tune of US$114 million with help from debt savings. In Niger, a special programme that focuses on rural education, health, food security and water systems has been fully financed through HIPC. This has mainly been used so far in building classrooms and rural clinics. In Burkina Faso, HIPC relief has been spent on health (33%), education (39%) and rural roads (28%).

As Jubilee Zambia coordinator Teza Nchinga notes, "Respect for the basic human rights (food, health care and education) of millions of Zambians should take priority over repayment of debts to comparatively wealthy creditors especially when capital on these debts has already been paid a number of times over." The African Union Commission must lead on behalf of African countries by aggressively demanding debt cancellation from the G8 in 2005. African Governments on the other hand, must follow the example of these six countries who have had re-channeled monies freed up from debt relief into strengthening health systems including the retention of health workers.

Industrialised countries must deliver on their aid commitments

Currently, despite the increases pledged in the UN Financing For Development Conference in Monterrey, rich countries spend half of the foreign assistance they did in 1960. If they were to meet the OECD targets of 0.7% of their GNP this would increase aid levels from US$70 billion to US$190 billion dollars. Yet, only the UK and Spain have set dates to meet these targets. 12 other countries are far from this and do not seem to be in a hurry.

Compared to expenditure on defense or domestic agricultural subsidies, this would be a very small amount. Looked at in terms of the cost to individual taxpayers, it would cost an additional US$80 dollars per person per year or put more simply, the average price of one cup of coffee a week.

G8 countries continue to prioritise aid to countries where they have geo-political interests rather than fighting poverty. Over 2004, America set aside US$ 65 billion dollars for fighting the war in Afghanistan and Iraq. This could have financed the exact annual budget deficit for the entire continent of Africa. Put another way, six months of US funding for the war in Iraq (US$ four billion) could have met the annual budget deficit for the global fund against HIV/AIDS, Malaria and Tuberculosis. Yet increasing aid is only one measure, improving its quality is another. For instance, nearly 30% of aid is tied to goods and services from donor countries. In the case of the US, this figure is as high as 70%.

The quality of foreign assistance also continues to be undermined by IMF and World Bank fiscal and macro-economic models, which act to constrain expenditure on basic social services. In a study of twenty Poverty Reduction Strategies, sixteen were found to contain fiscal targets for inflation and the budgetary envelope that had not been subjected to public discussion. They were targets that had been established by the World Bank or the IMF. Last year for instance, Ethiopian and Tanzanian Governments will have to meet 85 and 78 policy conditions respectively.

The AU clearly sees itself providing leadership, monitoring states performance and accountability, advocacy with states and beyond, setting up standards, harnessing new continental initiatives, and as a knowledge hub. This clear emphasis on harmonising the plethora of new initiatives and monies that are offered for flooding Africa and which are, in many cases, confusing national plans and programmes, is welcome.

To this end, the AU must challenge the proliferation of uncoordinated initiatives such as the US PEPFAR Presidential Initiative. Bilateral initiatives such as PEPFAR may reinforce donor-driven approaches, increase the administrative burdens of recipient countries and drain resources away from existing, experienced, multilateral initiatives. Such initiatives create parallel systems where the national government using inexpensive generic fixed dose combinations and that of PEPFAR using expensive brand names. This leads to confusion of both patients and health providers.

The African Union must take a more vigorous lead in engaging the international community to deliver the Monterrey promises and improve the volume and quality of foreign assistance to Africa. It is vital that donors’ initiatives and programmes should implement nationally defined policies especially regarding access to medicines.

Improving Access to Care and Support

The major challenge facing the people living with AIDS and people affected by AIDS is the issue of access to treatment and care. The World Health Organization (WHO) in December 2003 came up with an initiative to treat three million people by 2005. This is believed to be approximately half of the estimated six million people in dire need of antiretroviral therapy. This is the popular 3 by 5.

Despite the fact that some African governments have subsidized distribution programmes, less than 1% of Africans in need of ARV treatment had access to ARVs, compared to 85% in developed countries in 2004. South Africa has committed to providing free treatment to 53,000 people by March 2004. This is a fraction of South Africa's HIV positive population, estimated to be over five million. The Nigerian government began a treatment programme to provide ARVs for 10,000 people in November 2002. At a conservatively estimated number of 3 million people living with HIV&AIDS in Nigeria in 2004, this is quite clearly inadequate.

Access to ARVs is also determined by power within and between households. Findings from CSO participatory research studies in Zambia and Nigeria suggest that intra-household power relations conspire to constrain women’s access to ARVs. Women in Zambia have a disproportionate access to ARVs (30%) despite comprising of 50% of the population. In January 2004, less than 30% of people who had access to ARVs were women in Zambia. In many families who cannot afford to have more than one person on ARV, it is the male head of household that is chosen. At another level, scanty or total ignorance of prevalent diseases, the weak bargaining position of women and the pervasive cultural endorsement of male liberty to have free and multiple sexual relationships (in and out of marriage) has escalated the distributive impact of STDs and led to the high prevalence of HIV/AIDS across communities all over Africa.

In many countries across Africa the right to health is not enshrined in either the constitution or laws. It is in this context that the African Union Protocol on Women’s Rights and in particular the provisions in articles 14 and 15 significantly contribute to grounding the obligations of Governments. Yet, despite encouragement by the African Union Commission under the leadership of President Konare and civil society campaigning, only seven Governments have ratified the Protocol, a further 33 have signed but not ratified. To this end, African Governments who have not yet done so must re-commit to ratify with urgency, the AU Protocol on the Rights of Women, as a major instrument in securing the right to health for Africa’s women and girls.

Class equities also affect the distribution of ARVs. Interviewed recently, a 29 year old father of three kids in Nigeria said;

“The ARV that come to the center are not given to those of us who have come out to declare our status, but to those BIG men who bribe their way through and we are left to suffer and scout round for the drug. “

Attempts to bring down the costs of ARVs are obviously the way forward. In Nigeria, Malawi and Zimbabwe, tariffs on essential drugs have been removed. The Governments of Zambia and Mozambique have issued compulsory licensing for ARVs for their treatment programmes. Zimbabwe has also allocated precious foreign currency to a local company to manufacture generic ARVs, and is currently running trials on AZT at two of its largest hospitals. However, Zimbabwe’s lack of foreign currency has made it difficult to secure an adequate supply of drugs. In Kenya and Malawi also many public hospitals have no drugs for treatment of HIV/AIDS-related infections.

Access to essential medicines rests on African countries being able to domestically produce or source cheap drugs from southern based generic drugs industries. The AU should consider initiating dialogue with WHO, UNCTAD and the EC to explore the feasibility of establishing African centers of excellence in the producing of high quality local production of medicine especially ARVs. African states should be encouraged to influence both public and private health service providers to dispel misinformation about generic drugs being inferior to brand products, eliminate the costs of ARVs to users and actively target the rural poor with special emphasis on gender equity. Key to this will be the replication of policies that cut taxes and tariffs and promote price regulation to countries that have not already done so.

We welcome existing plans for a continental conference on the rights of people with HIV/AIDS to raise the profile of rights abuses and to chart a new chapter in the evolution of national laws and standards consistent with the spirit of the African Charter of Human and Peoples Rights. We call on the AU Commission to extend an invitation to People with AIDS organizations and networks across the continent to help design this process.

African Governments must mandate the African Union Commission to champion for enabling laws and policies in member states and a coordinated global advocacy approach towards the WTO Hong Kong Inter-ministerial in December 2005. The AU must ensure that new trade agreements especially Trade Related Aspects on Intellectual Property Rights (TRIPS), bilateral and regional trade agreements do not undermine access to medicines in Africa.

The absence of effective conditions to fight HIV/AIDS and other infectious diseases such as malaria, tuberculosis and polio conditions and poor remuneration of African health workers has led to an exodus of trained health personnel. Calculating the cost of training, every doctor that leaves the continent costs Africa US$60,000. This results in a staggering subsidy to G8 countries of US$500 million every year just for health personnel.

To increase access to medicines African governments should redirect aid and debt money towards investing in basic health services including retention of health workers. Donors’ initiatives should follow national medicines policies especially using inexpensive generic fixed dose combinations. The AU should advocate with states, donors and the pharmaceutical industry to decrease the prices of second line treatment for HIV.


As African Governments meet once again in Abuja, they must embrace the opportunity of an invigorated African Union Commission to turn words into further deeds and directly confront the state of emergency. The temptation to simply re-affirm the 2001 Abuja Declaration must be avoided in order for the costs of this Summit to be justified. Increasing domestic resourcing, improving the quality of health programmes particularly to rural communities and delivery on debt cancellation are key to preventing hundreds of millions of Africans from being denied the right to health.


- African Governments must commit to increasing GDP allocation for health by three per cent each year in order to reach the 2001 Abuja Summit commitments of 15%.
- African government should ensure that treatment of AIDS and infectious diseases is provided free, reaches vulnerable groups and in an accountable manner.
- African Governments, who have yet to ratify the AU Protocol on the Rights of Women, must do so. It is a major instrument in securing the right to health for Africa’s women and girls.
- The African Union Commission must lead on lobbying the G8 in 2005 for debt cancellation and measures from industrialised countries to compensate for the brain drain of African health workers and stop recruiting more workers.
- African Governments must prioritise monies saved by debt relief for strengthening health systems that ensure the retention of health workers.
- African Governments must mandate the African Union Commission to champion for enabling laws and policies in member states and a coordinated global advocacy approach towards the WTO Hong Kong Inter-ministerial in December 2005.

* Useful Reading Materials
- African Union, Report of the African Summit on HIV/AIDS, Tuberculosis, and other related infectious diseases. Abuja Nigeria, April 2004
- African Union, HIV/AIDS Strategy 2005-2007
- ActionAid International, Responding to HIV/AIDS in Africa, a comparative analysis of responses to the Abuja Declaration in Kenya, Malawi, Nigeria & Zimbabwe, June 2004
- ActionAid International, 3 by 5: Ensuring HIV/AIDS Care for All. June 2004
- Fahamu/SOAWR, Pambazuka News 190: Special Issue on the Protocol on the Rights of Women in Africa: A pre-condition for health & food security, January 2005
- Oxfam International, Paying the Price, January 2005

Compiled By: Eve Odete, Pan Africa Policy Officer, Oxfam GB
Summary of Decisions of the African Union Fourth Ordinary Summit, Abuja, Nigeria Jan 2005

Key Meetings

Assembly of the African Union, Fourth Ordinary Session
30-31 January 2005
Assembly /AU/Dec.55-72 (IV)
Assembly/ AU/ Dec. 1-2 (IV)
Decisions and Declarations

Executive Council
Sixth Ordinary Session, 24-28 January 2005
EX. CL/Dec. 165-191 (VI)
EX. CL//Rapt/ Rpt (VI)
Rapporteur’s Report of the Sixth Ordinary Session
Of the Executive Council

Permanent Representatives Committee
Ninth Ordinary Session

PRC/Rpt (1X)
Report of the Ninth Ordinary Session of the Permanent Representatives’ Committee

Rationale for this compilation and the policy cycle it documents

This summary has been prepared for policy analysts working for Oxfam, international, continental and regional networks and allies to inform us on the key deliberations and decisions of the most important decision-making organ of the African Union. It captures key decisions, upcoming dates and opportunities for continental policy development.

The sequence of the Summits is as follows; one week of intense meetings starting with the Permanent Representatives Council (Addis based Ambassadors), Council of Ministers (National Ministers) and the Assembly itself (Heads of States). While the Assembly is the supreme decision making body, the discussions from Ambassador level are important to understand the issues being prioritized and deliberated. Opportunities for policy influencing decrease as the meetings go on. Indeed, even lobbying space becomes more difficult to secure particularly with the Commissioners.

1. Health and HIV/AIDS

Permanent Representatives Committee
Ninth Ordinary Session
PRC/Rpt (1X)

On HIV/AIDS, tuberculosis, malaria and other related infectious diseases, the PRC observed;

The need for Africa to take the lead in Trade Related Intellectual Property Rights (TRIPS) negotiations to promote access to affordable generic drugs - Africa has to plan properly for dialogue at TRIPs negotiations and other fora;

Assembly of the Africa Union
Fourth Ordinary Session
Decisions and Declarations

Assembly/ AU /Dec. 55 (1V)

CALLS UPON the international community, especially the rich industrialized countries,
to fully fund the Global Fund in line with previous commitments made in this regard, and taking into account the magnitude of the health emergency presented by these diseases in Africa;

URGES Member States to:
Take the lead in TRIPs negotiations and in implementing measures identified for promoting access to affordable generic drugs;
Ensure that every child receives polio immunization in 2005;
Prepare inter-ministerial costed development and deployment plans to address the Human Resources for Health crisis;
Prepare health literacy strategies to achieve an energized continent-wide health promotion endeavour;

URGES Member States to intensify efforts towards more effective and well-coordinated implementation of national programmes to promote health systems development as well as improve access to prevention, treatment, care and support; along the “Three ones initiative”; the “3 by 5 Strategy” and Global “Child Survival Partnership”;

RESOLVES to take all the necessary measures to produce with the support of the international community, quality generic drugs in Africa, supporting industrial development and making full use of the flexibility in international trade law and; REQUESTS the AU Commission within the framework of NEPAD to lead the development of a Pharmaceutical Manufacturing Plan for Africa;

CALLS UPON the International Community to match the US$19 billion gap in health financing which the WHO has determined that Africa is not in a position to self finance;

2. Trade

Permanent Representatives Committee
Ninth Ordinary Session
PRC/Rpt (1X)

On on-going WTO negotiations the Commissioner for Trade and Industry

highlighted the need for Africa to send a strong political message to the international community to find a solution to the cotton initiative which affects more than 10 million African producers living below the poverty line. She further pointed out the issue of the unfair behaviour of the Northern countries with regard to agricultural subsidies and the need to lay emphasis in the political message on the importance for Africa to meet food security objectives, rural development and poverty reduction. In conclusion, she stressed the need for the African Group to maintain solidarity and unity with the G90 on issues of substance within the WTO.

The PRC recognized the importance of the WTO negotiations for the socio-economic development of Africa and emphasized the need for capacity building in Member States and RECs and for better coordination of efforts among New York, Geneva, Brussels, African Groups and the AU Commission in Addis Ababa. It agreed with the recommendation for a fast-track approach to the cotton issue while emphasizing the need to come up with a common position on cotton, springing from the outcome of the recently held Bamako meeting. It further called for the document to be enriched with more information on the roadmaps finalized in Geneva and the reaction of the RECs on the issue as well as with the outcome of the Bamako meeting on cotton. It highlighted the importance of coming out with concrete proposals on the issue of Special and Differential Treatment; on the possibility for African countries to have access to required drugs for public health inclusion in national legislations as decided by the WTO Council. The PRC also emphasized the need to pursue the proposal for support to cotton producers in their exports and for the creation of a fund to compensate losses. In this regard, the PRC also called for other commodities to be part of the list of tradable goods for negotiations at the WTO.
It also called for a meeting on services in order to deal with African concerns in that sector. It recommended that, in addition to other partners, the expertise of ECA should be tapped for capacity building purposes. The PRC recommended that the AU Commission take the necessary measures to implement the proposal to send a strong political message to the international community to fast track negotiations on the cotton issue.

On Negotiations of the Economic Partnership Agreements:

The Commissioner recalled the provisions of the Cotonou Partnership Agreement (CPA) which aim at making EPAs, instruments for the promotion of rapid and sustainable development, the eradication of poverty and the smooth and gradual integration of Africa into the global economy. She quoted in particular Article 37.3 which provides for the strengthening of capacity in the public and private sector during the preparatory phase through measures that increase competitiveness and support regional integration initiatives such as assistance to budgetary adjustment and reform, infrastructure development and investment promotion. She added that the first phase of negotiations was not sanctioned by a formal agreement and that all 48 ACP African countries had embarked on the second phase within four groupings without any country expressing desire to remain outside the process. She then drew the attention of the Committee on the major challenges involved in the negotiations for African countries as raised by the RECs during the first meeting of the coordination mechanism between the AU and the RECs. These are: (i) geographical configuration of the EPAs, (ii) the issue of compatibility between WTO and EPA Rules; (iii) the reciprocal relationship between the EU and ACP countries given the gap between their levels of development, (iv) the imbalance in the present multilateral trading system, (v) the heavy procedures of access to EDF resources and additional resources to African countries to face direct and indirect adjustment costs.

She stressed the fact that, although EPAs were about to enter into force in three years’ time, the provisions of Article 37.3 were still not implemented. In this regard, she highlighted the need for RECs to remain united and proposed that Council calls on the EU to allow the AU Commission as an integration Organisation to access EDF resources for the implementation of the NEPAD programme.

The PRC expressed concern about the geographical configuration for the negotiation of EPAs which does not coincide with the RECs as organised within the AU. It called for the AU to develop capacity for the coordination of EPA negotiations to ensure that Africa speaks with one voice although EPAs divide Africa into RECs/negotiating groups and that the North African countries are part of the Barcelona process.

On the issue of resources, the PRC pointed out that EU resources were categorised into programmable and non-programmable resources and that the AU not being a party to the CPA was not eligible under the first category but should be able to access the non-programmable resources. In conclusion, the PRC stressed the need for African countries to build capacity not only for market access but above all in order to face supply-side constraints so that they can make good use of whatever agreement they will enter into in 2007.

The Executive Council
Sixth Ordinary Session

Doc. EX.CL/151 (VI)

Decision on WTO negotiations

RECALLS the Doha Ministerial Declaration in which the international community undertook to place the needs and interests of developing countries at the heart of the WTO Work Programme;

COMMENDS the African Group for its efforts aimed at bringing to the Doha Work Programme back on track and for remaining engaged in the WTO negotiations in accordance with the technical guidance and policy framework provided under the Kigali Declaration and Consensus on the post-Cancun Doha Work Programme ;

RECALLS ALSO the outcome of the Special WTO General Council session held in Geneva from 27 July to 1 August 2004;

TAKES NOTE of the July Package adopted by the WTO General Council on 1st August 2001;

RECOMMENDS the speedy adoption of an approach to resolve the cotton issue based on the results of the meeting held in Bamako from 12 to 13 January 2005;

ALSO RECOMMENDS the early consideration of the issue of agricultural subsidies and the adoption of an Africa Common Position on commodities in general;

CALLS UPON the African Group in Geneva to continue to engage fully and actively in the negotiations with a view to achieving a pro-development outcome from the Doha Round;

ALSO CALLS UPON the same to finalise the Tunis roadmap and Work Plan in order to engage collaborative research and capacity building efforts from regional and international organizations on specific areas to enable Africa to positively contribute to the modalities stage of the negotiations leading up to the 6th Session of the WTO Ministerial Conference;

URGES Member States to continue to coordinate efforts both at the technical and political levels with like-minded groups, in particular, the G90;

WELCOMES Egypt’s invitation for a meeting to be held in Cairo, in May 2005, to discuss ways to deal with the challenges facing cotton producing countries in Africa;

REQUESTS the Commission to convene a Ministers of Trade meeting to chart the way forward as far as Africa’s Agenda is concerned.

FURTHER REQUESTS the Commission to report on progress to the 7th Ordinary Session of Council.

Executive Council-Rapporteur’s Report

With regard to the on-going WTO negotiations, Council recommended that special attention should be given by the AU to the crucial issues of agricultural subsidies and commodities, particularly cotton.

Decision on the negotiations of ACP-EU economic Partnership Agreements

COMMENDS the Commission and the RECs for concluding the establishment of an informal Coordination and Information Exchange Mechanism on EPA Negotiations with the European Union (EU) for which the Commission has been entrusted the coordinating role and also for holding the first meeting of the mechanism successfully;

ENDORSES the recommendations of the Commission/RECs meeting and URGES the Commission to:

Develop institutional capacity building programmes for the Commission and the RECs so as to make work synergies viable and reliable and accelerate the integration process in Africa;

Prepare, in close collaboration with the RECs, requests to the European Union and other development partners for financing of projects that will enhance continental integration;

Identify thecommon supporting programmes relative to implementation of EPAs at the level of the RECs;

Mobilize African research institutes, including the ECA, to appraise the adjustment and other costs of EPAs on African economies.

STRONGLY RECOMMENDS that efforts between the Commission and the RECs be further strengthened and coordinated in the second phase of negotiations, especially with regard to priorities and roadmaps set for negotiations so as to ensure that the process of continental integration in Africa is deepened in accordance with the Constitutive Act of the African Union;

WELCOMES the establishment of the Joint AU-EU Monitoring Mechanism whose objective is to ensure, through exchange of information and discussion of key issues, the consistency and coherence of the EPA process with Africa’s plans and aspirations for regional and continental integration and the establishment of a Pan-African Market and the promotion of synergies between the EPA process and ACP-EU cooperation, notably in the context of regional indicative programmes;

URGES the Commission and the EU to operationalise the mechanism in an effective manner so as to ensure that EPAs indeed enhance the regional integration process and development in Africa as well as the building of regional markets through the effective removal of production, supply and trade constraints;

ALSO URGES the EU to grant access to the Commission as an integration organization to EDF resources for projects of a continental nature;

REQUESTS the Commission to report on progress made on the EPA negotiations to the 7th Ordinary Session of Council in July 2005.

Candidature of Hon. Jaya Krishna Cuttaree, Minister of Foreign Affairs, International Trade and Regional Co-operation of Mauritius, to the post of Director General of the World Trade Organization, at elections scheduled to be held in 2005.

3. Food Security

Permanent Representatives Committee
Ninth Ordinary Session
Report (1X)

Follow-up on Maputo, Sirte and Ouagadogou Declarations on Food Security:

The Commissioner concluded by proposing the creation of an African Food Security Committee to serve as a platform of exchange on matters of food security in the continent, and the establishment of an African Union representational office in Rome to coordinate Africa’s food security matters with relevant world bodies mandated with the issue.

Executive Council
Sixth Ordinary Session
Rapporteur’s Report

Follow-up of Maputo, Sirte and Ouagadogou Declarations on Food Security

On the status of food security in Africa, the following observations were made:

A reliable early warning system be established as it constitutes the preferential tool for combating food insecurity – the early warning system should be capable of anticipating the emergence of food crises, taking stock of production and available resources, and monitoring phenomena such as natural disasters (floods; droughts; invasion or outbreak of endemic diseases affecting animals, crops and plants);

Once established, the early warning system together with continued monitoring should be relied on to generate a steady flow of situation reports as this would facilitate the generation and communication of relevant information to Member States and all stakeholders in time for them to take appropriate measures;

Special attention should be given to the Southern Sahelian region as this area constitutes the main locust corridor between the Sahara and the countries further north;

Regional strategic desert control measures should be implemented by the concerned Member states;

There was need to strengthen the capacity of Member States in the area of fighting migratory pests and animal diseases that pose a threat to food security, and in so doing
to make use of recent technological methods in veterinary science and pest control.
Dakar-Agricultural Initiative

The Senegalese delegation informed Council of the holding in Dakar, Senegal from 4 to 5 February 2005, of the Dakar-Agricultural Initiative which would be a Forum at which agricultural issues would be discussed. It indicated that various key figures from Africa and the rest of the world would be taking part in this meeting and, in this regard, invited all countries of the African Union to participate in this Forum.

Meeting of Ministers of Agriculture
The Egyptian delegation highlighted the importance of agriculture for African economies and underscored the need for Africa to meet to discuss strategic issues such as cotton. It informed Council that Egypt was organizing in May 2005 a meeting of African Ministers of Agriculture with the participation of UNCTAD and other institutions to examine the situation and come up with a Common Position for the defence of African agricultural products.

Assembly of the Africa Union: Decisions and Declarations

Assembly /AU/Dec.59 (IV)

NOTES WITH GRAVE CONCERN the serious economic and social impacts of the 2004 desert locust invasion of the Northern, Western and Eastern regions of Africa;

REQUESTS the Commission and Member States to take all necessary measures to implement the Maputo, Sirte and Ouagadougou Declarations and their relevant Plans of Action;


Decision on allocation of 10% national budgetary resources to agriculture and rural development over the next 5 years

REQUESTS the Chairperson of the Commission to define, in collaboration with Member States and the NEPAD Secretariat, the core areas of agriculture and rural development relevant to the 10% allocation adopted in the Maputo Declarations;

CALLS UPON Member States to implement the present Decision in order to improve the financing of agriculture.

Food security, rural development and health equity in Southern Africa
Executive Summary: Equinet Discussion Paper Number 22, produced by Dr Mickey Chopra, University of the Western Cape, South Africa

Up to two-thirds of all Africans in east and southern Africa (ESA) live in rural areas, three-quarters of them living below the poverty line. Agriculture contributes 35% to the southern African regional GDP and 13% of total export earnings. In addition, about 70% of the population of the region depends on agriculture for food, income and employment. The recent widespread food crisis in the region that pushed more than sixteen million people into severe food shortage is further evidence that agriculture and food security still play a fundamental role in determining the development and health of the poorest in the region.

The Regional Network for Equity in Health in Southern Africa (EQUINET) recognising the importance of food security in health equity, commissioned a paper that explores equity concerns around food security and nutrition within the SADC and East Africa region, drawing information from available secondary data. The paper aims to analyse the current food security and nutrition situation in the region and the health and equity issues and policy concerns arising. EQUINET has commissioned this analysis of the determinants of the current situation, and the policy influences that enhance or undermine equity in food security and nutrition, to propose areas for policy and programme engagement and for research and debate by EQUINET.

This paper argues that there are at least five good reasons why food security and nutrition should be given high priority in actions to improve health equity and socio-economic development across the region:

1. Poverty, hunger and under-nutrition are getting worse in ESA, even though they are improving in almost every other region. This undermines the achievement of UN Millenium Development Goals in this region.
2. Instead of the potential virtuous cycle that could be created between improved nutrition and improved economic wellbeing, ESA is currently caught in a vicious cycle of worsening poverty, hunger and under-nutrition accentuating income and health inequalities and increasing vulnerability.
3. Proven effective interventions indicate that public policy can make a difference, that nutritional improvements can be effected, even under conditions of poverty, and that these can have positive impacts on economic wellbeing.
4. Implementing public policies that address food security provides an opportunity to deal with the demands of AIDS, the challenges of the competing signals from global trade to health and development and the challenges to equitable public policy in the current governance of the food supply system.
5. Confronting hunger and nutrition provides one further area where alternatives can be built that promote policy objectives of justice and equity. This calls for interventions that build a multi-disciplinary and integrated response to food security and nutrition, especially focused upon gender inequalities, community control over productive resources and fair trade - ie one that is shaped on food sovereignty.

This analysis suggests that equity in health will be difficult to achieve in this region unless there more explicit attention is paid to the underlying nutrition and food security determinants. These in turn are being shaped by larger forces such as trade rules, corporatisation of the food supply chain, HIV/AIDS, gender inequalities etc. However we can start to identify areas of common action that would strengthen equity in food security, nutrition and health outcomes.

At a minimum an equity programme should focus on:

- Building civil - state alliances around a programme of action that links a food sovereignty perspective with the equitable public policy that supports this.
- Promoting further assessment of the links between trade and health in the region to feed into advocacy for trade policies and agreements that strengthen public health.
- Supporting, informing and evaluating policies and initiatives that provide safety nets to those most affected by negative effects of trade and agricultural policies and of HIV and AIDS.
- Continuing to identify how gender inequalities exacerbate the impact of globalisation and HIV and AIDS on the poorest families and decrease the efficiency of policy responses and propose programme and policy responses for these problems.

* The full article is available at http://www.equinetafrica.org/bibl/equinetpub.php

* Please send comments to admin@equinetafrica.org

Who cares for Health Care Workers?
South African Municipal Workers Union, Municipal Services Project and Industrial Health Research Group

Following the 1994 elections in South Africa, the new ANC government committed itself to the development of a District Health System that would meet the health needs of local communities and allow for grassroots input into the management of primary health care. Ten years later, there is still indecision and confusion surrounding the governance and financing of primary health care delivery and it is not clear which authorities will take leading responsibility for administering the district health services.

Municipal health workers together with their provincial counterparts and community health workers stand in the front line of delivering primary health care to the majority of South Africans. The SAMWU/MSP/IHRG National Survey into the State of Occupational Health and Safety in the Municipal Health Clinics asks “Who cares for health care workers?” While the health care profession embraces important ethics of service and sacrifice in meeting the health needs of the public, our research points to neglect of the health and well-being of health care workers themselves.

We found little taking place to identify hazards, evaluate risks, prevent workplace injury and illness and ensure that the conditions in which health workers care for others allows them to care also for themselves. Even where measures are provided, there is little employee involvement in shaping these health and safety practices.

We found that probably the biggest health and safety hazard facing health care workers in the public health sector in South Africa is the shortage of staff. Growing queues of patients lead to stress, burnout and increase the risk of accidental injury. Lack of facilities, equipment, and medicines further frustrate clinic staff and add to tensions between staff and the communities.

This situation is not simply a management problem- it is also reinforced and reproduced by health workers themselves. The inclination of the majority of health workers to accept appalling working conditions, to isolate themselves, and to individualise their workplace traumas, stress and exhaustion, presents an enormous challenge to SAMWU and other unions organising in the public health sector.

We intend to shape an alternative to that neglect. As activist investigators, we are challenging the silence and neglect that characterises work in the health sector. This starts with our research activity - asking questions; identifying workplace hazards; documenting case studies of workplace injury and illness; interviewing management and workers in the clinics; sharing stories of needle-prick incidents; interrogating policy and protocols; challenging employers’ non-compliance; discovering rights and responsibilities; and examining the extent of effective representation and functioning of health and safety committees.

* This briefing is edited by the EQUINET secretariat at TARSC. Please send feedback or queries on the issues raised in this briefing to Nick Henwood, IHRG at ihnick@ihrg.uct.ac.za or to the EQUINET secretariat email admin@equinetafrica.org .

* The research report cited will be available in late January as a downloadable pdf file from the Municipal Services Project website (http://www.queensu.ca/msp/) or from the EQUINET website at www.equinetafrica.org

Building capacities and knowledge for health sensitive trade policy in Southern Africa

Call Closes On January 7 2005

This call invites applicants to participate in the EQUINET programme on trade and health being held in co-operation with the Southern and East African Trade Information and Negotiations Institute (SEATINI) and with the EQUINET Secretariat (Training and Research Support Centre)

The call:

EQUINET invites middle to senior policymakers, academics and civil society members working in areas of trade and / or health from countries in East and Southern Africa to participate in a capacity building and research programme on trade and health, i.e. to
- Participate in country-level training on trade and health to be held between January and March 2005
- In country level teams, to undertake and report on national assessments of trade and health, supported by technical and financial resources, between March and June 2005
- Review the country level assessments at a regional meeting in mid 2005
- Make recommendations on follow up of the programme

Initial countries will be selected on the basis of a critical mass of interested people from across both trade and health disciplines and from state, academia and civil society.

The programme

Southern African countries developing equity-oriented policies face significant external pressures. Globalisation has deepened the liberalisation trends initiated by the structural adjustment programmes, while WTO agreements have extended trade liberalisation to significant new areas, including trade in services, trade related investments and intellectual property rights. As a result of these intrusions, governments enjoy less policy flexibility to pursue pro-equity goals and to regulate in the public interest. Commercialisation of health systems, exacerbated under the WTO TRIPS and GATS agreements undermines: access to care; access to essential drugs and medical technology; cross-subsidy from the wealthy to the poor; cost-containment measures in both the public sector and to users; retention of skilled health workers in public facilities and; the regulation of the private sector to promote equity. Instead of the health system becoming a vehicle for social cohesion, solidarity and equity, it runs the risk of reinforcing existing social, economic and health inequalities.

New agreements such as the Trade Related Aspects of Intellectual Property Rights (TRIPS) do provide limited space for countries to act in interests such as public health. They demand significant institutional resources and capabilities to identify and take advantage of those spaces. These resources are not always available to individual countries in the south. Regional co-operation, such as at the Southern African Development Community (SADC) level, is important for responding to these global pressures. It offers a strategic platform for countries to reinforce their bargaining power, co-ordinate their efforts and provide regional solutions to challenges faced.

To support regional responses, EQUINET aims to build proactive capacity in the region to understand, assess the health consequences of and respond to these agreements. EQUINET has with its partners in the region proposed options for using TRIPS flexibilities, for protecting national authorities and public health systems under and from the GATS and for resisting the commercialisation of health services. EQUINET advocates for government authority to regulate trade in areas where this is needed to deliver on obligations to protect the right to health and for the protection of public over commercial interests in health.

With support from IDRC and SIDA and through the Centre for Health Policy (Wits University) and SEATINI, EQUINET is implementing a programme of work and capacity development in the field of trade and health that seeks to:
- Pilot a training programme and materials on trade and health systems for countries in Southern and East Africa
- Provide technical and resource support for country level teams to carry out national assessments, identify options for promoting health systems and equity goals within current trade and investment policies and agreements and identify areas for follow up work, policy review and negotiation.

The programme will
- Carry out country-level training workshops on trade and health between February and March 2005
- Support country level teams to undertake and report on national assessments of trade and health with mentoring from SEATINI and CHP between March and June 2005
- Review the country level assessments at a regional meeting of the country teams to be held in mid 2005 to identify options for promoting health systems and equity goals within current trade and investment policies and agreements and identify areas for follow up work, policy review and negotiation, together with relevant stakeholders and expertise.
- Make recommendations on follow up training, on widening the programme and on specific areas for research and follow up work.

Call for participation and applications:

Interested applicants should submit a 1-2 page ‘expression of interest’ that provides
- a personal CV,
- brief information on the institution that they work in, and their position in the institution.

Please send applications to the EQUINET secretariat (admin@equinetafrica.org)/ Fax 263-4-737 220) and the programme co-ordinators (riazt@iafrica.com and haroon.wadee@nhls.ac.za) by January 7th 2005.

Applicants will be informed by mid-January 2005 on the outcome of their submission, including sponsorship and of the logistic follow up. Participants of existing EQUINET programmes are welcome to apply.

The focal points for queries on this programme are Riaz Tayob, SEATINI (riazt@iafrica.com) and Haroon Wadee, Centre for Health Policy, Wits University (haroon.wadee@nhls.ac.za or haroonwadee@hotmail.com).

**Investing in our health workers: approaches to the scarcity and loss of health personnel in southern Africa
EQUINET briefing November 2004

Antoinette Ntuli, Health systems Trust South Africa, Co-ordinator EQUINET HRH theme network

After decades of neglect, Human Resources for Health (HRH) has in the past few years moved to centre stage of both international and regional debates. Within southern Africa health personnel continue to be scarce in services where they are most needed, are a critical bottleneck to the uptake of new resources from global funds and the region is suffering from escalating out migration of health workers.

Dealing with this impact of the migration of health personnel raises debates about effective and just strategies. Those that restrict health worker rights of movement often don’t work and punish individuals. ‘Ethical human resource’ policies and codes appear to have made little difference to practice on the ground, especially when movement is driven by pull and push factors in both sending and receiving countries. So what comprehensive measures will secure the human resources that southern Africa needs for its health services?

EQUINET is addressing this through a network of institutions from government and non government sectors in southern Africa and working with institutional hubs in Canada, Australia and the UK (given their role as countries absorbing significant numbers of the regions health workers). The network aims to collaborate on research and use the evidence to harmonise policy engagement and advocacy.

At a meeting in April this year the network of researchers developed the analytical framework to guide this work. This framework takes the policy interest of the country planners and authorities in the region as the starting point, and includes four major components:

1. Equitable human resource policies- what will encourage health workers to work in areas of greatest need? This work is looking at what positively and negatively affects the internal distribution of health personnel, including both traditional and allopathic practitioners. In Zimbabwe, Oliver Mudyarabikwa at the UZ Medical School is identifying the factors that cause a maldistribution of public sector health workers. Yoswa Dambisya of the University of the North in South Africa is following up on the distribution of pharmacists who trained at the University of the North, to understand what drives their choices of both sector and location of work. Steve Reid of the University of KwaZulu-Natal in South Africa is exploring what educational factors influence the choice of rural or urban sites of practice of health professionals.

2. Ethical Human Resource Policies- how to respond to international migration of health workers?. Given the work already taking place on codes of practice, and reasons for health workers leaving EQUINET is focusing its work on identifying “what makes health personnel stay”. If the retention factors are known then ethical policies in other countries should reinforce and not undermine these factors and should contribute resources towards their achievement. Scholastika Lipinge of the University of Namibia is exploring how health professionals perceive their conditions of service, and the extent to which this acts as a factor keeping them in the country and the public sector. In Malawi, Adamson Muula from the College of Medicine in the University of Malawi is exploring the coping mechanisms of health workers who stay in the Malawi health sector to identify possible strategies to support these mechanisms and reinforce health worker retention.

3. How are the HIV and AIDS epidemic and the resources for AIDS affecting the distribution of health personnel? The network has built links through its work on HIV and AIDS and its networks with Municipal Services Unions to understand the impact of HIV and AIDS on health workers, and to explore how new resources for treatment are being used in relation to improving (or undermining) the availability, conditions and retention factors of health workers, especially within district health systems.

4. What can we learn as a region and where do we need to act regionally? Country level evidence will be shared regionally, recognising the gain for exchange of experience, policies and interventions across countries in the region. This is also a regional issue, both in terms of the flow of health personnel across national boundaries and the need for a regional policy response to international factors. Common evidence from all countries in the region, and more detailed evidence from Swaziland, Botswana, Namibia, South Africa, Zimbabwe and Malawi will be used to build a more detailed regional picture of the distribution and flows of personnel and the factors affecting this. We will also carry out in early 2005 an analysis of the policy environment, in terms of the priorities, actors and forces in this area and the options this raises for national and regional authorities.

EQUINET and HST are aware of the significant volume of work taking place in different institutions and countries on this issue. We have a database on human resources for health on our website at www.equinetafrica.org through which we hope to share materials and information that we access and encourage people to use and contribute to it.

When the African Ministers of Health raised issues of health personnel migration at the 2004 World Health Assembly they were profiling a situation that calls for policy recognition, such as through protocols and codes, but also for wider strategies and interventions. Those strategies should as first call reinforce the health workers who stay in the system, particularly those who work at primary care and district level, and strengthen the environments that encourage health workers to do this.

* EQUINET briefings are edited by R Loewenson, EQUINET secretariat, Training and Research Support Centre. Please send feedback or queries on the issues raised in this briefing to the secretariat email admin@equinetafrica.org . Reports cited are available as a downloadable pdf file from our website at www.equinetafrica.org

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).