The EQUINET regional meeting on Human Resources for Health August 19-20 2005 in Johannesburg South Africa discussed and debated Human Resources for Health (HRH) research and policy with a view to improving the equitable distribution of HRH within southern Africa. By the end of the deliberations, the delegates from government, non government, health worker, national, regional and international level at the meeting highlighted key areas of shared perspective on HRH.
The delegates noted an HRH crisis in east and southern Africa that has become more marked with the inadequate resourcing of the health sectors under economic reforms. The migration of HRH from the region to high income countries and the outflows of health workers from primary and district levels of health systems and from the public to private sectors leaves many low income communities with high health need with inadequate personnel for their health care services. This is a perverse outflow of public resources that undermines equity and the health system response to the major public health challenges in the region.
The multisectoral nature of policy implementation on HRH within government, and the international pull factors for migration of HRH were noted. Following the example of some countries in the region it was proposed that HRH be taken up as an issue for government as a whole and not just for the health sector, led by the highest level of government. At the same time Ministries of Health need the institutional latitude to facilitate training and strengthen retention of health workers. Constructing an appropriate policy framework given diverse contextual imperatives implies building a portfolio of policy measures and building policy implementation capacities.
Acting on HRH requires new resources, and, as raised by the African Ministers at the World Health Assembly in 2004 and again in 2005, delegates proposed international action and global transfers to address migration of and reinvestment in HRH.
It was proposed that HRH issues be addressed within the context of building and strengthening the public health sectors in the region. Towards this three areas of focus were identified for action:
- Valuing health workers so that they are retained within national health systems. This includes reviewing and implementing policies on non-financial incentives for HRH such as career paths, housing, working conditions, management systems and communication. To support this delegates proposed greater investment in training in HRH supervision, in management and communication systems, HIS and HRH, and measures to support health workers own health.
- Promoting relevant production of HRH, particularly in terms of the health personnel for district and primary care levels, and drawing on experience in the region on training of auxiliaries. For equitable distribution and retention the delegates noted the importance of appropriate selection of students and the need to locate training within career paths and incentives that recognise the HRH trained within the public health sector.
- Responding to migration, which requires closing the evidence gap with respect to migration (levels, flows and causes), financial flows, costs (benefits, losses) and return intentions and mapping the effectiveness of current policies. Delegates noted that migration represents a perverse subsidy calling for international policy responses that provide for reparation.
* This is the consensus statement from a report of a regional meeting on 'Equity in the Distribution of Health Personnel in southern Africa', held 18 to 20 August 2005, Johannesburg, South Africa. For the full report please visit http://www.equinetafrica.org/bibl/docs/REP082005hres.pdf
Editorial
Introduction
The Global Forum’s annual conference was held in Mumbai, India from 12-16 September 2005, and focused on “poverty, equity and health research”. EQUINET was extremely well represented, with four papers presented, three in full plenary sessions, on EQUINET research in the area of: participation and health, ART, fair financing and policy analysis. The papers presented by the EQUINET conference participants can be found on the Equinet website.
Forum 9 was attended by delegates from around the globe; one of the great attractions of the Global Forum conferences is that it includes participants from a wide range of research disciplines, policy-makers and civil society organisations. The conference had seven main themes: poverty; equity; innovation; neglected diseases and conditions; policies, systems and priorities; research capacity strengthening; and reproduction and human development. Some of the issues discussed and conclusions arising from the two core themes of poverty and equity are summarised below.
Poverty theme
The key role of poverty in contributing to ill health, and the lack of access to health services for the poorest were highlighted in a number of presentations. There was also an emphasis on how out-of-pocket payments for health care leads to further impoverishment for vulnerable households.
One of the most interesting ‘debates’ at the conference related to whether or not the Mexican PROGRESA (now called Opportunades) program has been successful or not. This program involves monthly payments to poor households on condition that the household attempts to improve their education, health and nutritional status.
For example, a household will receive up to US$28 per month per child if the child attends 85% or more of classes, and up to US$12 per month per family in ‘food transfers’ if each child receives 2-4 health checkups per year, each adult receives one health checkup per year and pregnant women receive seven pre-and post-natal checkups.
Findings from evaluations of this program, undertaken in two different sets of villages, were presented in two different sessions and contained divergent results. The one study, undertaken by the World Bank and IMF, claimed very positive results of the program with a very high proportion of beneficiaries being in the poorest section of the population and improvements in health status and educational enrolment, as well as poverty reduction, being attributed to the program.
The other study, undertaken by a team of local researchers in one of the poorest areas of Mexico, found less positive outcomes. In particular, they highlighted that although the program was targeted at the poor, many poor households were not being reached. Very importantly, the program appears to be creating conflicts and “destroying the social fabric” of communities. There appear to be conflicts between those who are benefiting from the program and those who are not, despite being “equally poor”, and there is resentment at the paternalistic monitoring of family education and health choices. Unfortunately, no opportunity was presented to debate these studies or the PROGRESA program in detail. Nevertheless, these presentations highlighted the need to carefully monitor poverty reduction programs and to identify unexpected negative impacts.
One of the key recommendations arising from this theme was that mechanisms of accurately and comprehensively identifying and protecting the poor are urgently needed.
Equity theme
Much of the research presented at the conference again highlighted the extent of inequities at household, community, national and global levels and the effects of inequities on vulnerability and risk of infection, disease and injury; access to care, treatment interventions and health outcomes. Unlike many other conferences which focus almost exclusively on inequities on the basis of socio-economic status, considerable emphasis was placed on gender inequities and inequities related to disability at Forum 9. While this was very positive, it was noticeable that the gender and disability sessions were more poorly attended and it was noted that inequities related to ‘race’, ethnicity, age, language and cultural affiliation received very little attention. There was also quite limited discussion on how to successfully address inequities.
One of the particularly interesting series of papers presented at the conference, which might provide insights on fair financing approaches to be considered in the African context, related to the EQUITAP project. This project has undertaken an extensive analysis of equity in health care financing in a large number of Asian countries. The results very clearly demonstrate that countries, such as Hong Kong, Malaysia and Sri Lanka, which have strong public health systems with general tax revenue being the major source of finance in the health sector are the most equitable. Health systems that have universal health insurance systems, such as Thailand, also fare quite well. The EQUITAP project has also analysed the level of catastrophic out-of-pocket payments in Asian countries. The findings from the EQUITAP and other research projects all highlighted the need to move away from out-of-pocket payments as a health care financing mechanism and to increase tax and insurance funding for health services.
Other observations
In the closing plenary, there was a general sense that many interesting issues had been raised and that there had been valuable engagements between participants. A number of suggestions were made on how to improve on these engagements in future, including:
- Greater care should be taken in the language that we use, to enable communication between different researchers and between researchers and policy-makers. Sometimes unnecessary jargon is used, but more concerning is that certain terms (e.g. equity) are commonly used but may have a number of different interpretations depending on the underlying ideological perspective. In order to ensure effective communication, it is important that everyone clarify their specific definition or interpretation of key terms.
- It is critical to pay greater attention to the context within which particular research has been undertaken, both in interpreting the findings but also in assessing the generalisability of findings.
- Forums such as this should create opportunities for more deliberately structured and challenging debate. Many participants regarded the lack of explicit debate on contradictory research findings, as highlighted above in the case of the PROGRESA program, in order to better understand what works and what does not, and why, as a missed opportunity.
- There was a perceived need to invest more energy in trying to consolidate and synthesise existing knowledge to a greater extent. In particular, there is a need to disseminate information on positive experiences and success stories.
The next Global Forum conference will be held in Cairo, Egypt from 29 October to 2 November 2006 and will focus on “Combating disease and promoting health”.
* Di McIntyre is with the Health Economics Unit, University of Cape Town.
* Please send comments to admin@equinetafrica.org
An EQUINET partner, the Centre for Health Policy at Wits University, has released a report examining policies in the SADC region on the retention of human resources for health. This report has been prepared for the Health Systems Trust (HST), South Africa and the Regional Network for Equity in Health in Southern Africa (EQUINET). It presents a review of issues in the regional policy context that are of relevance to the retention of human resources for the health sector (HRH) within the region, based on a rapid appraisal in selected countries and at regional level.
This work specifically focussed on the actions needed to stem the flow of international migration by encouraging the retention of health staff within countries. A particular concern raised across countries is staff retention in the public and rural services that preferentially serve the poorest populations. Importantly, policy documents and national respondents see the problems of retaining staff in these locations (the push factors underlying migration) as linked to the factors that undermine motivation and productivity. Policies to address retention issues (and so encourage health workers to stick and stay in country settings) are, thus, also likely to address poor motivation and weak productivity. In addition, these three sets of problems often go hand in hand with poor health worker attitudes and behaviours towards patients. So tackling these problems may have double benefits for health system performance – contributing to adequate availability of competent staff, as well as enhanced staff responsiveness to patients.
The report presents the findings of this work in sections 3-5 covering:
- Review of current international and regional HRH policy initiatives of relevance to the Eastern and Southern Africa region;
- Review of national level policy environments, with specific consideration of Malawi, South Africa and Tanzania;
- Implications for the future role of EQUINET in supporting implementation of HRH policy initiatives within the region.
In summary, the report notes that:
- encouraging HRH retention requires a complex package of actions/ /working through different entry points, rather than single policy actions;
- implementation of any HRH retention policy package is challenging because of the need to coordinate efforts across a wide range of governmental actors as well as get the support of a range of external actors;
- regional co-operation to support country level action to encourage retention appears to be, as yet, little developed, although recent discussions within the African Union and SADC, provide possible bases for such co-operation;
- current international initiatives may provide regional opportunities for addressing HRH problems (as a core constraint on health system development), but also hold the danger of over-burdening health systems, and in particular leadership and management within them.
In supporting initiatives to promote HRH retention within the region we suggest that EQUINET could, in broad terms, engage with others in providing a focal point for regional networking in support of HRH policy action. Such networking could, more specifically, focus on two sets of activities (see section 5 for details).
First, analytical work could fill current gaps by supporting cross-country analysis of the implementation of financial incentives, developing ideas and proposals around how to strengthen non-financial incentives and monitoring the impact at country level of externally driven initiatives on HR issues or initiatives (such as those for HIV/AIDS) likely to have impact on HR.
Second, dialogue and engagement with key actors (such as parliamentarians, senior health and other civil servants, professional groupings) could be supported by the development of policy briefs on key issues and collaboration with WHO AFRO, SADC, NEPAD and the AU.
* The report, which is available from http://www.equinetafrica.org/bibl/page.php?record=594, was presented at a "Policy and research meeting on equity in the distribution of health personnel in southern Africa" in August. The meeting:
- provided an update and recap on major policy issues and positions on HRH in east and southern Africa at the country and regional level;
- presented brief summaries of the work that has been done under auspices of EQUINET;
- identified policy positions and issues that require further research;
- explored capacity building and policy intervention within the region;
- identified priority issues in order to deliver clear agendas for action; and
- identified some key collaborations to assist in taking the work forward effectively.
The meeting report will be available on the EQUINET website at the end of September.
The conception and birth of the Global Health Watch
Five years ago, about 1500 people from 80 countries met in Bangladesh at the first Peoples Health Assembly. The Assembly was organised as a counter-balance to the official World Health Assembly convened every year by World Health Organisation, and represented a protest against the failure to achieve health for all by the year 2000.
The Assembly gave renewed expression to social objectives such as fairness and the universal right to health care, as well as to the public health principle that in addition to providing health care, health systems and health professionals must act to abolish poverty and work towards people having access to education, nutrition, water, sanitation and peace.
It also gave birth to the Peoples Health Movement – a network of individuals and organisations from all regions of the world, formed with the understanding that the principles of the Charter would only be achieved through social mobilisation and political engagement. The Global Health Watch, an alternative world health report from the perspective of civil society, was designed as an instrument to support advocacy and mobilisation. Amongst its aims is to provide a platform that will embrace the science and politics of development, and thereby, simultaneously involve academics, health practitioners, parliamentarians, journalists and civil society in improving health and equity.
More than 120 people – researchers, health workers, non-government policy analysts and campaigners - and 70 non-government organisations contributed to the report. The connection of the Watch to the Peoples Health Movement and a wide range of NGOs will hopefully ensure that it doesn’t end up as another report gathering dust – disengaged from the vehicles that can help translate analysis and recommendations into actual action. Already a number of NGOs have volunteered to host launches of the Watch in other countries, including Malaysia, South Africa, Ireland, Egypt, Germany, Holland, and the US.
Watching
The Watch is not designed to report on the state of health and poverty – it is not about the size of the HIV pandemic, or the number of children who die every second; or the declining life expectancy in Africa. The aim is to provide a report on what is being done about improving health by reporting on the actions, policies and programmes of organisations charged with improving health. This idea of “watching” the performance of key institutions can also be viewed as a contribution to democratic deficits that exist at many levels of decision-making and the erosion of public accountability that has accompanied globalisation and the concentration of wealth and power.
Global political and economic institutions
According to the Universal Declaration on Human Rights, people do not just have a right to an adequate standard of living and medical care – they also have a right to live in a social and international order in which the rights to medical care can be realised. However, this right is continually violated. According to the World Commission on the Social Dimension of Globalisation, “none of the existing global institutions provide adequate democratic oversight of global markets, or redress basic inequalities between countries”.
The Watch questions the success story painted by proponents of the current form of globalization, pointing to increases in poverty in Africa, eastern Europe, central Asia and Latin America. Producers in developing countries have often been undermined by increased global competition from powerful nations after trade liberalisation. In Mexico, for example, the liberalisation of the corn sector under the North American Free Trade Agreement, led to a flood of imports from the United States, where agribusiness is massively subsidised. Mexican corn production stagnated whilst prices declined. Small farmers became much poorer and some 700,000 agricultural jobs disappeared over the same period. Rural poverty rates rose to over 70%, the minimum wage lost over 75% of its purchasing power, and infant mortality rates amongst the poor increased.
To change this will require a shift away from the dominant human rights discourse which focuses on the obligations of national governments towards their own citizens, towards more of a focus on a) the obligations of governments to the citizens of other countries; and b) the obligations of non-government actors, as well as the rules by which the world economy is controlled and governed. Furthermore, whilst some countries have social contracts, progressive taxation systems and laws and regulations to manage the human consequences of market failures at the national level, there is no ‘global social contract’ to manage the failures of globalization.
World Health Organisation (WHO)
A key chapter in the report is dedicated to WHO. The report argues that WHO is insufficiently resourced, inadequately empowered, undermined by national political agendas and handicapped by internal management problems. WHO does many things well and repeatedly demonstrates the need for a multilateral agency charged with protecting and promoting health, but the Watch calls for better funding and improvements in WHO’s operating environment. The report also notes that the proliferation of public private initiatives, vertical programmes and the insidious influence of the World Bank has resulted in WHO being further undermined as the leading global health agency.
But we need, for example, a WHO that can challenge and aspire to block trade and economic agreements that threaten to harm health and human rights. As a starting point, the Watch calls upon WHO to convene a delegation of public health and trade experts to attend the trade talks in Hong Kong this year, mandated with the role of providing public health advice to Ministries of trade and finance. But this simple request is unlikely to be granted without public lobbying. At the most recent Executive Board meeting of WHO, a mild resolution put forward by developing countries requesting WHO to conduct a more active analysis on the impact of trade on health was blocked by the US and other countries – illustrating the impotence of WHO in tackling the more fundamental determinants of health.
Other recommendations aimed at WHO include:
Steering the global health ship
- Substantially increase funding for WHO with more proportionately devoted to its core budget with fewer strings attached;
- Open a debate on WHO’s key roles to avoid mission-creep and to develop consensus within and beyond the organization;
- Strengthen WHO’s role at country level and give it a mandate to help governments co-ordinate global, bilateral and international NGO initiatives to improve health.
An organization of the people not just of governments
- Expand current efforts to reach out to civil society, especially in the developing world;
- Ensure that public-interest civil society organizations are differentiated from those acting as a front for commercial interests;
- Improve the nature of the WHO leadership elections – possible solutions include a wider franchise, perhaps of international public health experts and civil society organizations. Candidates should be required to publish a manifesto and debate their vision for the organization publicly.
Improve the management of the organization
- Improve the mix of the professional staff, ensuring that there are more social scientists, economists, public policy specialists, lawyers and pharmacists. More representation from developing countries should be coupled with stronger regional offices run by experienced professionals.
The corporate sector
Of the 100 largest economic entities in the world, 51 are businesses; and the combined sales of the top 20 businesses are 18 times the combined income of the poorest 25% of the world’s population. Transnational corporations wield immense power through their wealth, control of resources and influence on governments and key decision-making bodies, with profound consequences for health and development.
The price of medicines and the radical changes to the way we construct patents; the resistance to making the required changes to address climate change; widespread labour exploitation and occupational health hazards; the dumping of cheap, subsidised food in Africa; the corrupt trade in weapons; the unchecked pollution of many extractive industries; and the unhealthy changes in food eating practices are just some examples described in the report, of the causal relationships that exist between profit-seeking corporate activity and the state of global health.
While commercial activity and free enterprise in themselves should not come under attack, the deterioration of democratic control and oversight over corporate actions and power must be highlighted. The imbalance between corporate freedom and social obligations is unhealthy, and health professionals need to assert their public health authority to limit the negative consequences of corporate actions, and ensure proper regulatory frameworks.
The attention paid to the corporate sector also leads us to shift thinking away from an exclusive focus on poverty towards an equally necessary focus on wealth, and in particular one what many would call obscene wealth. One of the demands we make is for the establishment of an international tax authority to help recover the conservatively estimated US$255 billion that is lost annually through tax avoidance.
This is an amount of money, in spite of the low tax rates, that would fund comprehensive and functional health care systems in every poor country. Public-private partnerships and corporate social responsibility programmes are great, but the Watch calls for the greater use of legitimate, fair and non-punitive instruments of public policy to ensure the universal provision of health care and social security, and the redistribution that is required to reverse the politically unsustainable deepening of global disparities.
Health systems
The chapter on health systems sets a very different agenda from the one currently popular with donors, where the emphasis is on fragmented, vertical health programmes usually focussed on one or two diseases, or on particular selected interventions. The Watch describes how Ministries of Health in poor countries operate in a policy circus, pulled in a hundred different directions by different programmes, donors and agencies, undermining coherent and integrated health systems development. In many instances, these agencies also contribute to an internal ‘brain drain’ – sucking many of the most skilled professionals out of public health care systems.
In the poorer countries, this has come on top of economic crises, structural adjustment programmes and neoliberal reforms that have decimated public health care systems and extended the commercialisation of health care to the detriment of equity, accessibility and efficiency.
The Watch presents new evidence which suggests that higher levels of private finance and provision lead to worse health outcomes, and explains how private financing and provision leads to a commercialisation of health care systems which widens health care inequities, lowers access to care for the poor, causes inefficiencies and deteriorates levels of trust and ethics.
Unless a common vision of health care systems development is established, we will not achieve the health-related Millennium Development Goals. The Watch therefore calls for the adoption of a 10-point agenda to repair and develop health care systems (more detail on the recommendations is available from both the Watch itself and the accompanying advocacy document, Global Health Action):
1. Provide adequate funding for health care systems;
2. Take better care of public sector workers;
3. Ensure that public financing and provision underpin health care systems;
4. Abolish user fees that push people into poverty;
5. Adopt new health systems indicators and targets that incentivize countries to improve the health system rather than simply tackle specific diseases;
6. Reverse the commercialization of health care systems by using regulatory and legislative instruments; and search for ways in which the private sector’s resources can be harnessed for the public good;
7. Strengthen health management and adopt the District Health System as the model for organising health care systems;
8. Improve donor assistance within the health sector;
9. Promote community empowerment to improve the accountability of the health system;
10. Promote trust and ethical behaviour to combat the corrosive effects of commercialization.
At the moment international health agencies consistently stress the importance of strengthening health care systems – but with little debate or discussion as to what this actually means. This is one area where WHO can really play a positive role and demonstrate health sector leadership.
Global Health Watch 2
Planning for the second edition of the Watch has begun. But between now and then, the challenge will be to actively mobilise the broader health community around the Watch and the advocacy agenda that accompanies it.
At the launch of the report in London, NHS organisations and professional associations were asked to think of institutional responses to the global health crises by:
- Developing long-term ‘partnerships’ with counterparts in poor countries - involving support, the transfer of material resources, skills and technology – and also providing a mechanism by which health workers in the NHS can learn and understand the impact of UK actions and policies on global health);
- Daring to put aside a proportion of money to promote global health until such time that we have a mechanism to recompense poor countries for training so many of our health workers;
- Implementing fair trade and ethical purchasing policies within our own organizations; and
- Campaigning for change. Medact, which was established specifically as a membership organization for health workers to promote global health, provide one concrete vehicle by which individual health workers can work together to lever change.
In southern Africa, the health and development community should consider ways in which the Watch can be used as a tool to strengthen and develop a progressive global public health movement and greater public accountability.
* David McCoy and Mike Rowson are managing editors of GHW
* Please send comments to admin@equinetafrica.org
The social and economic impact of the adjustment programmes of the International Monetary Fund (IMF) and the World Bank in developing countries has been a source of heated debate over the last two decades. Research on the effects of these policies has led to contradictory conclusions.
A number of World Bank evaluations indicate that 'adjuster countries' generally succeed in improving health, education, and social welfare programmes compared to 'non adjusters' (1-3). Based on such studies, the World Bank concludes that adjustment programmes do not necessarily adversely affect vulnerable populations. Furthermore, the World Bank believes that reforms that include these reforms are necessary for poverty eradication in developing countries.
On the other hand, publications from UNICEF and from representatives of academic institutions and non-governmental organizations (NGOs) indicate that adjustment policies may be particularly harmful for the most vulnerable populations. In "Adjustment with a human face", UNICEF reports studies from several developing countries which indicate that adjustment policies have negatively affected the health status of women and children (4).
Evidence suggests that the adjustment programmes may also create conditions favouring societal vulnerability to HIV/AIDS (5). Unfortunately, no study, to date, has systematically evaluated the relationship between IMF/World Bank economic reforms and the vulnerability of women and children to HIV/AIDS.
This paper reviews what is known regarding the social and economic consequences of adjustment policies on maternal and child welfare and explores the potential impact such consequences may have on the vulnerability of women and children to HIV/AIDS. We approach the impact of macroeconomic adjustment policies from a conceptual perspective. Our theoretical framework illustrates how adjustment policies may influence the predisposing factors for impoverishment of women and exposure of children to HIV/AIDS in sub-Saharan Africa.
The underlying assumption is not that adjustment is the only cause of vulnerability of women and children to HIV/AIDS. Antecedent predisposing factors, such as poverty and inequality, are responsible for the vulnerability of women and children to HIV/AIDS in the first place. However, adjustment policies may further contribute to a socioeconomic environment that facilitates the exposure of women and children to HIV/AIDS, especially when their implementation is not accompanied by specific measures protecting the most vulnerable populations.
AIDS in sub-Saharan Africa directly and indirectly devastates the lives of millions of women and children. According to the joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization, 19.2 million women and 3.2 million children aged less than 15 years are living with HIV/AIDS in the world. Almost two-thirds of them reside in sub-Saharan Africa. In 2003, over one million women and approximately 610,000 children died from AIDS.
Socioeconomic conditions of women and children are determined by a series of hierarchical factors that interact with one another at different levels of their ecosystem. These factors correspond to the household level (i.e. income of the family), the meso level (i.e. food prices, real wages, employment opportunities), and the macro level (i.e. economic policies, health policies, social welfare systems). The latter level is particularly important: macroeconomic changes modify the meso-economic conditions that, in turn, are transmitted down to the household level. Macroeconomic measures, such as adjustment policies, may have an impact not only on macroeconomic indicators, such as gross domestic product (GDP) growth and the external debt rate, but also on social indicators, such as access of women and children to shelter, food, healthcare, and education. Since poor access to basic human needs may facilitate the exposure of children to HIV/AIDS, economic policies at the macro level may ultimately be related to the socioeconomic conditions that reduce or facilitate the spread of HIV/ AIDS among infants and youths.
Economic reforms that decrease access to basic needs for poor households will eventually result in increased exposure of women and children to HIV/AIDS. Conversely, economic growth that leads to increased access to basic goods and services for the most vulnerable families may significantly reduce their exposure to the infection.
Since 1980, most sub-Saharan African countries entered into one or more adjustment programme(s) of the IMF/ World Bank. Many of these programmes have not been implemented as prescribed by the World Bank and IMF, but as implemented, these policies have not produced the expected results in terms of economic growth and reduction of unsustainable debt. A World Bank study of 26 African countries that implemented adjustment policies concluded that six countries had a large improvement in macroeconomic indicators, nine had a small improvement, and 11 had a deterioration (3). Moreover, Africa's external debt increased from US$ 120 billion in 1980 to US$ 340 billion in 1995 (14).
Adjustment policies mainly consist of currency devaluation and financial liberalization; privatization of government corporations; trade liberalization (including import liberalization and export promotion); elimination or reduction of subsidies for agriculture and food staples; and reductions in government spending (including expenditure for health, education, and social services).
Analyses of the effects of currency devaluation on prices for basic items, such as food, housing, and transportation, lead to controversial conclusions. Prices for basic commodities rise after the adoption of the adjustment policies because currency devaluation increases the cost of imports. In Zambia, devaluation increased the cost of bread from 12 kwacha a loaf in 1990 to 350 kwacha in 1993 (21). In Senegal, after currency devaluation, inflation rates dramatically increased especially for daily food and health products (22). In Kenya, the real price for maize rose by 29% between 1982 and 1983 (23). In Tanzania, commodity prices skyrocketed as a result of devaluation (24).
Despite these results, there is also evidence that currency devaluation may be an appropriate solution to prevent a further collapse of a failing economy (13). A study conducted in cocoa-growing areas of Ghana concluded that even the poorest smallholders benefited from the improved producer prices resulting from devaluation (25).
If currency devaluation produces mixed effects, removal of food subsidies has a more direct impact on access to food and basic commodities, especially among low income groups. In Zambia, after the removal of subsidies in 1985, the price of maize meal rose by 50% (26). In Zimbabwe, after eliminating food subsidies, the cost of living for lower-income urban families rose by 45% between mid-1991 and mid-1992. The increased cost of food items results in a sharp reduction of low-income household expenditure on other basic commodities.
Sharp increases in the cost of living and impoverishment of women not only increase the vulnerability of infants to HIV/AIDS, but also have a negative impact on vulnerable young people. Children of poor mothers are more likely to be exposed to predisposing factors for HIV (10). Socioeconomic constraints force these children to leave school and search work to support their families. Children may also be abandoned. Youths and children living in impoverished families are more likely to live and work on the street, where they may be forced into prostitution to exchange sex for money, goods, food, or shelter (31).
Privatization results in significant job losses in the public sector without necessarily increasing employment in the private sector (34-36). To improve efficiency and keep production costs low, public enterprises reduce costs of labour by freezing wages and reducing employment.
This results in a decline of real wages or an increase in unemployment, especially among low-income workers. During the 1980s, average real wages declined in 26 of 28 African countries (34). In Ghana, between 1984 and 1991, after privatization of the 42 largest state enterprises, more than 150,000 workers lost their jobs (31).
These cutbacks in public-sector employment disproportionately affect women (4,37,38) who traditionally hold positions, such as clerical workers, cleaners, nurses, or teachers. In Ghana, the least skilled women working in the public sector lost job protection, security, and benefits as a consequence of policies aimed at increasing efficiency, while others lost employment altogether (39). Privatization not only affects women in urban areas, but also impacts those in rural areas since informal land privatization is linked to a reduction in access of women to subsistence food production (40).
Unemployment, low wages, and job insecurity caused by privatization not only increase women's adoption of survival strategies, including prostitution, but also modify existing gender-related relationships. Employed women tend to be more empowered by having more opportunities for education, more experience in public life, more self-confidence and self-esteem, all basic prerequisites for negotiating safe sex with male partners (41). Conversely, unemployment, job insecurity, and reduced purchasing power increase the exposure of women to sexual harassment and sexual abuse, especially among those working in low-earning jobs (42).
Reduced employment opportunities resulting from privatization may also increase the proportion of African children forced to live on the street or work to support their families (43). In Zambia, due to privatization and retrenchment of government employees, 72,000 people lost their jobs and child labour increased nine folds among females aged 12-14-years (44).
In regions where a significant proportion of population live in miserable conditions, indiscriminate cost-recovery measures disproportionately affect those who cannot afford to pay user-charges. The World Bank and other organizations which support the implementation of user-fees for health services insist that even poor households are willing to pay for higher quality, more reliable health services. In a household survey conducted in Rwanda, most respondents, regardless of income, indicated a preference for higher fees to assure the availability of medications (59).
However, populations living on less than a dollar per day can rarely afford to pay user-fees and their inability to pay may negate their 'willingness' to pay (60). The literature repeatedly shows that introducing user-charges at STI clinics result in a dramatic drop in women's use of services (61-64). Access to free STI treatment and condoms increase their use (65-66), and the introduction of user-charges creates an obstacle to HIV-preventive behavioural practices among women. Women and youth without access to AIDS education, HIV screening, STI treatment, and reproductive health services have little control over their AIDS-related risk factors. Untreated STIs increase the risks of HIV transmission (67) as shown in Uganda where over 90% of new HIV infections were attributable to other STIs (68). The introduction of user fees for health clinics is likely to increase the number of untreated STIs consequently producing high HIV susceptibility in women (66). These HIV-infected women infect their children through vertical transmission of the virus.
Following the prescriptions for structural adjustment and stabilization policies, many sub-Saharan African countries reduced public expenditure on education and introduced school fees limiting access to education, especially among those children who cannot afford to pay such charges (4,36). The introduction of school fees causes a dramatic fall in primary school enrollment rates and increases the number of children who drop out of school. Sub-Saharan Africa has the lowest primary school enrollment ratio in the world. This ratio fell from 77.1% in 1980 to an estimated 66.7% in 1990 (69).
Certain components of adjustment reforms, such as currency devaluation and trade liberalization, may produce mixed effects on the vulnerability of women and children to HIV/AIDS. Other reforms, such as financial liberalization, removal of food subsidies, and introduction of user fees for healthcare and education have a negative impact on the spread of the epidemic among poor women and children. In most cases, adjustment policies create synergies making it extremely difficult to identify their net social effects. Clearly, there is, currently, no single study capable of demonstrating a causal link between adjustment policies and the exposure of women and children to HIV/AIDS. However, this analysis provides some evidence that adjustment policies may inadvertently facilitate societal conditions that increase the vulnerability of women and children to HIV/AIDS in sub-Saharan Africa.
It must also be acknowledged that the World Bank is, at present, the largest single investor in health in sub- Saharan Africa. Such investment may reduce the HIV epidemic through some mechanisms. However, the unintended consequences of adjustment policies may have greater negative effects on the same health outcome.
Given the potential for adjustment policies to exacerbate the AIDS pandemic among women and children, there is an urgent need to either demonstrate that such measures are not harmful to maternal and child welfare or to modify policies. The present buffering mechanisms designed to protect the most vulnerable segments of the population during macroeconomic stabilization and structural adjustment are not sufficient. The IMF and the World Bank need to provide adequate scientific evidence demonstrating the effectiveness of their policies. Failure to do so may undermine their international credibility and further exacerbate the already tragic social conditions of marginalized women and children at risk of HIV/AIDS in the developing world.
* This article is composed of extracts from the original review paper, done with permission of the author. For the full paper and list of references visit http://www.phishare.org/documents/icddrb/3205/
* Roberto De Vogli is with the Department of Epidemiology and Public Health, University College of London. Gretchen L. Birbeck is with the African Studies Center and Departments of Neurology and Epidemiology, Michigan State University.
* Please send comments to admin@equinetafrica.org
The report launched today, by WHO and UNAIDS, as a status update on where the world stands in the provision of treatment for AIDS is a predictably fascinating document.
There will be comments aplenty. I have five.
First, the 3 by 5 initiative seems to me to be entirely vindicated. Mind you, I can even now hear the curmudgeonly bleats of the detractors, whining that we will fall short of the target of three million in treatment by the end of this year. Tell that to the million people who are now on treatment and who would otherwise be dead. The truth is that the 3 by 5 initiative --- which, I predict, will be seen one day as one of the UN’s finest hours --- has unleashed an irreversible momentum for treatment. I see it everywhere as I travel through Africa. Governments are moving heaven and earth to keep their people alive, and nothing will stop that driving impulse. It is surely noteworthy that 3 by 5 has ushered the phrase “universal treatment” into the language of the pandemic, meaning that we’re now all fixated on getting everyone who needs treatment, into treatment, as fast as possible. It is, I readily admit, both painful and horrifying to see the numbers who are dying as they wait for treatment to be rolled out, but at least there is hope amidst the despair.
Second, it becomes irrefutably clear that treatment has been a boon to prevention. I can recall from many quarters all the caterwauling about the neglect of prevention as the world began to focus on treatment. But the detractors were wrong again. Not only do we continue to emphasize prevention and reinforce it at country level, but the provision of treatment significantly accelerates testing and counseling, one of the primary ingredients of prevention. Buried in the report, is the astonishing statistic from a study of a district in Uganda, showing a 27-fold increase in counseling and testing as a result of the introduction of treatment!
Third, the G8 certainly has its work cut out for it. What this report appears to do is to throw many of the financial estimates of resource needs for Africa into a cocked hat. WHO and UNAIDS categorically assert that we will need an additional $18 billion dollars, over present commitments, for the three years 2005-2007. We know from the recent UNAIDS estimates for 2008, that we will require $22 billion annually, minimum, from that year forward. In the face of these resource imperatives, the idea of doubling foreign aid for Africa by 2010, which would represent another $25 billion per year, is clearly inadequate, some might say paltry. The $25 billion is supposed to address all of the Millennium Development Goals; it will barely address the one goal of defeating communicable diseases. Unless the G8 can do a lot better than the present calculus, Gleneagles will be much like all the G7/G8 summits before it: a rhetorical triumph, a pragmatic illusion.
Fourth: the report has one particularly evocative diagram. It’s a world map portraying the twenty countries with the highest unmet treatment needs … twenty countries where the estimated number of people in treatment is pathetically low. Six of those countries --- South Africa, Zimbabwe, Tanzania, Nigeria, Ethiopia and India --- represent fully half of the unmet treatment needs. Five of them are in Africa. South Africa alone has the largest shortfall in the world, some 866,000 people who should at this very moment be in treatment. The country appears to have something slightly in excess of 100,000 people in treatment, but that represents only 10% to 14% of those who are desperately in need. The numbers for the other African countries, while smaller, are proportionately even more grim. This is where the international community must rally urgent support.
Fifth, the report says, without caveat, that treatment should be provided free at the point where it is given. Finally, we’re building a new consensus around the destructive nature of ‘user fees’, particularly as they prejudice the poor. User fees are a sordid relic of the old economic conditionalities: it will be excellent to see the end of them.
It was a good and illuminating report that was released today. It identifies many of the obstacles and bottlenecks, and with spirited intelligence suggests, in each case, a way around them. It’s a first-rate blueprint at this point in time.
* Click on http://www.who.int/3by5/progressreportJune2005/en/ to read the press release about the report and for a link to the full report,
The mass media hype about “a new deal between rich and poor”, in response to the powerful Group of Eight industrialised countries’ plan to cancel multilateral debts owed by 18 mainly African countries, has led many people to believe that a new era of international social justice has dawned. The deal is expected to be ratified by G8 leaders in Scotland on July 6-8. The uncritical endorsement of the plan by large international aid agencies like Oxfam, the driving force behind the Make Poverty History (MPH) coalition of non-government organisations, and big-name celebrities like Bob Geldof and Bono, has reinforced this hope. Unfortunately, celebrations to mark what British deputy PM Gordon Brown described as “the intention of world leaders to forge a new and better relationship between the rich and poor countries of the world” are premature.
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
http://www.zmag.org/Sustainers/Content/2005-05/11shiva.cfm
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.
* 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.
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