In a landmark moment on May 21 2010, the World Health Assembly adopted the Code of Practice on the International Recruitment of Health Personnel. It marks the culmination of a decade of advocacy on the recruitment and flow of skilled health workers, particularly from Africa to high income countries. In 2001 Southern African Development Community (SADC) health ministers called recruiting health workers from their understaffed, overburdened health systems ‘looting’ and observed that the outmigration of skilled people ‘further entrenches inequitable wealth and resources’. In 2009, despite having 25% of the global disease burden and 60% of people living with HIV, Africa had only 1% of global health spending and only 2% of the global health work force. It is clearly inequitable to lose health workers from low income countries with high health need to the richest countries in the world with significantly lower disease burdens.
Migration is not the sole factor leading to understaffing. In 2000, WHO estimated that African-born doctors and nurses working in high income OECD countries represented no more than 12% of the total shortage in the region. Inadequate production, limits to health worker training, employment and conditions imposed by resource shortages and fiscal thresholds, the disincentive of falling real wages in the health sector and other factors have been cited for shortfalls. Neither are the drivers for migration solely due to pull factors from high income countries. Economic, political, social and health system conditions in Africa are significant push factors driving migration.
In 2004, motivated by African countries, the World Health Assembly (WHA) requested the Director-General to develop a code of practice on the international recruitment of health personnel and to give consideration to the establishment of mechanisms to mitigate the adverse impact on developing countries of migration. Notably African countries sought to address both ethical recruitment and compensation for the losses they were experiencing through migration, including lost public investments in training, weakened capacities in health systems, loss of expertise and social disruption. Estimates set this at $60 000 in training costs alone for each doctor. In 2001 WHO estimated that South Africa lost US$37 million annually in direct financial losses in training costs, against OECD report of a combined (multilateral and bilateral) total education assistance received by the country in 2000 of US$35.5 million. Further, having experienced continued and rising outflows and foreign employment of health workers even in the face of codes such as the 2001/4 UK Code of Practice, African countries were concerned about how to ensure compliance with any instrument for managing recruitment. Within the SADC region, more binding measures were being used, such as the 2006 South African policy on recruitment and employment of foreign health professionals, which forbade individual applications from identified developing countries, in particular from SADC countries.
After six years of advocacy and work on the issue, the 2010 WHA adopted the global Code of Practice on the International Recruitment of Health Personnel. Its development has included multi-stakeholder consultation and review, including civil society through the Global Health Workforce Alliance, and the WHO regional forums. EQUINET was one of the more than 75 organisations making submissions on the draft. Country submissions on the draft submitted to the Assembly through the WHO Executive Board continued to reflect polarised positions on certain issues (see A63/INF.DOC/2 at http://apps.who.int/gb/e/e_wha63.html). The consensus outcome on the code was thus cause for specific recognition of role of the USA and African delegations in reaching agreement. The new Code of Practice is now the fourth WHO global legal instrument. The Framework Convention on Tobacco Control (FCTC) and the International Health Regulations are legally binding international treaties, while the Code of Practice on the International Recruitment of Health Personnel and the International Code of Marketing of Breast-Milk Substitutes are both voluntary instruments.
The new Code includes ten articles advising both source and destination countries on how to regulate the recruitment of health personnel, as a core component of national to global responses to health systems strengthening. The text makes clear that it is voluntary, and serves as a reference for countries in establishing or improving more binding national laws, policies, bilateral agreements and other international legal instruments on health worker recruitment. It links “properly managed” recruitment to health systems strengthening, especially in developing countries, and to safeguarding the rights of health workers, including their labour and social rights. It raises that countries should mitigate the negative effects and maximise the positive effects of migration on the health systems of the source countries, should plan workforces to reduce dependency on migration and should facilitate circular migration. It provides for gathering and sharing of data and information on international recruitment of health personnel.
Will it address the equity concerns that African countries have raised?
The commitment to developing countries, to health systems strengthening, to fair treatment of migrant workers and to ethical recruitment all signal that the code is a major step towards just outcomes.
Equity is less explicitly addressed within the code than in the debates that led to it. There is no reference to compensation. This was resisted by countries such as Canada, UK and Australia, who did not sign the earlier 2003 Commonwealth Code of Practice in part for its reference to this. Even reference to “mutuality of benefits” or “balancing” of gains and losses included in earlier drafts has been removed in the final draft. The code does make reference to the obligations of governments to protect population health and to equitable health systems. It recognises the “negative effects of health personnel migration on the health systems of developing countries” (Article 3.2), and the greater need of developing countries to health systems strengthening. In its remedies, while Article 5.1 seeks to ensure that both source and destination countries derive benefits from international migration, it does not include any reference to balancing or fairly distributing these benefits. Measures of technical assistance, training and other areas of support are thus included as means to “promote international co-ordination and co-operation on international recruitment of personnel” (Article 5.2), and not as measures of redress for negative effects of migration.
Perhaps this outcome reflects the balance of resources, political forces, power and formal evidence. The resource flows between source and receiving countries are neither simple to collect nor manage. The costs and returns accrue at different levels to individuals, households, communities, private and public sectors. Many of the flows and the measures to manage them lie outside the health sector, in economic, tax, immigration, employment, social security and other areas.
Nevertheless, these constraints and the goodwill around the code should not make it a smokescreen for the continuing research, innovation and dialogue needed to build on the code to further improve fairness and equity in managing these flows. The code has not limited itself to health sector measures, as some measures proposed such as “circular migration” will have implications for immigration, citizenship and labour market laws. Further, an explicit commitment to equity in Article 5.7 provides that “member states should consider adopting measures to address the geographical maldistribution of health workers” could be read to call for measures and resources at national, regional and international level. The code should thus be taken as a platform from which to further explore, develop and raise through its future review at WHA the options for measuring and fairly managing the resource flows between countries, including through tax and funding measures.
Taking the voluntary code to binding agreements and practice is the next front of action, as is monitoring and raising evidence to inform implementation for the next formal global review of the code at the 2012 WHA. Both areas raise challenges if countries in the region are to keep the push for equitable outcomes: to overcome information and evidence gaps, to inform and negotiate fair bilateral agreements, and to ensure that bilateral agreements reinforce and do not disrupt agreements that encourage skills production, circulation and retention within the region, such as the SADC protocols and strategies on education and training, on the movement of persons and on attracting and retaining health professionals.
Experience on prior codes suggests that civil society can play an important role in advancing implementation if effectively engaged. In particular, health workers, and especially female health workers, should not become commodified ‘objects’ to be traded in negotiations, but actively informed and involved through their associations.
Philemon Ngomu of the Southern African Network of Nurses and Midwives (SANNAM) reminds us, further, that the code is only one of a number of measures to address the conditions affecting recruitment and migration: “The very negative implications of political unrest and socio-economic crisis are major driving factors, and the code should not be taken in isolation of peace keeping and socio-economic and welfare initiatives. We cannot stop brain drain without addressing these issues”. When countries report back to the next United Nations General Assembly on the code, as feedback on Resolution 64/108 on Global Health and Foreign Policy, hopefully they will raise this, and make the point that the code is a significant milestone, but not a finishing line, in the path towards the fairer outcomes for health that African Health Ministers sought in 2001.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org. The next newsletter will provide the text of the code and all final resolutions from the World Health Assembly. Interim documents can be found at http://apps.who.int/gb/e/e_wha63.html
Editorial
African countries face a dilemma that if not reasonably resolved could threaten access to essential medicines. On the one hand countries need to protect their populations against potentially harmful counterfeit medicines, and to protect producers against unfair competition. On the other hand, the laws and measures that do this should not act as a barrier to cheaper, generic medicines. The current proposals for laws to protect against counterfeits in east Africa seem to be excessively weighted towards protecting intellectual property at the cost of access to legitimate generic versions of medicines.
There seems to be no universally accepted definition of ‘counterfeits’. This has caused confusion and created a loophole in determining what a counterfeit product is. The World Health Organization (WHO) has defined a counterfeit medicine as: ’one which is deliberately and fraudulently mislabelled with respect to identity and/or source. Counterfeiting can apply to both branded and generic products and counterfeit products may include products with the correct ingredients or with the wrong ingredients, without active ingredients, with insufficient active ingredients or with fake packaging.’
This definition makes the element of fraud essential in defining a counterfeit medicine, either in relation to the identity or the source of the product. WHO points to the public health risk of using products that have the wrong ingredients or which lack active ingredients.
From an intellectual property perspective, counterfeits are defined in Article 51, Footnote 14 (a) of the Trade Related Aspects of Intellectual Property Rights (TRIPS) Agreement which limits the definition of counterfeits to trademark and copy right infringements. Under this provision, counterfeit trademark goods mean ’any goods, including packaging, bearing without authorization a trademark which is identical to the trademark validly registered in respect of such goods, or which cannot be distinguished in its essential aspects from such a trademark, and which thereby infringes the rights of the owner of the trademark in question under the law of the country of importation’. This definition refers to only one aspect of intellectual property, that is trademarks, and associates counterfeiting with the issue of trademark infringement.
In their efforts to address counterfeits, East African countries are enacting anti counterfeit legislation. Kenya has a law in place, Tanzania has regulations while Uganda has a draft Bill. These laws have adopted a broad definition of counterfeits. For example section 2 of the Anti Counterfeit Act in Kenya provides that: ’counterfeiting includes manufacture, production, packaging, re-packaging, labelling or making, whether in Kenya or elsewhere, of any goods identical or substantially similar to protected goods without the authority of the owner of any intellectual property right (IPR) subsisting in Kenya or elsewhere in respect of those protected goods….. In relation to medicine, this includes the deliberate and fraudulent mislabelling of medicine with respect to identify or source, whether or not such products have correct ingredients, wrong ingredients, have sufficient active ingredients or have fake packaging’.
Such a definition goes beyond the provisions of the TRIPS Agreement Article 51 above.
It implies that legitimate generic versions of medicines fall within the scope of counterfeits. The provisions have thus raised deep concerns among manufacturers and consumers of generic drugs in low income countries as they effectively withdraw the flexibilities provided in the TRIPS agreement to produce and procure generic medicines for public health reasons, and may thus deny patients access to safe and effective, high quality generic drugs.
Generic drugs are produced and distributed without patent protection. They should contain the same active ingredients as the original formulation and be tested to ensure that they are safe and effective. They are usually available once the patent protections afforded to the original developer have expired. However generic drugs can be available during the life time of a patent if national laws provide for the TRIPS flexibilities, under which governments may issue compulsory licences to purchase generic drugs if they are needed for public health reasons. The provisions for compulsory licensing allow for exact copies of the brand to be produced without the consent of the patent owner. Generic drugs made available on under compulsory licensing are not counterfeits, as they are neither fraudulent nor do they infringe trademarks. The proposed legislation on counterfeiting in many east African countries does not recognise this.
For instance the law already enacted in Kenya (Kenya Anti-Counterfeit Act 13 of 2008) and that being proposed in Uganda (Uganda Counterfeit Goods Bill 2009) require the consent of the intellectual property owner to produce a generic version of the drug. This implies that should the manufacture of the generic drug take place without this consent, then what is manufactured is a counterfeit. This requirement undermines the States’ ability to use the TRIPS flexibilities and wrongly applies controls for fraudulent medicines to producers of generic medicines.
The TRIPS flexibilities have been contested in the past as they bias trade law towards social equity and away from corporate interests. The new counterfeit laws open a new possibility for multinationals to limit the flexibilities. The East African Community (EAC) is currently working on a policy and law on Anti-Counterfeiting, Anti-Piracy and Other Intellectual Property Rights Violations, as a “robust legal framework for the protection and enforcement of Intellectual Property Rights” in the region. The technical inputs to this need to be adjudicated for the interests they are advancing. For example, the East African Business Council has reported receiving support for its inputs on anti counterfeiting laws from the Investment Climate Facility. Based in Dar es Salaam, Tanzania ICF describes itself as a unique partnership between private companies, development partners and governments. As viewed from their website, ICF aims to work with receptive African governments to make the continent a better place to do business (http://www.icfafrica.org/). While there are legitimate business interests in protecting against fraud or infringement of trademark, it seems unlikely that an organization like ICF would thus draw attention to provisions that limit business, like the TRIPS flexibilities, when these open branded drugs to price competition from generics. An imbalance in the focus on intellectual property to the cost of access to medicines is precisely what motivated the TRIPS flexibilities, and the same imbalance appears to be creeping back.
Governments should ensure that their counterfeit laws continue to protect gains won through the TRIPS flexibilities and use these fully. For this, counterfeit laws should be clear in their definitions and exclude any possibility of generic medicines being covered by these definitions. Producers of generic medicines should not have to apply for permission from the intellectual property when they are covered by government compulsory licenses and provisions for parallel importation. Drug regulatory authorities should have a role in administration of proposed anti-counterfeit laws where this relates to determinations on counterfeit medicines. It is important for countries in East Africa, and the region as a whole, to ensure that in solving one problem they do not create another. The harm caused by communities in African countries not accessing essential medicines would be enormous.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this editorial please visit the EQUINET website at www.equinetafrica.org.
“I feel free- I am liberated by this new skill- I am now able to communicate my world.”
Meso Ulola, a community member from Bunia, eastern Democratic Republic of Congo pointed to his camera as the instrument of his liberation. Behind him a sequence of photographs from his community told a story: a pregnant woman blocked by a river from the road to health services; community members discussing issues around chalk images on a board; young men heaving logs across a river and images of a motorbike crossing a newly constructed bridge.
In the last five years EQUINET has through Training and Research Support Centre and Ifakara Health Institute been supporting institutions that work at community level to carry out participatory action research studies in east and southern Africa. In each of the nine country sites, in both rural and urban settings, these studies have explored how communities are interacting with health systems. The issues they addressed ranged from how to overcome the barriers people who consume harmful levels of alcohol face in adhering to ante-retroviral treatment, to how to improve communication between people and health workers in local health planning. The reports of these studies can be found on the EQUINET website (www.equinetafrica.org). However, we struggled with how the communities involved could themselves communicate the realities of their lives, actions and insights, and be useful to community discussion on how to address the determinants of health.
We proposed to use photography as one tool for this. Facilitators and community members from the participatory work in seven sites coming from DRC, Kenya, South Africa, Tanzania, Uganda, Zimbabwe and Zambia were trained in photography skills and we embedded photography within the participatory work. We wanted the photos to express the lives of the people involved, to show the diversity of views, to allow both painful and hopeful images to surface, to pose questions, probe, give visions of solutions and actions. The photos were as much a means to encourage local community discussion as to raise wider awareness and community voice on issues. This was not an academic exercise, or about outsiders documenting people as victims, but about community members documenting their own situation and actions to improve social justice in health. We called it “Keeping an eye on equity: Community visions of equity in health”.
It wasn’t straightforward. How to recharge batteries of cameras in communities that had no electricity? How to share photographs so all could comment when internet access is limited and slow? However even from remote areas in Western Kenya or a border town in Zimbabwe, the photos were uploaded to a shared website, we sent comments to each other, and the stories began to emerge through the images. After several months, the photographers chose those images that best communicated their reality and stories. These were compiled, have been shown locally in each setting in different ways, and will be used in ongoing work. They were also compiled by TARSC into an exhibit from all the countries at EQUINETs regional conference on equity in health in September 2009, and used to stimulate discussion on the issues raised, and on the power of different kinds of evidence in catalyzing action on health equity. As one participant at the conference commented: “From other sources of evidence I imagined reality. From the photos I saw reality”.
Some of this work is now produced as a book newly available on the EQUINET website at www.equinetafrica.org/bibl/docs/Eye%20on%20Equity%20book2010.pdf. The book introduces and communicates the work underway, and opens discussion on community photography as a tool for change.
Did we achieve our goal, of raising reality and issues as communities see them, and giving communities more direct voice in advancing equity in health?
When we brought the work of all the countries together, new patterns emerged. For example children and women featured strongly across the images. Its clear that we feel injustice strongly when we see children in unfair and harmful situations. It motivates us to act. Women constantly appeared in the images as active not passive. The images showed how women, often invisibly, are using the resources available to take diverse actions for health. The photographs provided a new lens to discuss what was going on in communities, often raising issues that had become invisible or hidden. Discussing the experience, the community photographers observed that “the camera allowed is to connect with people in unexpected ways, and to hear people’s opinions of their health and health care. The camera seemed to open new channels of communication, raising issues that may otherwise have been buried”. Others observed, “our photographs made us look afresh at unhealthy situations. They have also encouraged us by showing what we have achieved”.
This is important given that our participatory research showed that our health systems have high legitimacy, but weak capabilities for social roles. They weakly address barriers and facilitators to uptake of services and there are many communication gaps between health workers and communities. These issues are well within our grasp to change, but communication is vital for this. The most vulnerable in communities often face an imbalance in power, skills and common language in communicating with health workers, and may deal with this by dropping out of services. Our experience suggests that community photography, embedded within participatory, collective processes, may be one way of offering new power to communities to collectively show their realities, without feeling limited by language.
The way we use and respond to photography has as much to with reclaiming the resources for health as the way we implement research or use evidence. We are bombarded by visual images every day of our lives – pictures on billboards, on many of the consumer products we buy, in leaflets, posters, books, on television or media. Every day we unconsciously interpret and respond to these images, influencing our attitudes, beliefs, values and life style. As Susan Sontag said in 1973, photographs invite us to think or feel in particular ways and “… are inexhaustible invitations to deduction, speculation and fantasy.” In our work as health facilitators and activists, we see that photography in the hands of communities has the potential not only to give communities the power to present reality as they see it, but to use these images to move people from a point of feeling to questioning, to thinking about what change is needed. This is the power of the visual in the right context – to play a part in this process.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please read the PRA reports on the EQUINET website and the Eye on Equity Book.
In the last weeks of 2009, the UN held a meeting in Copenhagen to thrash out a comprehensive global agreement that could be converted into an internationally legally binding treaty to prevent dangerous global warming. By the end of the Copenhagen conference, the outcome was far from this: The conference accord preserved the Kyoto protocol, and while it recognised that global warming be limited to an increase of less than two degrees centigrade, it did not set targets for greenhouse gas cuts. While it set an aim to provide $30bn a year for poor countries to adapt to climate change rising to $100bn a year by 2020, it did not detail the source of these funds. It set no deadline for the conclusion of the climate talks.
The failure at Copenhagen has deep implications for people’s health, particularly in Africa, where the Intergovernmental Panel on Climate Change warn that consequences of global warming, such as loss of wetlands, will lead to increased frequency and severity of drought, further jeopardising food security (http://www.ipcc.ch/ipccreports/tar/wg2/index.php?idp=667). But what role do health activists play in this struggle? What are the special interests of health activists in relation to climate change and what special leverage might people’s health networks contribute in controlling the drivers of global warming? With the prevailing global inequities and the heavy disease burden and high barriers to health care in low income countries, such as in Africa, we need to understand the North- South dimensions of the Copenhagen fiasco.
It appears that the high income countries approached Copenhagen with low ambitions and high conditions, including conditions that tied their own action to comparable commitments from the big developing countries like South Africa, downplaying the role that emissions from high income countries have played in the historical accumulation of greenhouse gases. It appears that the big developing countries, led by China and India, were unwilling to accept the kind of restrictions on their economic development that were being canvassed and were unwilling to slow down what they described as the liberation of millions of desperately poor people from poverty. With pathways to less harmful economic development dependant on access to the necessary non-polluting technologies, the developing countries were not happy with the offers from the rich countries on this front.
Control of global warming and opportunities for economic development are both framed by the wider regime of global economic governance. The inequities, imbalances and instabilities of the global economy, manifest in the global food crisis and the global financial crisis, are direct reflections of this regime. Neoliberal globalisation is built upon a consumerism (with concomitant carbon pollution) that marginalises a billion humans, who are required neither for their labour power nor their buying power. In Copenhagen these inequities were again unmasked, in relation to the crisis of global warming.
It is untenable that these global policy challenges should be allowed to force a choice in low income and developing countries between economic development OR a mitigation of global warming. Rather we need to work towards a regime of global economic governance which reconciles the need for sustainable economic development for countries in Africa and other parts of the global south, and the need to contain global CO2 levels to 350ppm. Such a regime is technically and economically possible. The main challenge is political.
What does this mean for health activists? It raises four imperatives:
Firstly, we need to get our facts straight and build a robust analysis. We need to understand clearly the positions that were advanced by the various groups of countries at Copenhagen, put them in the context of the political economy of energy and global economic governance, and explore their health implications.
Secondly, we need to put sustainable economic development at the forefront of a shared struggle for health and for tackling global warming. This is not the high consumption, low employment, neoliberal globalised production model of development, but a more sustainable autonomous development, based to a large degree on local production and supply.
Thirdly, we need to build pressure on all governments, north and south, to accelerate the reform of domestic energy production and energy use, while continuing to work for binding international agreements.
Fourthly, in addition to energy efficiency and the move to renewables, we need to profile energy equity, or the fair distribution of energy resources across countries, social groups and generations. This has implications for high income countries, where the profligate use of carbon based energy is embedded in culture, economy and infrastructure. It also has implications for the elites and middle classes of low income countries. It calls for an alternative culture of global solidarity.
These four imperatives have implications for the work of health activists.
Comprehensive primary health care is fundamental for improving access to health care and action on the social determinants of health. It is also a strategy of social change through community mobilisation based on partnerships between PHC practitioners and the communities they are serving. It follows that energy reform must be included in the discourse on ‘the social determinants of health’ and community mobilisation for health. It must also be clearly contextualised in relation to the same problems of current economic globalisation that drive inequity in health, raising the challenge of global economic reform.
Global solidarity is central to taking forward comprehensive PHC. This calls for health activists to build communication channels and opportunities for collaboration across various axes of difference (nation, race, gender, religion as well as class) so that the forces for progressive global change can be more coherent and effective. Energy reform (including energy equity as well as efficiency and the use of renewables) must be included in this communication, in the context of economic globalisation.
Intersectoral collaboration is a core principle of all public health work. This calls on health social movements, like Peoples Health Movement, to build relationships with social movements who share common perspectives and values within other sectors, including with those engaging on global warming, environmental justice and energy reform.
Under the banner of the ‘right to health’, health as a basic human right de-normalises the status quo and inspires communities in their struggle for access and for decent living conditions. This is a political struggle as much as it is a moral claim. The political analysis which guides this practice must take us beyond the noise of Copenhagen to explain the workings of neo-liberal globalisation in relation to health, economic development and global warming. Opportunities like the Third People’s Health Assembly, planned for Cape Town in July 2011, are thus important for us to deepen our understanding of these relationships and what this means for our work as health activists in Africa, and globally.
Editor's comment: This issue EQUINET includes a focus on what the climate change discussions mean for health in east and southern Africa. We welcome materials, comments and editorial input from others working in this area, to further develop our work and understanding in the region. Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please also visit the websites of the People’s Health Movement http://www.phmovement.org/ and International People’s Health University http://www.phmovement.org/iphu/
The Trade Related Aspects of Intellectual Property Rights (TRIPs) Agreement of the World Trade Organisation came into effect on 1 January 1995 and set standards for intellectual property systems. Least Developed Countries (LDCs) have until 2016 to bring their systems into line with TRIPS for pharmaceutical patents. Five years may seem a long time. But how far have we come in the 15 years since the agreement was passed?
One of the most important steps taken after the agreement was the successful advocacy at the WTO Ministerial conference in Doha in 2001 to include flexibilities in the TRIPs agreement so poorer countries could address their public health crises, especially given the AIDS epidemic. Paragraph 17 of the Doha Declaration provided that the TRIPS Agreement be interpreted in a manner supportive of public health by promoting access to existing medicines. The flexibilities provided for compulsory licensing or the right to grant a license, without permission from the license holder; for parallel importation or the right to import products patented in one country from another country where the price is less; for exceptions from patentability and limits on data protection and for early working, known as the Bolar Provision, allowing generic producers to conduct tests and obtain health authority approvals before a patent expires, making cheaper generic drugs available more quickly at that time. The World Health Organisation (WHO) in its 2008 Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property, urged for these flexibilities to be implemented in national laws and international agreements, including facilitating, through export, access to pharmaceutical products in countries with insufficient or no manufacturing capacity.
Nine years after Doha, a review of legislation shows that the intellectual property regimes in place in many east and southern African (ESA) countries have not been significantly changed. Patenting laws in many countries (eg Botswana and DRC) were passed before the TRIPS agreement or Doha round. Some (such as Zimbabwe and Zambia) already provided for the flexibilities, but some still have gaps, such as in South Africa, where flexibilities enabling production and export of medicines to the region are still to be enacted. Some countries, such as Kenya, have enacted new laws providing for flexibilities, while in others (such as Uganda and Namibia), these proposals still remain in draft form. While WTO provides for countries to provide the TRIPS Council with "as much information as possible on their individual priority needs for technical and financial cooperation in order to assist them in taking steps necessary to implement the TRIPS Agreement, " so far in ESA only Uganda has taken this step. LDCs in ESA do not have to give exclusive marketing rights to pharmaceuticals that are subject of a patent application until 1 January 2016, but it is unclear how many countries have yet conducted self-assessments to prepare negotiating positions for possible extension of this waiver.
Even those ESA countries that have the flexibilities in their laws are not fully implementing them. They face a number of constraints. Most ESA countries lack domestic pharmaceutical research and manufacturing capacities and have insufficient technical and infrastructural capacities to effectively regulate medicines. Countries have weaknesses in their pharmaceutical management and procurement systems, and in accessing pricing and patent status information. Countries also face economic and political pressures. Stronger property rights (including of intellectual property) is urged as necessary for foreign direct investment and countries face trade and investment pressures not to use the TRIPS flexibilities.
African configurations are at various stages of negotiating comprehensive Economic Partnership Agreements with the European Union, for example. While the underlying 2000 Cotonou Agreement does not oblige ESA countries to negotiate IPR rules and aims for “co-operation” in the field of IPRs, the overall intention of the agreement is to protect intellectual property rights. EU business seeks to open new markets for its exports and this includes protecting intellectual property, given the heavy involvement of EU companies in research and development. The African Growth and Opportunities Act (AGOA (2000) has unilaterally extended market access to ESA countries, with one of the requirements for eligibility being that the country should commit itself to eliminating barriers to US trade and investment by “protecting intellectual property rights,” and desist from interfering in the economy through measures such as price controls, subsidies and government ownership of economic assets. Most recently, anti-counterfeit laws, such as those passed in Kenya, under debate in Uganda and effected through amendments to existing law in Tanzania, while seeking to prevent the damage caused by fake medicines, have the potential to limit the legal production and distribution of generic medicines. When Anti-Counterfeit Laws define a counterfeit as a good that is identical or substantially similar to a good protected under an intellectual property right, they appear in effect to include legal generic products. It seems these states have not designed their anti-counterfeit laws to adequately take into account the protection of TRIPS flexibilities.
A lack of vigilance to protecting the ground won at Doha is now apparent in a new problem. The 2001 public health related aspects of the TRIPS flexibilities now have to be formally adopted at the World Trade Organisation. For this two thirds of countries need to propose the formal adoption. By December 2009, according to the WTO (http://www.wto.org/english/tratop_e/trips_e/amendment_e.htm), only Mauritius and Zambia in ESA had added their names to this proposal. In other words the ESA countries have not added their names to the critical mass needed to enable a formal adoption of the protocol amending the TRIPS agreement at the WTO. This formal adoption should have been implemented by December 2007. The deadline was extended to December 2009, and on 17th December 2009, WTO members agreed to a second extension to December 2011. It is important for ESA countries to now formally propose adoption to avoid the unnecessary renegotiation of these critical amendments to the TRIPs agreement.
Advances can never be taken for granted in a rapidly changing world, and neither can the five year period we have left before TRIPS is fully enforced, for us to put in place a self determined legal, institutional and investment environment for drug manufacture and procurement in ESA countries. For now there is an urgent need for all ESA countries to endorse the protocol on the TRIPS amendments that the flexibilities are entrenched. In the next five years we still appear to have much to do to take advantage of the flexibilities through our laws, policies and capacities, including with respect to the production and export of medicines within the region, and to set the terms for discussions on intellectual property regimes (IPRs) with trade and development partners in a manner that puts us in a stronger position to produce and procure medicines and to protect public health. Our national health strategic plans in ESA should all include clear roadmaps of how we will effectively use the next five years to achieve this.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the SEATINI website at http://seatini.org/ and the EQUINET website at www.equinetafrica.org.
Since the 2005 World Health Assembly resolution calling for member states to pursue universal health systems, there has been growing interest in how this can be achieved in low- and middle-income countries.
The promotion of universal coverage means that health systems should seek to ensure that all citizens have access to adequate health care (adequately staffed with skilled and motivated health workers) and financial protection from the cost of using health care. Universal coverage requires both income cross-subsidies (from the rich to the poor) and risk cross-subsidies (from the healthy to the ill) in the overall health system. This stems from our understanding of equity, which requires that people should contribute to the funding of health services according to their ability to pay and benefit from health services according to their need for care. Prior work in the fair financing theme in EQUINET indicates that there is still a heavy dependence on external funding in some east and southern African (ESA) countries and heavy burdens on poor people through high levels of out of pocket financing.
A key impetus for the World Health Assembly resolution was the growing evidence on the extent to which households in many countries were being impoverished by having to pay for health care on an out-of-pocket (OOP) basis. This has led to an international consensus that prepayment health care financing mechanisms (tax funding and health insurance) should be the preferred sources of funds and that reliance on OOP payments should be reduced, if not completely eliminated. A number of ESA countries have removed user fees at some or all public sector facilities (e.g. South Africa, Uganda and Zambia). While there have been positive effects, such as dramatic increases in the use of public facilities particularly by poorer groups, this has been hard to sustain where there is inadequate funding of public facilities from tax revenue and/or grants from overseas development aid. This has meant that some facilities do not have medicines available and have too few staff to cope with the increased number of patients. Where this has occurred, patients have had to increasingly rely on private health services, paid for on an OOP basis and again face the possibility of impoverishment if costs were high relative to their income levels.
This experience has demonstrated that while it is critical to reduce out-of-pocket payments for health care, it is equally important to improve public funding of health services. This is particularly so, if we are to progress toward universal health systems that provide financial protection and access to needed health care for all. Although private health insurance is a form of prepayment financing, it does little to contribute to universal coverage in low- and middle-income countries. This is because very few people can afford the premiums for such insurance and only those who contribute benefit from the services funded by private insurance schemes. Instead, what is required is the creation of as large a pool of funds as possible that can be used to fund health services that will benefit the entire population. This can be achieved through allocations to the health sector from tax funds, which can be supplemented by mandatory (i.e. compulsory) health insurance contributions by those with the financial means to contribute in this way. Development aid funds can also contribute to this integrated pool of funds, but given the unreliability of external funding and that this source is unlikely to be sustainable in the long term, it is critical that the emphasis increasingly is placed on domestic public funding for health services.
For many years, we have been told that this is simply not possible. The reality is that unless we take steps to make increased domestic public funding of health care possible, we will never achieve universal health systems in Africa. What steps are required? There is a need to increase tax revenue. A number of African countries (including Kenya, South Africa and Uganda) have managed to dramatically increase tax revenue without increasing tax rates, through improved tax collection. Consideration is also being given by some countries to introduce new taxes whose burden falls on the wealthy (such as levies on foreign exchange transactions). Equally importantly, the allocations from tax revenue to the health sector should be increased. Most ESA countries are very far from the Abuja target of devoting 15% of government funds to the health sector. The ability of governments to allocate more funds to the health sector is enhanced greatly by debt relief. Malawi is one country that has made progress towards the Abuja target. This has occurred due to active lobbying by parliamentarians, who put forward a private members bill to secure a government commitment to move towards this target. From the Malawian experience, it is clear that it is important to emphasise that it was the Heads of State that signed the Abuja Declaration (rather than simply Ministers of Health). Many parliamentarians and government officials are unaware or ill-informed about the Abuja target. In addition to improved general tax funding of health services, mandatory health insurance contributions (which are often very similar to a dedicated health tax) could be introduced. The key lesson from other low- and middle-income countries, particularly in Latin America, is that it is critical to integrate general tax allocations for health and mandatory insurance contributions in a single pool of funds to be used for the benefit of the entire population if universal coverage is to be achieved.
While improved domestic public funding of health services will not happen overnight, we need to start moving in this direction as a matter of urgency. We need to understand better how countries have managed to improve their tax collection and how some have managed to successfully motivate for increased allocations to the health sector. We need to continue to mobilise for debt cancellation to free up limited domestic resources for funding social services. We need to protect our health systems from interventions promoted by international organisations that will take us further from achieving universal coverage (such as efforts to commercialise health care delivery and funding). We need to convince our policy-makers that universal health systems can only be achieved through improved domestic public funding of health services.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the Health Economics Unit website at http://heu-uct.org.za/ and the EQUINET website at www.equinetafrica.org.
Worldwide, according to World Health Organisation (WHO) in 2001, mental and behavioural disorders affect 450 million people and account for 15% of the overall burden of diseases from all causes. Yet, nearly two-thirds of those affected do not receive adequate care due to stigma, discrimination, neglect and poverty. Mental health is an integral part of the whole health of a person. Even when physical illness predominates, the mental health status of the person can influence the course and outcome of physical illness. While the prevalence and pattern of mental health disorders are similar in high and low income countries, for low income countries the challenges of providing mental health services are myriad. They range from mental health being given low priority by policy makers, to poor or unavailable services in terms of infrastructure and services, to inadequate health workers oriented to mental health care needs.
Health worker shortages have received increasing attention of late as one of the most critical gaps in the provision of services. Too often, however, the critical gap in mental health personnel is overlooked. There is a particular shortage of mental health workers in low income countries. Estimates show that there is an average of one psychiatrist for two million people in low-income countries compared to one for every 10,000 people in the high-income countries. In Kenya for example, there is one psychiatrist per four million people and mental health services at the primary level are largely left to general nurses and clinical officers. Kiima and colleagues in 2004 found that these personnel readily recognise psychosis, but are less able to recognise learning disorders, emotional disorders and conduct disorders in children and adolescents. Primary care staff who feel uncertain of their skills in this area may not adequately diagnose mental health problems, or may refer cases to higher level facilities. Besides being expensive, this leaves a large number of mentally ill patients untreated. The social and economic cost, as with other areas of unmet need, then falls on the individual, family and community.
It seems unlikely, in the foreseeable future, that we will achieve the psychiatrist: population ratio levels in developing countries that compare to what has been attained in developed countries. This is especially so as internal and external migration draw specialized personnel out of our health systems and out of services in poorest communities where health needs are high. How then can we meet the significant deficit in addressing a public health burden like mental health, at a time of major shortfalls in our health systems?
WHO has in recent years proposed task-shifting as one way of filling the gap in availability of health workers. This implies transferring skills to less academically qualified but more available personnel to provide key services. There are some emergent efforts in Kenya to replicate this for mental health services. The various mental health issues and service roles in different stages of the cycle of prevention, treatment and care are explored to assess where task-shifting provides a feasible possibility to reach the community and improve service provision. These efforts must still be shown to make a real difference in effective services for communities. They need to link skilled health personnel with those in frontline care through supervision and support so still demand these high skill personnel for leadership, and in research and higher training. So task shifting makes it even more important to find effective options for retaining these high skill personnel in their own countries and to link their own desired career paths to the needs of the health system. Kenya has been notable in the region for its production and retention of psychiatrists and could make a very interesting case study on the success of national retention psychiatrists, even though these personnel may not be equitably distributed in the country.
The task shifting debate also draws attention to wider, primary health care (PHC) oriented and innovative options that integrate mental health into other promotive, preventive and curative services at community level. A holistic approach is in accordance with the WHO definition of health, that encompasses physical, social and mental wellbeing. Wiley-Exley in 2007 in a 10-year review of community mental health care in low- and middle-income countries showed that community based care can provide improvements in mental health, even though more work is needed in specific areas such as services for children and adolescents. Preliminary work by Jenkins in Kenya shows that retraining of primary health workers in mental health can have an impact in the number of correctly diagnosed mental health cases and the quality of referrals. Othieno and colleagues, with Department of psychiatry, University of Nairobi and with EQUINET support, have worked with community members in Kariobangi in the suburbs of Nairobi using participatory methods to recognize and find ways of dealing with cases of mental illness in their community. A similar approach has been used to encourage compliance among those with HIV infection who engage in harmful alcohol use. These case reports, both found in more detail on the EQUINET website, suggest that participatory action research methods could be effective in detection and management of mental health issues at primary care services and in the community. More work is needed in this area and if replication in other parts of the country proves its efficacy, it could be included in the curriculum for the health workers at all levels. As noted with the task shifting discussion, however these approaches should be complemented by developing referral and tertiary services, and skilled personnel. This is not only needed to support the implementation and supervision of PHC approaches to mental health, but also because as the needs are recognized, referrals from the primary care facilities are bound to increase.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit EQUINET: www.equinetafrica.org.
In 2008, Members of Parliament from twelve countries in East and Southern Africa pledged to advance health equity and sexual and reproductive health in the region. How much progress had been made a year later? This was the question that was in focus in a follow up regional meeting in September 2009.
At a meeting in September 2008 hosted by Partners in Population and Development Africa Regional Office (PPD ARO), Regional Network for Equity in Health in East and Southern Africa (EQUINET), African Population Health Research Centre (APHRC) and Southern and East African Parliamentary Alliance of Committees of Health (SEAPACOH) with international partners, the members of parliamentary committees on health made commitments to promote primary health care, health equity and reproductive health.
These reflected the fact that parliaments can and do play a key role in promoting health and health equity through their representative, legislative and oversight roles, including budget oversight. EQUINET reports have documented examples of how these roles have been exercised in East and Southern Africa (ESA) to prioritise health in budgets, to monitor the performance of the executive, to strengthen laws protecting health and to keep the need to redress inequity in health and to promote sexual and reproductive health high on the public agenda.
As a unique measure to consolidate this, members of the health committees came together in the Southern and East African Parliamentary Alliance of Committees of Health (SEAPACOH) in 2005, to build a more consistent collaboration of the committees towards achieving individual and regional goals of health equity and effective responses to HIV and AIDS. The committee members carried out field visits to local governments at districts and lower levels to appraise themselves with the prevailing health needs, and mobilised and sensitised leaders at local government levels, in civil society and in communities on health and reproductive health issues. The parliamentary committees on health have met to review this work on health with EQUINET and various partners in 2003, 2005, 2008, and most recently in September 2009. In April 2009 with PPD support SEAPACOH developed and adopted a Strategic Plan for 2009 – 2013. The three main areas of focus identified include: ensuring needs-based resourcing of the health sector; ensuring effective domestication, implementation and compliance with agreed upon commitments in the health sector by governments; and ensuring sustainability of the alliance.
The follow up meeting in September 2009, hosted by the same organizations provided an opportunity to review progress, share experiences and lessons learnt over the past one year on the implementation of the resolutions of the September 2008 meeting.
Parliamentarians shared information on their progress, challenges, and on how to move commitments further forward. Progress had indeed been made since September 2008. For example:
• The East Africa Legislative Assembly have developed model laws on HIV, AIDS and female genital mutilation and is working to develop pooled procurement of drug, medical supplies and medical equipment; to review health insurance schemes, and to explore options for contracting health workers.
• In Kenya, the Parliament is scrutinizing the government budget through interrogating line ministries’ budgets. They have promoted an economic stimulus package, which provides for model health centers to be set up across the country and for twenty nurses to be hired in each constituency. In Kenya, a parliamentary taskforce has been set up to monitor and oversee action on socio-economic inequalities, including inequality in health and access to health care. The health committee have sensitized fellow MPs and the Ministers of Health and Finance on health issues, leading to legal provisions for Health Committees to be include in the budget process.
• In Malawi, Parliamentarians have moved a motion to persuade government to draft legislation on research activities to prevent abuse of citizens in clinical research trials.
• Namibia’s Committee on Human Resources, Social and Community Development were trained in gender based violence, reproductive health and HIV and AIDS in 2009. They undertook field visits to assess the implementation of government policies and programmes with regard to health and education issues; and revised and costed the national roadmap that outlines strategies and guidelines for improving maternal and child health, as a contribution to reducing illness and mortality in 2009.
• The Parliament of Swaziland reported implementing capacity building work on sexual and reproductive health for members. Members have also moved several motions, including on access to health services, and to promote investigation into the increase in abortions among young people and into the increase in maternal mortality.
• In Uganda, Parliamentarians have engaged Ministries of Health and Finance and the media on the need to fund sexual and reproductive health issues and recommended policy changes in the management and administration of the budget for drugs, including for reproductive health commodities. The committee has with the executive allocated additional government resources for reproductive health and HIV and AIDS. The committee has successfully advocated for a budget line of 200 million Uganda shillings (US$105 000) for activities to address female genital mutilation and prepared and presented a private member’s bill entitled “The Prohibition of Female Genital Mutilation Bill, 2009.
• In Zimbabwe, the Parliament has improved the allocation of resources to health in the budget. The committee on health has tabled a motion on the need to link sexual and reproductive health and HIV in programmes and policies that address vulnerabilities of women and children, has lobbied for the provision of appropriate, affordable, accessible and friendly adolescent and reproductive health services and are currently crafting a policy on male circumcision as one of the added strategies to reduce HIV infection. This was supported by a number of research studies in areas of sexual and reproductive health.
With these areas of progress taking place, the need to network regionally to share progress and experience was evident. In agreeing on a way forward over the next year, the committees agreed to operationalize the SEAPACOH Strategic Plan, including strengthening their own networking and communication across the region. This will enable those making progress in key areas of health to share information on achievements, to exchange experiences in their oversight of regional commitments and international agreements and to support new and innovative programmes to enhance health, including reproductive health. The adoption of common platforms and a regional agenda can only make the work of the individual committees stronger.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed and the regional parliamentary meeting please visit the websites of PPD ARO: www.ppdafrica.org; EQUINET: www.equinetafrica.org; and APHRC: www.aphrc.org. The SEAPACOH strategic plan is at http://www.equinetafrica.org/bibl/docs/SEAPACOHstrategicplan09.pdf. The 2009 commitments are included in this newsletter and are also at http://www.equinetafrica.org/bibl/docs/RegParl%20mtg09%20res.pdf. The resolutions and report of the 2008 meeting are at http://www.equinetafrica.org/bibl/docs/REPMET0908parl.pdf and http://www.equinetafrica.org/bibl/docs/RESsep2008parl.pdf.
The Third EQUINET Regional Conference on Equity in Health in East and Southern Africa, held 23 –25 September 2009 in Munyonyo, Kampala, Uganda brought together over 200 government officials, parliamentarians, civil society members, health workers, researchers, academics and policy makers, as well as personnel from United Nations, international and non-governmental organisations from East and Southern Africa and internationally.
Conference delegates recognised the significant, growing, avoidable and unjust inequalities in health and in the resources for health in our countries, our region and our world. The conference reiterated the findings of the World Health Organisation Commission on the Social Determinants of Health that this social injustice is killing people on a grand scale.
We note that we have the resources for health within our region; that many resources important for health, including health workers, flow out of Africa; that the remaining resources do not reach those with greatest health needs, and that inequality blocks economic opportunities from reaching those who need them most.
We affirm that we stand for equity and social justice in health. We recognise that unless we address inequalities in health and in the resources for health, we will not achieve the policy goals set in the 1999 Southern African Development Community Protocol on Health, the resolutions of the Ministers of the East Central and Southern African Health Community, nor the United Nations Millennium Development Goals;
We affirm that it is imperative that we act to improve heath equity, and to reclaim the resources for health.
Our deliberations indicated that health equity is advanced when:
• health is integrated within national policies and goals,
• equity in health is a political and social goal, advocated, planned for and monitored,
• our health systems have strong public sectors, and redistribute resources towards those with highest health need, and
• the role of people – communities and health workers- is valued, resourced and supported;
Towards this, we call on all in the region, our international partners, and propose ourselves, to intensify efforts to:
Advance equity in health as a political and social goal and in all policies:
• Monitor and ensure that the right to health is included in our constitutions, provided for in our laws and universally applied, especially for vulnerable groups;
• Strengthen community awareness and capacity to claim these entitlements;
• Advocate for the promotion and protection of health in all policies, particularly those that provide for the social determinants of health, including education, safe water and sanitation; food sovereignty, energy and technology;
• Organise evidence and raise awareness on health implications of trade and intellectual property regimes and of new technologies and strengthen negotiating power to ensure that they protect health, particularly given the corporate control of resources;
Build universal, redistributive and people centred health systems:
• Identify and advocate for clear, comprehensive and integrated health care entitlements that secure universal coverage of health systems;
• Identify and implement options to strengthen, resource and organise primary health care and inter-sectoral action for health as a priority in health systems;
• Generate and share evidence on and implement options to close gaps in access to key services for priority health conditions, including for maternal, family and child health, for mental health and for improved nutrition;
• Organise the evidence, advocacy and political support to meet and go beyond the 2001 Abuja commitment of 15% government spending on health - excluding external funding; and to promote increased per capita spending on health, supported by debt cancellation;
• Meet the “people’s Abuja” of at least 25% of government spending in health allocated to the primary care and community level of the health system;.
• Support plans and strategies for harmonising the various health financing schemes into one framework for universal coverage, reducing out of pocket payments, providing for cross subsidies and pooling resources from progressive tax funding and prepayment schemes;
• Support the removal of user fees through a sustainable, planned strategy that strengthens the health system;
• Support the development and implementation of plans to deploy and retain health workers in decent working conditions and to ensure consistent availability of vital and essential drugs and supplies at primary and district levels of health systems;
• Draw on the growing body of evidence on the causes of health worker migration and measures for health worker retention, promote constructive engagement across health workers, trade unions and governments to ensure that country driven strategies for retention are negotiated, resourced, implemented and monitored;
• Strengthen public sector systems and capacities, including for financial management, to improve equity in the allocation of resources, and to absorb and effectively use the resources for health;
• Through civil society and parliaments, monitor how funds are used and how services are provided;
• Ensure effective regulation of the private-for-profit sector so that it complements public sector provision and to prevent negative impacts on health equity;
• Identify, make visible and overcome the barriers that disadvantaged and vulnerable communities face in accessing and using health and essential services;
• Noting that AIDS is one of a number of disease burdens and that approaches to HIV and AIDS should integrate with programmes for all major health problems, resource and strengthen rights based, holistic, integrated primary health care oriented approaches to prevention, treatment and care for HIV and AIDS, that recognize and act on the social barriers to access and uptake of services; that build links between communities and services; that recognize and train traditional healers, community health workers, peer support networks and non-medical health providers; that provide prevention and treatment to health care workers; that strengthen local safety nets and that address disparities in access to services across gender, area and income and for children, commercial sex workers and other vulnerable groups.
Recognise and support the central role of people – communities and health workers –leadership and alliances in advancing health equity:
• Recognise and formally provide in laws, budgets, mechanisms and programmes for the central role of people in health systems; to build informed empowered communities and health workers and participatory processes for community involvement in health;
• Demand and strengthen capable strategic leadership, stewardship and management in health systems; who consult, engage with and harness the range of constituencies and resources needed to advance health equity;
• Develop the communication, engagement, capacities and networking to strengthen government, civil society, health worker, parliament and researcher alliances to shape, advocate, implement and monitor the policies that promote health equity;
Monitor and make visible progress and gaps in advancing health equity:
• Monitor and make visible the progress and gaps in advancing health equity through implementing an Equity Watch at country and regional level, in a manner that builds alliances across actors; that analyses health disparities, including gender differentials; that makes visible progress against benchmarks and drivers of health equity; that complements a core framework of parameters with deeper district and household level assessment and that combines different forms of evidence, including from community level photography, to stimulate action on equity.
• Develop and promote investment in and capacities for a research agenda on health equity, including on new challenges, such as how climate change and globalisation are affecting health; on operational issues, such as how health systems are functioning after the removal of user fees; and to inform policy development, such as on the effects of the private-for-profit sector and of commercialisation in health systems on health equity;
• Build capacities amongst researchers to involve stakeholders from the earliest stages of research and to effectively communicate evidence.
We call for these efforts to be supported by wider levels of social justice globally and for a more just return for east and southern African countries from the global economy. The net outflow of resources from Africa must be reversed and the strategic resources of Africa used for the development and security of its populations.
We call on our international partners to advocate and engage with us to achieve:
• The global commitment to and resourcing of the universal rights to health in the International Convention on Economic and Social Rights, the Convention on the Rights of Children and the Convention on the Elimination of Discrimination against Women,
• G8 targets of universal access to prevention, treatment and care for HIV and AIDS and the UN Millennium Development Goals;
• Debt cancellation, with the resources released channelled to human development;
• Economic justice, fair trade, and democracy in the governance of global financial institutions;
• Bilateral and multilateral agreements that recognise and redress the resource outflows that affect African health and health systems, particularly from health worker migration.
• Genuine partnerships and external funding aligned to national priorities, that are developed through participatory and informed consultation with the people.
We will all take these commitments forward into our various organisations and forums. The conference has set a programme of work and action for all of us. EQUINET, as a consortium of institutions from the region, is committed to take and support these actions to advance health equity, to produce and share evidence and good practice and to advocate and monitor equity and social justice, especially through the equity watch. EQUINET is committed to building the intergovernmental, parliamentary, civil society, health worker and academic forums in East and Southern Africa to strengthen our values based leadership, democratic states and regional integration and co-operation in Africa, to reclaim the resources for health and advance health equity.
In the face of injustice it is imperative that we act.
A note from the editor: This oped presents the resolutions made and adopted by delegates at the EQUINET Regional Conference September 2009. In future issues of the newsleter we will give profile to specific areas of and reflections from the conference, whose ideas, community and exchanges re-energised and informed our work, actions and interactions towards advancing health equity. The abstract book for the conference is available at http://www.equinetafrica.org/bibl/docs/EQ%20Conf%20Sep09%20abstract%20bk.pdf and the conference report will be available on the EQUINET website in November. Please contact the EQUINET secretariat admin@equinetafrica.org for any queries or feedback on issues relating to the conference or resolutions. For further information on the conference, the papers presented or EQUINET work please visit the EQUINET website at www.equinetafrica.org.
Throughout Southern Africa, there are few programmes to protect the health of workers, or occupational health. Public funding in the region for occupational health services and the enforcement of occupational health laws generally comes from tax or social security funds. However these funds are inadequate to do more than run basic systems. Programmes to develop personnel, do research or expand services into new areas such as for informal sector workers or for women, rural or other marginalised workers, often relies on aid from high income countries.
These areas are some of the more challenging areas of occupational health, and often those with greatest burdens to population health. They are thus important for workers, communities and countries. Yet as aid funded, the developmental objectives for such programmes are often set by funders, with little in-country stakeholder consultation, and with relatively unpredictable financing.
Two recent Southern African regional programmes have deviated from this. These are the Swedish International Development Agency funded Work and Health in Southern Africa (WAHSA) programme and the Fogarty International Centre funded University of Michigan Southern African programme in Occupational and Environmental Health. To their credit, and strongly contributing to positive features noted in the evaluation of these programmes, the international partners involved in both the WAHSA and Michigan programmes made efforts to consult with relevant stakeholders in the region. Nevertheless their objectives and support are still subject to the priorities of their funding agencies.
The “Paris Declaration on Aid Effectiveness” (the “Paris Declaration”) in 2005 established new ground rules. At the 2005 conference convened by the high income OECD countries, but also including developing country representation, a revised and co-ordinated approach to development aid was promised. The Paris Declaration aimed to better manage the process of providing aid; ensure alignment with national development strategies and encourage beneficiary control and leadership in development programmes.
There is already recognition of some gaps between the noble promises and the outcomes to date. A 2009 OECD report commented on some fragmentation of effort, observing that ‘‘the international development effort now adds up to less than the sum of its parts’’. Sixteen Sub-Saharan countries were noted to have between 24 and 30 external funders, and eight of these to have between 15 and 20 external funders, suggesting that the rationalisation intentions of the Paris Declaration have not been met. The north – south network ‘Reality of Aid’ (http://www.realityofaid.org/) noted that there has been limited community participation in setting in-country agendas for aid. In their January 2007 newsletter, the network argue that the influence of external funders in recipient country policies has persisted through funder -imposed conditions on funding. This was highly contentious during the discredited Structural Adjustment Programmes of the 1980’s, and a United Nations Conference on Trade and Development report in 2000 identified eighty two governance-related conditions out of an average of one hundred and fourteen conditions for each IMF and World Bank agreement in Sub-Saharan Africa.
Despite the promise of better co-ordination, the Paris Agenda has also left a significant gap in partnership on occupational health, despite recognition of the contribution of employment and workplace risks to health equity in the recent report of the WHO Commission on the Social Determinants of Health. Funding for occupational health does not seem to be on the agenda of any major bilateral funder (excluding foundations such as the US Fogarty International Centre and the US National Institutes of Health). Given negative experiences of early termination of long term external funding support to occupational health in the region in the 1990s, the Paris Agenda offered optimism for sustained predictable support to this neglected area. Instead, since 2005, two bi-regional externally funded programmes in Southern Africa (WAHSA) and in Central America (SALTRA) met early termination, as the funding agency realigned from regional to country support.
As the Paris Agenda discussions recognised, achieving meaningful impacts in health outcomes or in institutional policies, capacities and practices calls for long-term time frames and commitments to plans, backed by predictable resources and clear processes for monitoring, evaluation and reporting. Uncertain funding leads beneficiaries and funding partners alike to focus on quick returns, rather than deeper impacts. Funding agencies, partners and local recipients may thus set and focus on meeting targets that seem feasible in short term time frames to justify use or continuity of funding, while not adequately yielding the long term gains from these investments. So, for example, numbers trained may be given more attention as targets than longer term structural outcomes, such as the integration of trained personnel into positions in institutions where they are able to influence policy and practice.
Past experience with development aid in this area has raised more questions than answers. How do national and regional organisations involved in a neglected area like occupational health strengthen self determined planning, resourcing and negotiation of programmes and partnerships in conditions of volatile external aid? How can unpredictable, limited and often inadequate funding be organised to support longer term capacity development? How can just demands for accountability and effectiveness be aligned to equally just demands for predictability and recognition of complexity? How best can the self interests of different partners be made explicit, negotiated and factored into partnerships from the beginning?
One way of addressing national leadership must be for countries to improve their own resources for occupational health, not just to run the systems, but to enhance and improve them. If we pursue “fair trade not aid”, then occupational health could be funded in a sustainable manner from improving returns on economic activities and strategic resources in the region. During the structural adjustment era, occupational health responsibilities were deregulated and corporate obligations and taxes reduced to attract foreign investment (which often did not materialise). The public health costs of structural adjustment in Africa are now recognised through the Macroeconomic Commission on Health. Claims for improved public funding for the health sector have had greater recognition, such as in the 2001 Abuja commitment made by African heads of state. There has not been a similar recognition for improved regulation and funding for occupational health. Yet as production and financial activities are increasingly globalised, with recognition of the environmental, economic and social obligations this generates, so too should investment in occupational health be prioritised and located as a matter of international responsibility, in line with fair trade, economic justice and rights to health.
It is time for a movement from within and beyond the trade unions, occupational health, economic and trade justice communities to link with the public health and health justice activists to raise occupational health within global, regional, national and local agendas. To support this with sustained and self determined action within the region, we need to strengthen regional organisation and networking to provide evidence for and engage with local and regional policy, including with intergovernmental forums such as SADC, to ensure sustainable domestic and regional resourcing of occupational health, and to advocate on the priorities for occupational health in the region within the international community.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For more information on occupational health in the region visit the EQUINET website and the WAHSA website at www.wahsa.net