Editorial

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

1. AFRICA MUST ACT WITH GREATER URGENCY ON HIV/AIDS AND THE RIGHT TO HEALTH

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

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

Summary

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

Recommendations

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

Situational analysis

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

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

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

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

Expand public financing for health and education

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

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

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

Debt cancellation is pre-requisite for progress

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

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

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

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

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

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

Industrialised countries must deliver on their aid commitments

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

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

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

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

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

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

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

Improving Access to Care and Support

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

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

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

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

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

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

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

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

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

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

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

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

Conclusions

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

Recommendations

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

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

2. SUMMARY OF DECISIONS OF THE AFRICAN UNION FOURTH ORDINARY SUMMIT, ABUJA, NIGERIA JANUARY 2005
Compiled By: Eve Odete, Pan Africa Policy Officer, Oxfam GB
Summary of Decisions of the African Union Fourth Ordinary Summit, Abuja, Nigeria Jan 2005

Key Meetings

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

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

Permanent Representatives Committee
Ninth Ordinary Session

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

Rationale for this compilation and the policy cycle it documents

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

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

1. Health and HIV/AIDS

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

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

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

Assembly of the Africa Union
Fourth Ordinary Session
Decisions and Declarations

Assembly/ AU /Dec. 55 (1V)

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

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

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

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

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

2. Trade

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

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

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

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

On Negotiations of the Economic Partnership Agreements:

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

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

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

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

The Executive Council
Sixth Ordinary Session
Decisions

Doc. EX.CL/151 (VI)

Decision on WTO negotiations

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

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

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

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

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

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

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

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

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

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

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

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

Executive Council-Rapporteur’s Report

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

Decision on the negotiations of ACP-EU economic Partnership Agreements

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

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

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

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

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

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

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

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

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

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

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

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

3. Food Security

Permanent Representatives Committee
Ninth Ordinary Session
Report (1X)

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

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

Executive Council
Sixth Ordinary Session
Rapporteur’s Report

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

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

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

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

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

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

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

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

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

Assembly of the Africa Union: Decisions and Declarations

Assembly /AU/Dec.59 (IV)

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

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

Agriculture

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

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

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

Abuja and more: Securing the resources for health
Rene Loewenson, TARSC/ EQUINET

On December 10 the Africa Public Health Rights Alliance launched an important “15% now!” campaign. We carry information on the campaign in this newsletter, and its call for African heads of state to allocate 15% on government spending to health, as promised at the African Union (AU) summit in Abuja, in 2001.

There is clear evidence of the pressing demand for significantly improved resources for health in east and southern Africa (ESA): We see it in high levels of poverty and deprivation, persistently high HIV, AIDS and other preventable diseases, high rates of child and early adult mortality, inadequately staffed and resourced public health services and massive inequalities in health outcomes between sub-Saharan Africa and other regions. The EQUINET newsletters in 2006 have presented different facets of this evidence. Health is determined by the conditions in which people live, work and interact, and depends on policies and spending beyond the health sector. The investments in the health sector are, however, critical, especially in the context of high levels of inequality and poverty. These investments can prevent avoidable illness and mortality, redistribute social resources to deprived households, protect against the impoverishing effects of ill health and demonstrate our values and commitment as a society to human security. As our May newsletter editorial suggests, health sector investments have greatest impact on low income communities when they are made in public sector primary health care and district health systems.

The World Health Organisation estimated in 2000 that an expenditure of US$60 per capita is the minimum level of health expenditure needed for a health system to function well. The Macroeconomic Commission on Health estimated in 2003 that a minimally adequate set of interventions to meet the basic health needs of poor communities is between US$34 and US$38 per person per year, not including some of the wider systems demands for a functional health system. However African health systems and communities face challenges that call for additional resources: The World Bank estimated in 2002 that Africa would need an additional US$4.2 billion to meet the costs of HIV prevention and AIDS Care, given the scale of the epidemic. Meeting the Millennium Development Goals (MDGs) adds to this cost. This makes an expenditure of US$60 per person per year a not unreasonable estimate, and one that would need to be made largely in the public sector if the benefits are to reach poor households.

Yet many public health sectors in ESA are trying to deliver health systems, pay health workers and respond to health challenges on less than $15 per person per year, and some on less than US$10 per year. Overall per capita expenditures on health in the region, public and private combined, average less than US$30 per person per year, while government spending on health is less than 10% total government spending for the majority of countries in the region.

Increasing to 15% of Government spending on health is an important and necessary sign of government commitment to health, even while it would not on its own for most countries in ESA provide adequate per capita resources for health. The call for “15% now!” justifiably calls for implementation of this commitment. If the 15% target is met through increased donor resources and not through increased application of domestic revenue, it is not a clear test of that commitment and is vulnerable to donor withdrawal. The “15% now” should thus be understood to exclude donor resources.

However, many countries in the region need more than the 15% government spending. Additional resources must be applied.

One of the sources for this must be debt cancellation. With over US$ 100 billion external debt in ESA in 2003 and even more paid out over three decades to service the debt, current debt relief measures are inadequate to overcome “debt domination”. Applied over many decades, with relatively small reductions in annual debt, they still leave African countries with significant debt burdens and deplete domestic resources for heath. As in last year’s call by civil society organisations and governments in the South-North consultation on alternatives to debt domination, the a call for “15% now!” must go together with a call for “Debt cancellation now!”.

Debt servicing is only one of the many ways resources are flowing out of our region. As demonstrated in the April EQUINET newsletter editorial, unfair and unequal terms of trade, outflows of private finance, shifts to speculative foreign investment, phantom aid, a massive outflows of health workers and global exploitation of non renewable African resources represent some of the vast and ongoing outflows of the continent’s existing and potential wealth. A recently released UN WIDER report included in this newsletter observes that inequalities in wealth have widened, with the richest 2% of adults in the world owning more than half of global household wealth, while the bottom half of the world adult population –a large share in Africa - own barely 1% of global wealth. Net outflows of African wealth represent a perverse flow of resources for health from those with greatest health needs in the poorest regions, to those with least health needs in the wealthiest regions.

This calls for a global response. An increase in predictable long term overseas development aid would provide one means of addressing this situation, and could be applied to increase the per capita spending on health to more meaningful levels, over and above the “15% now”. Efforts by some G8 countries to explore new sources of tax funding for global transfers are important steps towards this. So while African governments must be accountable for their 15% to health, so too wealthy countries must honour their commitment to “0.7% GDP to ODA now!”

But achieving global commitments to health in ESA calls for more than increased aid. Global commitments to universal access to antiretroviral treatment discussed in our June newsletter editorial, or the social development goals set at the 1995 World Summit for Social Development (WSSD), discussed in our November editorial, call for enabling, accessible, responsive and accountable states committed to mobilize the resources for health (15% now!), unencumbered by excessive debt servicing (Debt cancellation now!) and supported by ODA (0.7% GDP to ODA now!) Yet this can leave governments and people in ESA heavily reliant on external aid for their health, while wealthy groups in high income countries and corporates continue to benefit from trade, finance and resource outflows from the region. Levering increased investments in heath must be backed by challenge to these resource outflows and to the trade and macroeconomic policies that intensify inequities in control over the resources for health. “Reclaim African wealth for African health...now!”.

Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat at TARSC, email admin@equinetafrica.org

Access to antiretroviral treatment in Africa
Rene Loewenson and David McCoy

The demand for people living with HIV and AIDS in Africa to access treatment cannot be ignored. At the same time the challenges to meeting this demand are many. They include the shortfalls in health services and lack of knowledge about treatment, making decisions about newer regimens, and the risk of resistance to antiretrovirals highlighted in the paper by Stevens et al (p 280). (1 2) The challenges also include ensuring uninterrupted drug supplies, laboratory capacities for CD4 monitoring, accessible voluntary counselling and testing, trained healthcare workers, and effective monitoring of resistance to antiretroviral drugs.(3) A series of papers produced in 2003 through the southern African regional network on equity in health raised further concerns about measures to ensure fairness in the rationing of scarce treatment resources and the diversion of scarce resources from strained public health services into vertical treatment programmes.(4-8)

The reasons for these challenges are not a mystery. They stem from the chronic under-resourcing of health systems, the underdevelopment of strategic public health leadership, the attrition of health personnel, and the high prevalence of poverty, factors that already limit the delivery of many less complex primary healthcare services.(5-7) Given this context, how should resources best be allocated to ensure access to treatment for HIV/AIDS in Africa?

Existing initiatives provide some indications of what to do and what not to do. Making treatment accessible through private and non-government sectors or through redeployment of personnel without addressing the staffing, pay levels, and working conditions of health personnel in public health services can further increase attrition from essential services and aggravate uncoordinated health planning. (7)

Providing treatment on a "first come, first served" system favours urban, higher educated people who are not poor. It also unfairly delegates frontline healthcare workers to decide who does and does not access treatment, resulting in inconsistencies and even corruption. (8)

Providing treatment at central hospitals without strong links to community outreach or primary healthcare services weakens the link between prevention and care. It also limits the benefits that treatment brings in reducing stigma to the higher income users of these hospital services. (5 7) Vertical programmes established to achieve rapid delivery against unrealistic targets can divert scarce resources from strained public health services and bring undesirable opportunity costs and inefficiencies through the creation of parallel management and administrative systems.

In contrast, approaches to expand access to treatment can simultaneously strengthen health systems; build synergies between treatment, prevention, and primary healthcare services; and reach vulnerable groups. For example, when treatment is linked to prevention of parent to child transmission of HIV, provided through maternal health services, the likelihood of women having enhanced access to treatment, reduced social stigma around AIDS in women, and strengthening general maternal health services for all women is greater.

Criteria for selecting patients that explicitly target low income groups or particular subgroups of the population such as health workers and teachers (because their job promotes services for poor people), or that involve communities in decisions about selecting patients, can enhance equity and prevent the development of patronage or corrupt practices around treatment. Community health workers have had an important role in Africa in nutrition, immunisation, maternal health, child spacing, and many interventions that enhance health and treatment related literacy. Developing their role in access to treatment could strengthen primary health care and should be further explored. (7)

Such approaches to treatment access on a national scale will be possible only if the health system is properly organised, coordinated, and managed, and if it is adequately resourced. Organisationally, the principles of a district health system should remain paramount as a remedy to the destructive effects of uncoordinated, disease focused, vertical interventions. For such systems to be functional, we need to address the growing shortfalls and maldistribution of personnel and resources in African countries. (8 9)

If effective, equitable, and sustainable approaches to treatment access are to be replicated, considerable new resources will need to be channelled to Africa's health systems, particularly for district level services. Such resources should come from national public budgets, overseas development aid, global funds, and from the cancellation of debt. The International Monetary Fund and World Bank medium term expenditure framework constraints currently limiting the uptake of increased resources in the public health sector also need to be revisited.

The global recognition of rights to treatment reflects a significant shift in mindset. Another shift is now needed to deliver on those aspirations. Health systems cannot be built from a patchwork of non-government, vertical, ad hoc services around a crumbling public sector core. For treatment access to become a reality for more than a minority, a further step needs to be taken towards an explicit global and national commitment to refinance Africa's public health sector and district health systems.

* For a list of references, please click on the link below. This article was an editorial in the 31 January issue of the British Medical Journal. http://bmj.bmjjournals.com

Further details: /newsletter/id/30256
ACCESS TO ESSENTIAL DRUGS MAY BE UNDERMINED BY GLOBAL PATENT AGREEMENT
December 1, World AIDS Day

A third of the world’s population still has no access to essential drugs. In the poorest countries of Africa and Asia this figure rises to half. With the global agreement on intellectual property rights (TRIPS) forcing countries to introduce new patent protection laws over the next decade, this situation could worsen, according to a new report from the London-based Panos Institute.

Developing countries have until 2005 or 2016 to implement TRIPS-compliant legislation on pharmaceuticals. So far many governments have drafted or enacted legislation that seems to prioritise patent rights over public health. Some countries are being pressurised into adopting policies that go further than TRIPS in protecting patents. Patents give big international pharmaceutical firms monopoly over production of new drugs, including, for example, those needed to treat HIV/AIDS.

There is concern they may push up prices, and the TRIPS rules could thus limit poor countries’ freedom to buy cheaper “generic” versions of patented drugs. For example, in January 2001, South African HIV/AIDS treatment activist Zackie Ahmat went to Thailand to buy 5,000 pills of the generic version of an anti-fungal drug patented by the US pharmaceutical giant Pfizer. He paid $0.21 a pill. The price of the patented version in South Africa was $13.

The Panos Report, 'Patents, Pills and Public Health: can TRIPS deliver?' warns that patent legislation is not being debated widely enough in most developing countries, and the process of introducing it needs to be more consultative and transparent. In Uganda, for example, American consultants were brought in to review the country’s patent laws and make proposals for reform. The result was the drafting of laws which, according to local campaigners, are skewed in favour of business interests rather than social or development needs. The principle of extending access to essential drugs in poor countries is widely supported, but the means of doing this is still hotly disputed, says the report.

According to the World Bank, middle-income countries may benefit from increased foreign investment, but if the cost of drugs rises as a result of patent systems spreading throughout the developing world, there is a real danger of restricting access to drugs, such as anti-AIDS drugs, where they are most needed. The World Health Organisation suggests that implementing patent protection where it did not already exist would result in the average price of drugs rising, with projected increases ranging from 12 to 200 percent.

The pharmaceutical industry argues that patent systems promote innovation and investment in research and development. Without patents, new ones would not be developed to tackle diseases such as tuberculosis and HIV/AIDS. They believe the real barriers to making drugs more available are poverty, weak political leadership, lack of trained health personnel and poor health infrastructures.

The report examines alternative approaches and gives examples where differential pricing (where poorer countries pay considerably less for a product than wealthier ones) and compulsory licensing (where a patent is overridden in return for a payment of a royalty) have potential, although they are not free of problems. Two countries highlighted in the report, show how differently patent protection can impact on the nation’s public health: Brazil is seen as a model for other countries of what can be achieved for public health by boosting local production of drugs such as the anti-AIDS drug AZT, lowering prices through competition and negotiating discounts on patented drugs. Between 1996 and 2001 around 358,000 AIDS hospitalisations were prevented, saving around $1.1 billion. On the other hand, Thailand’s capacity to provide essential drugs for its people has been severely limited in the last decade due to relentless pressure from the US to tighten up its patent laws which, they complained, meant the loss of $30 million a year in sales for the American pharmaceutical industry because it referred only to pharmaceutical processes and not products. The US went as far as imposing $165 millions’ worth of sanctions on eight Thai products exported to the US. The US continued to exert pressure until the patent laws were changed and made even more restrictive than the international TRIPS agreement requires.

“This report should be a wake-up call to developing countries to look carefully at how they go about complying with TRIPS legislation and make sure that access to essential drugs is kept as an overriding right for the entire population – not just a wealthy few” says Martin Foreman, author of the Panos report.

* The full report and additional country studies can be downloaded from this website http://www.panos.org.uk/

* The Panos Institute is an independent, non-profit organisation specialising in communication for development. It works to catalyse informed public debate, particularly in developing countries. It has 12 offices in Africa, Asia, Europe and the Caribbean.

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

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

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

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

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

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

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

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

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

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

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

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

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

Accountability for Health Equity: Reflections for Southern Africa
Cynthia Ngwalo Lungu, Johannesburg, South Africa


In July 2017, I attended a conference by the Institute of Development Studies (IDS) themed ‘Unpicking Power and politics for transformative change: Towards Accountability for health equity’. The conference examined the practices and politics shaping accountability in health systems from local to global levels. As a southern African, these are my reflections on this from the conference discussions.

Accountability for health equity is essentially about citizens being able to hold governments to account to deliver health for all. It is about inclusivity and ensuring better health for the less privileged, marginalised and vulnerable people.

It is commonly known that within Southern Africa public sector financing for health is meagre and below the 15% committed to in the Abuja declaration. People in need struggle to access health care. In some countries people walk up to 30 km to get to the nearest health centre, only to find that it doesn’t have the basic resources to function. In countries where the health system has largely been privatised it can be virtually impossible for poor people to afford health care. This situation is worsened when there is abuse of resources, a lack of transparency in health management, a lack of public information on health budgets and expenditures, when budget and policy processes are centralised in a top down approach that allows for little or no citizen participation in decision-making.

In response, the region has seen a rapid development of social accountability initiatives that trigger active citizenship, where communities actively participate in health decision making and hold governments to account on how resources are mobilised and used. The Centre for civil society capacity building, a Mozambican organisation, recounted in conference how social accountability initiatives in that country have improved transparency in resources for health and but influenced the development of formal national mechanisms for health accountability using scorecards for citizens to input to decisions and provide feedback on services.

While these efforts have achieved varying positive outcomes, they often tackle ‘low hanging fruit’, addressing local challenges like health worker attitudes or cleanliness within the vicinity of health facilities, thereby bringing about change in local practice. While these changes are commendable, they are often tied to project timelines, are localised and often do not trigger national level changes. Community level initiatives have struggled to address more systemic challenges, such as access to information, budget setting or expenditure tracking and bottlenecks in procuring and supplying medicines. The IDS meeting argued that this is because social accountability efforts have failed to respond to higher level constraints affecting the ability of local service providers to respond to community feedback. Much more broadly social accountability initiatives have in some cases failed to recognise the complex power dynamics that are typical of health systems. Social accountability efforts ought to engage with power if they are to bring about equity and social justice, otherwise, there is the risk that initiatives will simply replicate existing social hierarchies.

Another factor affecting these social accountability initiatives is sustainability and ability to outlive short-term project timelines. There is a need to cultivate an active citizenship that raises voice to point out accountability concerns without relying on external drivers. Given the weaknesses in general environments to support this, we need to recognise and explore the role of formal structures for accountability in health, notwithstanding their pitfalls. This implies critically considering the extent to which the community voice can be integrated with local level formal accountability structures without being compromised or ‘swallowed’ by them. In the Northern part of Malawi, for example, the Catholic Commission for Justice and Peace has cultivated an active citizenship that engages within the formal mechanisms in health, as a form of structured and sustainable citizen engagement with the health system.

From the convening it was very clear that social accountability initiatives should respond to particular contexts. For example, in the case of politically charged states within Southern Africa, communities and civil society pushing for health rights and social justice are often tackling a wide range of issues that may confront power and carry unintended political connotations. Traditional social accountability tools and approaches which work in accommodative participatory environments may not be useful in politically charged contexts as Social accountability proponents become human rights defenders who need a unique set of skills to pursue issues without risking their own lives and security. The operating environment calls for unique capacities, language, strategies and mechanisms to achieve results without exacerbating conflict.

While many of these social accountability initiatives appear to focus on public sector services, there are other non-state and private for profit actors involved in the delivery of health care. Across the region health has attracted markets and business operators resulting in a range of providers, in some cases in public -private -partnerships. How do we ensure that in the face of a growing private sector, public interests continue to take centre stage as a means to achieving equity in health? What mechanisms can be used to hold these private actors to account on social goals and health needs, when their preoccupation is with profit margins and ‘fair returns’? Lessons from the negative effects of pluralistic health markets in other countries, such as Mongolia, can be used by the region to inform the development and implementation of sound regulation of the ‘business of health’ and to ensure that PPP’s and health financing schemes including health insurance are developed in an accountable manner and in line with equity goals.

These are significant challenges, but there are also opportunities to strengthen accountability through innovation. Despite low internet penetration and high telecommunication charges in some parts of the region, information technology is spreading. Throughout the region, technology is fast becoming a powerful tool in pushing for social economic rights- with the click of a button communities can voice public health concerns or access critical health sector information. With these tools, the means to accountability for transformative change may indeed lie in people’s hands!

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the IDS meeting can be found at http://www.ids.ac.uk/opinion/naming-the-moment

Acting on health through theatre for a change
Ethel Chavula, Grace Mathanga, Theatre for a Change, Malawi


Grace was born in a family of 9 children. She was still in school when her mother became ill, so she dropped out to care for her. She married when she was young. “God blessed us with 2 children, both girls. Then my two children and my husband died of AIDS. I too have HIV and will never marry again”, she says. When her husband died she had no support for her life as their property was taken by her late husband’s relatives. She was left with nothing and helpless. She did not want to do commercial sex work, but she couldn’t see another option, and it gave her a means to earn enough to live a poor, risky and insecure daily life in Lilongwe.

This is not an unusual story. For some even younger than Grace, the AIDS epidemic has increased the risk of sexual, physical and emotional harm and neglect. Young women and children who have been deprived of care and support are particularly susceptible to working in the commercial sex industry. They face risk environments for HIV transmission for themselves and their clients, as well as of violence and other forms of abuse.

Today the story, at least for Grace, is different. She describes the changes she has brought in her own life and in her community. She herself has a more secure and healthy life. She also talks about commercial sex workers that have now accessed loans and are moving out of bars and running small businesses. Others have gone back to school. A meeting of women involved in commercial sex work raises rights and decisions, where to get counselling, testing and treatment for HIV, how to get greater control over their sexual activities and fertility, and how to build skills for other forms of work.

Grace points to the lever for this health affirming change - theatre.

“In 2007 some of us in commercial sex work trained on legislative theatre. Theatre for a Change contributed to the transformation of my life.”

Theatre for Change in Malawi equips socially and economically marginalised communities with the communications skills, knowledge and awareness to transform their lives and the lives of others personally, socially and professionally. In Malawi, it works with groups including commercial sex workers to reduce the risk of HIV. It involves women from the core group of former commercial sex workers who work as peer facilitators among younger people getting involved in sex work. Through the theatre and by performing their stories to a variety of audiences, the women access a voice and a platform to raise concerns and open debate. The process known as Legislative Theatre. The performances involve the audiences in coming up with solutions to the issues these women face, in the process changing attitudes and catalysing change in both the women themselves, their communities and even in policy makers when they are involved. The theatre work is supported by other programmes to provide access to female and male condoms, to HIV testing and counselling, and to relevant health services, including antiretroviral treatment. These services are available, but their uptake has been blocked by barriers like stigma. This process provides a vehicle for raising the health, gender and sexual rights and responsibilities of sex workers and their clients.

As Grace comments: “Now I know my rights and no one can violate my rights. I have self esteem and I am able to make decisions about my own body.”

It is already known that it is more effective to send former commercial sex workers to mobilise and reach out to others, as much as positive peer pressure from men has influenced other men to go for testing and counselling. For the women who have been involved in commercial sex work, the theatre work has helped to reach other commercial sex workers, especially adolescents. It has led to greater openness on health problems and changed attitudes towards commercial sex workers, including amongst the health workers who used to stigmatise commercial sex workers.

Those involved learn while they teach. They are trained in psychosocial issues and counselling to support their interactions with people of different ages, gender, place and occupation. They also build a more affirmative view of themselves, from being victims of economic insecurity and social stigma to people who plan and set goals for their own and their family lives.

Grace sums it up: “Everyday of my life brings an opportunity for a new beginning…I waste not a moment mourning yesterday’s misfortunes, defeats and challenges. These have been my stepping stones."

While antiretrovirals provide a therapy for the physical effects of HIV and AIDS, it seems that theatre can also be a powerful and equally necessary therapy for its social effects.

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, a film and further information on the Theatre for a Change programme visit www.tfacafrica.com/What-we-do/TfaC-in-Malawi/Sex-worker-programme

Activism as a social determinant of health
Mark Heywood, SECTION27, South Africa


We are living during a time of unprecedented threat and opportunity for the right to health. We are seeing cutbacks in the funding for prevention and treatment of HIV, retreats from commitments to ‘universal access’ to HIV and TB treatment, attacks on human rights and new threats to national and global health, including through climate change and food insecurity. At the same time there are new and better technologies available for health, new medicines and diagnostics for common diseases like tuberculosis, and an array of interventions that could improve health and reduce malnutrition. Some states, particularly South Africa and Brazil, are seriously seeking to improve health on the principle that health is a human right. But it is questionable whether they have the resources to do it. There are examples of growing global co-operation and legal agreement around social challenges, such as climate change, although not yet around the most immediate social challenges that face the poor. Activist movements exist around AIDS, health and around social justice.

The Commission on the Social Determinants of Health pointed to the demand for a response to this moment of contradiction between threat and opportunity from a leadership and governance that is driven by social justice. It stated: “In order to address health inequities, and inequitable conditions of daily living, it is necessary to address inequities – such as those between men and women – in the way society is organized. This requires a strong public sector that is committed, capable, and adequately financed. To achieve that requires more than strengthened government – it requires strengthened governance: legitimacy, space, and support for civil society, for an accountable private sector, and for people across society to agree public interests and reinvest in the value of collective action. In a globalized world, the need for governance dedicated to equity applies equally from the community level to global institutions.”

This is not a new call. It resonates with the recognition of the right to health as a human right found in the 1946 World Health Organisation Constitution, the 1966 International Covenant on Economic Social and Cultural Rights (ICESCR), the 1978 Alma Ata Declaration and the 2000 UN Committee on Economic, Social and Cultural Rights ‘General Comment 14’ on Article 12 of ICESCR. Increasingly it is also reflected in the incorporation of the right to health into the national constitutions of over seventy countries in the last decade.

Nevertheless good health and access to adequate health care services remains out of reach to billions of people. Nearly two billion people (a third of the world’s population) lack access to essential medicines and about 150 million people suffer financial catastrophe annually due to ill health, while the costs of care pushes 100 million below the poverty line.

The world is well aware of these facts. They are published by the WHO and others. When these facts are raised in international forums, it has led states to make bold promises….that they later do not keep. In Africa, 19 of the African countries who signed the 2001 Abuja Declaration to spend 15% of their government budget on health al¬locate less now than they did in 2001. Yet the WHO indicate that low-income countries could raise an additional US$ 15 billion a year for health from domestic sources by increasing health’s share of total government spending to 15%. Neither are high income countries meeting their promises. According to the ‘Africa Progress Report 2010’, published by a unique panel chaired by Kofi Annan, when the $25 billion Gleneagles commitment comes due at the end of 2011, the resources allocated by G8 countries will have fallen short by at least $9.8 billion. The panel calls this a “staggering shortfall.”

Does this mean that the right to health has no value? No. Has the right to health been sufficiently popularised or used? No. Are the state and United Nations institutions who have a duty to protect and realise the right to health fulfilling their obligations? No.

In the last decade AIDS activists have established in practice the principle that states must fund treatment as a right, with the organisation of resources globally to meet this obligation. Currently we are seeing a reversal of this basic entitlement, as the right to these resources are being challenged by arguments over cost effectiveness, a retreat from funding treatment in middle income countries, despite the fact that three quarters of the poorest people in the world live in middle income countries; and a claim that too much money is going to AIDS treatment, despite the fact that an estimated ten million people still need treatment globally. Some states in low income countries claim to have inadequate resources for health even while their political and economic elites grow visibly wealthier, and even states who have met the Abuja commitment try to fairly distribute unfairly inadequate amounts of money for health.

The Commission on the Social Determinants of Health called for conditions that would enable civil society to organize and act in a way that promotes and realises the political and social rights affecting health equity. It seems that we should go further than this, given the reversals in progress and growing inequalities in health. We need to see the level of activism by civil society as a key social determinant of health. The fight for health should be a central pillar of all movements for social justice and equality, not in the abstract, but for the specific goods, institutions, demands and resources that will realise the right to health.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.This is an edited extract of a speech given at the Southern African Regional Dialogue on Realising the Right to Health in March 2011. For more information on the issues raised in this op-ed and for this and other presentations made at the conference see: www.section27.org.za.

Addressing health inequities through Universal Health Coverage
Lara Brearley, Save the Children


Addressing inequities in access to quality needed care and financial risk protection must be a first priority in efforts to achieve Universal Health Coverage (UHC). We have the opportunity to implement equitable pathways towards UHC by including appropriate targets and measures in the post-2015 development framework. These are the main messages of a joint report titled ‘Universal Health Coverage: A commitment to close the gap’ launched this month by Save the Children, the Rockefeller Foundation, UNICEF and WHO and available at http://www.savethechildren.org.uk/resources/online-library/universal-health-coverage.

Prioritising equity in pathways towards UHC is not just the right thing to do from a moral perspective, but it also brings value for money. Research implemented for the report reveals that the deaths of 1,8 million children under-five and 100 000 mothers could be averted each year by eliminating wealth related inequities that occur within countries in the coverage of essential maternal and child health interventions in 47 of the 75 countries where more than 95% of all maternal and child deaths occur (http://www.countdown2015mnch.org/). If in 2013 to 2015 all groups were able to reach the coverage levels of the highest fifth of people by wealth, this would reduce maternal and child mortality by almost one-third and one-fifth respectively.

We present evidence in the report that more equitable health financing saves lives. Pooled funding comes from prepayments and pooling makes it available to distribute to those with higher need. If the share of health financing that is pooled were to increase by ten percentage points, while keeping total health expenditure constant, we estimate in the report that there would be fifteen fewer deaths in children under five years of age for every 1000 live births in the same 75 countries on average. This could enable thirteen countries that are currently off-track to achieve their Millennium Development Goal (MDG) 4 target of a two-thirds reduction in the rate of child mortality. In countries where health services are more equitably distributed, the reduction in child deaths may be even greater.

It is thus possible to make huge improvements in health outcomes and access to health care. It is possible, for instance, to reduce by almost half the number of children who die each year when compared to the rates in 1990. Despite this, too many people are denied their right to health. In 2012 for instance, 6,6 million children died before the age of five and most of these deaths could have been prevented. High levels of out-of-pocket payments (cash at point of care) for health care act as a barrier for poor people to access the care they need or can lead to an increase in poverty due to health spending. About 150 million people are estimated to incur catastrophic (impoverishing) expenditures for health care each year. This is a scandal that must be addressed.

The health system’s response to this challenge must be Universal Health Coverage – which we define as ensuring “that all people obtain the health services they need, of good quality, without suffering financial hardship when paying for them”. Momentum for UHC is soaring at country and global levels, and this must be seized to ensure the needs of the poor and vulnerable are prioritised as countries design and implement the policy reforms for UHC.

In the report we identify a number of policy lessons for equitable pathways towards UHC in low- and middle-income countries, particularly in relation to health financing. One policy lesson is that countries increase equitable funding for health through mandatory, progressive prepayment mechanisms, including revenues from taxation, and eliminate out-of-pocket spending. Risk and resource pools must be consolidated to facilitate effective redistribution. A universal benefit package should be designed for all, and delivered in a manner that meets the needs of the poorest and most vulnerable in society, through strategic purchasing of services and through providing incentives that ensure health providers promote quality of care. The policy lessons point to the importance of taking a ‘whole-system’ approach to UHC, and for coordinating reforms across health system building blocks such as financing, health workers, commodities, social participation and others. To overcome pervasive inequities in the coverage of quality health services and to ensure that people are not impoverished from health spending we need to also act on the wider social determinants of health. Political will and strong mechanisms for effective accountability are critical for implementing the measures needed for equitable pathways towards UHC.

As the MDGs have shown, what gets measured is more likely to get done. Negotiations on the sustainable development agenda must guide equitable progress towards UHC, with clear indicators of and targets for such measures that strengthen health systems and close the equity gap.

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 visit www.savethechildren.org.uk/resources/online-library/universal-health-coverage and www.equinetafrica.org

Adolescent health: What they don’t know CAN hurt them
Barbara Kaim, Training and Research Support Centre, Zimbabwe


A quarter of the population in Sub-Saharan Africa are young people between the ages of 10 and 19 years. These young people carry the hopes and dreams of their families, their communities and their nation. They are the future leaders and, perhaps as important, the future parents of the next generation.

They live in a world where to be an adolescent is increasingly risky. Adolescents typically take risks, but with the AIDS epidemic, risk-taking can be fatal. When adolescents have unplanned and unprotected sex, sexually transmitted infections can cause infertility or cervical cancer, and pregnancy in adolescents is more risky, with higher rates of death in both adolescent mothers and their babies than in adults. Unsafe abortions amongst adolescents are unacceptably high, and early sexual activity may limit educational attainment and deprive young people of the opportunity to form mature, loving relationships. So it’s a tragic and unacceptable sign that most new HIV infections in sub-Saharan Africa occur among adolescents and young adults.

Adolescents grow up today in a different world. High rates of urbanization, extended periods of schooling and growing poverty contribute to a challenging social context for young people.

Traditional ways of preparing young people for adulthood, which relied on extended family members, are less practiced and might not be adequate to address the pressures that adolescents face. In the past, sexual maturity was closely followed by marriage. Today, young people reach puberty at younger ages and wait longer to marry. Because the aunt or uncle may not be available, or may not be considered relevant, many adolescents turn to other sources. Today, many young people learn from peers or the media. Much of this information is inadequate and sometimes it is just plain wrong.

Schools are an ideal setting in which to reach large numbers of young people with the information they need, including reproductive knowledge and life skills. Yet, wherever it has been introduced, the teaching of reproductive health in schools has generated controversy. Debate exists around what information should be given and how much, especially regarding sexual intercourse, pregnancy and disease prevention. Some adults are resistant to even acknowledging that teenage sex is taking place. Others are concerned that sex education will lead to sexual activity. These viewpoints are often based more on values and beliefs than on facts. Hence the same arguments are repeated again and again, year after year, despite contrary evidence. Its very likely these same views will continue to be expressed into the future.

Nevertheless, facts do help. Studies have shown, both regionally and internationally, that comprehensive sex education is effective in improving knowledge and reducing sexual risk behaviours, and that it does not increase sexual activity. In 1997, a UNAIDS study reviewing 53 sex education programmes globally found that 22 had a positive effect of safer adolescent sexual behaviour, and 27 had no impact. In the 3 studies where there was an increase in sexual activity, there were concerns about the design of the assessment and the validity of conclusions.

Such studies suggest that rather than sex education causing young people to have sex, the opposite is more likely to be the case: Giving young people more complete and accurate information, and more opportunities to discuss issues in an open and non-judgemental environment enables them to make more responsible choices.

Clearly the design and quality of the programme matters. Strengthening sex education programmes can be difficult in resource-strained countries. However some aspects of effective programmes that have been identified from reviews can be applied across different settings, including those where resources are scarce. These include:
• adopting school curricula that provide comprehensive, accurate sexual and reproductive health information;
• supporting teacher training;
• reaching young adolescents with information early, before they leave school and before they begin sexual activity;
• strengthening health and other community services for young people and ensuring that these services are youth-friendly, and
• helping adolescents stay in school. Even if they do not receive sex education, young people who stay in school are less likely then their peers to have sex.

Successful reproductive health programmes are not simply a matter of education. They involve youth issues, gender issues, human rights issues, and health issues. They involve and give a central role to youth themselves. They encourage young people to articulate and discuss issues, to talk about their lives, to understand their options, and to get the skills and support they need for healthy choices. And of course, for young people, they must also be fun.

Our efforts towards reducing maternal mortality or new HIV infection cannot be said to be successful as long as we have not made significantly more progress in reducing the risk for adolescents. Achieving this and reaching young people can’t be left to teachers alone. Parents, civic leaders, health providers, other government ministries all have a role to play. Support of youth is a multi-sectoral effort. As adults planning for a better future for our young people, we are all their parents.

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 or see as an example of resources for adolescent reproductive health the Auntie Stella materials on the TARSC website at http://www.auntiestella.org/

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