With the major public health challenges that are found in Africa, making progress in public health clearly demands a significant spread of public health skills. While health workers are making tireless efforts to address preventable diseases across the continent, and many successful experiences exist, revitalizing primary health care oriented systems calls for revitalized public health leadership and skills.
Part of the challenge is filling the gaps created by out-migration. At a conference held in mid-June 2007 on 'Sustaining Africa’s Development through Public Health Education', hosted by the University of Pretoria School of Health Systems and Public Health, Professor Erich Buch, health advisor to NEPAD, depicted the prevailing health worker situation in Africa, including the extensive brain drain, low funding and insufficient, often inadequately compensated, staff. He emphasised the need to shift focus from the current responses taking place country-by-country to building wider continental responses, informed by vision, leadership, and energy. This leadership demands public health skills, and Professor Buch asserted that building 'centres of excellence and networks in Africa are key … to strengthen[ing] public health capacity at public health schools and institutions across the continent'.
The meeting discussed options for how to achieve this. With limited financial and institutional resources, governments and institutions can best maximise what is available by sharing existing African expertise across organisations and countries, and strengthening formal mentorship programmes for public health practitioners. This needs to be backed by investments in user-friendly technology to support the communication, collaboration and networking between research institutions, and to stimulate collaborative research and discussion forums and strong alumni systems.
Networking between institutions and professionals in Africa is sometimes weaker than between Africans and colleagues in the developed world. Building African networks needs active support and investment. One key area of concerned raised in the NEPAD strategy is establishing and maintaining an inventory of public health education capacity in Africa, enabling standardisation and accreditation of training institutions and encouraging innovative methods of training and the use of technology supported learning. As Professor Buch stated “We need to … build more cost-effective capacity on the continent'.
In line with these goals, the AfriHealth Project at the University of Pretoria recently completed a three-year mapping project of public health education and training institutions in South Africa. The project has developed a database of public health workers and educators to inform collaborations in Africa. While the mapping focused on South Africa, the information would be useful to strengthen the networking of institutions and individuals in Africa and to share these institutional resources. The AfriHealth Project seeks to secure a Pan-African Public Health body that is effective, inclusive, scientifically and politically supported, and well-resourced. The project has identified the strategic importance of developing a continental approach to improving public health in line with new socio-political realities, strengthening public health capacity by networking institutions, programmes and individuals, and promoting technology-supported learning and communication.
These initiatives do not see current skills scarcities as being an insurmountable block to development of new skills. Mentors can be drawn from existing academic institutions. But public health education must also move beyond universities, to provide other skills not always available from university education, such as for cultural sensitivity in health practice, or for strategic management. Short courses for public health practitioners can also bridge the gap between different entry levels and Masters' degrees in public health. Public health educators and researchers must also bridge the gap in research to reduce the drop out rate in Masters' courses.
There are new and emerging challenges to public health in the rapidly changing global environment. The content of public health training needs to match the new needs and opportunities for action in public health.
Gender issues have a major impact on health in the continent, and institutions should include gender in public health curricula. Improving women’s rights, eliminating violence against women and advancing health rights more generally calls for recognition of the central role played by women in providing health care. This doesn’t only mean looking at women's roles. As Dr Alena Petrakova from WHO (Geneva) noted at the conference, mainstreaming gender in public health curriculum design and development also means involving men and examining their impact on health. A recently-formed African Network for Public Health Educators on Gender (ANPHEG) is taking the issue of how gender is mainstreamed in the public health curricula on a sustainable basis.
Achieving the commitments set out in the continent and those set globally, like the Millennium Development Goals, calls for clear skills to best protect, use and advance the health resources in the region. Much focus has rightly been placed on retaining and valuing health workers. Beyond this, equal concern is now being voiced in the continent that those who do work in African health systems are adequately equipped at all levels with the knowledge and skills to lead effective and innovative responses to the continent's public health challenges.
K Tibazarwa is a masters' student, School of Public Health at the University of Cape Town. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat firstname.lastname@example.org.
African civil society through the Africa Public Health Alliance & 15% Plus Campaign are petitioning AU Heads of States through Malawi President Bingu wa Mutharika, Chairperson of the African Union on the grave concerns of African citizens that some Heads of State are being advised to repudiate crucial commitments on health and social development, in particular the 2001 Abuja pledge on health financing. They note that despite some recent progress, healthy life expectancy in Africa is at a low of 45 years resulting in un-fulfilled personal, national and continental potential and aspirations, and the loss of billions of dollars in productivity. They note that it would be a historic setback for African governments to drop health and social development commitments, or suggest in anyway that the health of African economies exists in isolation from the overall health of African citizens. Giving evidence to support the need for adequate health sector financing, the petition urges heads of state to ensure that the July 2010 AU Summit restates the Abuja commitments; and supports the AU Commission in working with governments and civil society to monitor and report on health gains, and ensure a 10th year review of the 2001 Abuja commitments by April 2011.
The author flags concern about the actions of some African finance ministers to reverse their Heads of state commitments, such as those made on 15% government funding to health in Abuja in 2001. South African, Rwandan and Egyptian finance ministers succeeded in deleting any reference to budgetary targets for education, health, agriculture and water from the report and resolutions of the annual meeting of the African Union and Economic Commission for the Africa Conference of Ministers of Finance, Planning and Economic Development held in Malawi in March 2010. Many consequences are seen to flow from this, if heads of state follow the same path. It could indicate an abandonment of the bold financing that has gone into reversing vulnerability to food insecurity, disease and denial of access to health care and education. It questions how Africa would, after reversing from its own commitments, hold the G8 and international community to their commitments to contribute 0.7% of their gross national product and to double development assistance to Africa. The dismissive nature with which the finance ministers have treated these targets begs the question of whether the MDGs and all the other decisions taken under the auspices of the African Union will go the same way.
My name is Nomfundo Dubula. I am a person living with HIV. I am from the Treatment Action Campaign in South Africa and I also represent the Pan African Treatment Access Movement.
I want to say that as communities and people living with HIV we are angry. Our people are dying unnecessarily.
African leaders, the ball is in your hands. You have to decide whether you want to lead a continent without people. So, stop playing hide and seek whilst people are dying.
The World Health Organisation has declared antiretroviral therapy a state of global emergency and our leaders are still in a state of denial.
The Doha and the UNGASS declarations have opened the way to decide about the future of Africa, so, when is your action? The Doha declaration on health is hope, and it must be implemented.
Two years ago, the Abuja declaration promised 15% of the budget on health but up to now that has not happened. How many people must die? Please, move from talks to real action.
Give women powers to decide and lead and they will overcome this epidemic.
African leaders, lead us. Don't divide people living with HIV, as we all want to assist in this fight.
We need CCM's in each country with positive attitudes towards treatment, especially ARV's, so that we have effective and unequivocal treatment plans.
We need you to speak out about nutrition and not confuse us with the debate about nutrition versus ARVs. Nutrition goes hand in hand with ARVs!
I also want to address the WHO. WHO has promised to give technical assistance in the procurement of drugs. Now we need your assistance in our countries to ensure that cheaper generic drugs reach every country, with or without manufacturing capacity.
You also have a key role in ensuring resources for poor countries. The 3 by 5 plan should also ensure that all treatment programmes include treatment literacy efforts. On our side, we commit ourselves in educating our people and ensureing adherence.
We need real leadership in the implementation of effective strategies to reach the 3 by 5 goal. We will assist you in this effort if you show commitment and independence in prioritising people's health over any other interest.
I want to refer to the drug companies, whose bags are full with profits. Stop squeezing poor Africans which only represent 1.3% of your global market.
Don't delay access by giving exclusive licenses that are only transferring the monopoly to local companies blocking competition.
Your diagnostics are still too expensive and inaccessible.
Provide low prices and allow our governments to bring us life-saving drugs and the necessary monitoring systems.
I want to say to the donors that they should donate more money to the Global Fund. We welcome the US initiative led by president Bush. But we want money that is free of hidden agendas. Put more money in the Global Fund and stop blocking our government's rights to import generic drugs.
The IMF and World Bank should cancel the debt, as Africa is fighting for its life. Don't even pinch the last drop of its blood.
And where was the Global Fund in this conference? How can you communicate with our brothers and sisters, and what is going on with their countries proposals? We need you to have a booth in the GNAP+ conference so that you can be visible, and we can ask questions.
The Pan African Treatment Access Movement - PATAM - is fighting for the lives of Africans. So, we will continue to mobilize our people as we did in the court case of the Pharmaceutical companies against the South African Government.
We will continue to mobilize our people as we South Africans did in the PMTCT court case against our government.
We will continue to mobilize our communities to ensure access to treatment and care.
We will continue giving treatment literacy workshops to ensure adherence, promote VCT, prevent new infections and promote openness.
We will be watchdogs in ensuring real implementation.
AMANDLA, AMANDLA POWER, TO THE PEOPLE.
One reason why many of our health policies fail to be fully implemented in our region is that we lack a robust mechanism to make sure of this. Parliaments play a key role in this. They provide a link between government and citizens on laws and treaties, budgets and in overseeing in implementation of national programmes. In the early 1990s, most African countries initiated reforms for their parliaments to play a more effective and visible role in these functions.
The idea to bring the Portfolio Committees on health in the region together was first mooted in 2003, in part due to falling budget allocations to health, to the devastating impact of AIDS and to evident inequalities in access to funds and services. We recognized that as members of parliament (MPs) we needed to use our representative mandate to communicate social expectations and strengthen social voice and power in health. A core group of MP used our own resources to visit other parliaments in the region to share the idea and listen to the feedback. The network was finally launched in 2005 as the Southern and East Africa Parliamentary Committees on Health (SEAPACOH). Today we have widened to all of Africa and are the Network of African Parliamentary Committees on Health (NEAPACOH). So far we have active participation from Angola, Botswana, Benin, Burkina Faso, Burundi, Ethiopia, Ivory Coast, Gambia, Ghana, Kenya, Kingdom of Lesotho, Malawi, Mali, Morocco, Mozambique, Namibia, Nigeria, Rwanda, South Africa, South Sudan, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe and we welcome other parliamentary committees on health in the continent.
Since 2008 and with technical partners like EQUINET and Partners in Population and Development Africa Regional Office, the network has annually brought together the health committee chair, clerk and several other MPs from committees across the continent. This provides a forum for parliamentary committees on health to share concerns, unify voice on common concerns and calls for action, to advocate for health as a fundamental human right and promote democratic principles in health, including in our engagement with global processes. It also allows us to share promising practice and lessons learned. Strategically, we use the annual conference to identify common challenges and resolve on areas for action and on commitments that national health committees/delegations undertake to implement and report progress on at the next conference. We have found that identifying joint areas of action that brings us on the same ‘wave length’ strengthens our effectiveness, individually and collectively. The experiences, views and success stories that we share inspire and inform the individual committees. For example from 2005 we took up a common cause on advocating our Ministries of Finance to meet the Abuja commitment of 15% of the government budget going to health, that raised attention to this issue and contributed to improved allocation in a number of countries. We also raised issues that affect other sectors and committees, such as the positions on intellectual property that are needed to support access to medicines. We produced with EQUINET parliamentary briefs on international treaties affecting health and other health issues that are common for all parliaments in the region. We have in the process built solidarity and collaboration with civil society organisations and regional networks, and with health professionals, academics, non-state actors, research institutes and international agencies. This has enabled us to better understand and synergise our different but complementary roles across all actors to ensure we deliver on social values and policy commitments, such as on health equity.
In our recently held 2016 NEAPACOH conference we have identified some key areas of attention and work for the coming year. Some are platforms we are sustaining from prior years, including to: facilitate greater public participation in health; to pursue and monitor achievement of equity in health; to advocate for improved health budgets and financing (in line with the Abuja commitment); and to promote access to key reproductive health, family planning and HIV/AIDS services. We agreed, further, to evaluate how far our governments have ratified and domesticated health related treaties and to engage on how far actions have been institutionalized and implemented to advance Universal Health Coverage and other Sustainable Development Goals (SDGs) that affect health, including within parliament. We see a need to mainstream the SDGs within the diverse areas of work of parliament, including the public information and consultation for them, and would want to spearhead work on this in health. We also plan to develop a handbook for African parliamentary health committee members as a practical resource to support their role.
The 2016 conference also raised a proposal for NEAPACOH to work with technical partners to evaluate how effectively parliamentary committees are taking forward resolutions, to understand the barriers and support practice. We will do this by visiting a selection of member committees in their countries before the next meeting.
The process of building this network has itself been a learning experience. Indeed we understand that the longevity of this network of parliamentary committees is unique in the continent, outside the formal all parliament unions. We have grown stronger over the years building on our constitution and founding values, and have a board of serving MPs from all five African regions chosen in our annual conference and an office hosted by the Parliament of Uganda. Over the 13 years since we were formed we have benefited from perseverance of leadership and retention of key founding personnel, from sound founding principles, and from a consistent collaboration with key technical partners in the region. At the same time we still have much to do to deliver on our mandate, to be more robust and effective at national, regional and continental level to protect shared health values and to play our role in ensuring that they are delivered on in practice.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: email@example.com. You can find out more on NEAPACOH at www.seapacoh.org
1. From 14-17 August 2003, we activists from across Africa, representing African civil society organisations, labour unions and other social movements, gathered in Johannesburg, South Africa to evaluate the current state of negotiations in the World Trade Organisation (WTO), and to strategise and make known our positions on the 5th WTO Ministerial Conference due to be held in Cancun, Mexico from 10-14 September 2003.
2. Our stand on WTO's role: We re-affirm our recognition of the WTO as a key instrument of transnational capital in its push for corporate globalisation. We noted the many destructive effects of WTO agreements on the lives of working people and the poor, especially women, in Africa and throughout the world. We renewed our determination to continue resisting corporate globalisation, and the WTO itself until it is replaced by a fully democratic institution.
3. The context of Cancun Meeting: We noted that the forthcoming WTO Ministerial meeting is taking place against a background of a crisis of credibility of neo-liberal policies and global capitalism, that have been deepened by the Enron and other corporate scandals exposing the duplicity and venality of the bosses of transnational capital. At the same time, the world is faced with the aggressive militarism of the United States under a political leadership whose illegal attack on Iraq under false pretences has shown that law and morality are no bar to what it will do to advance the interests of American capital. Across Africa and in other developing countries neo-liberal economic policies are putting basic services, such as health and education, beyond the reach of ordinary people and deepening unemployment, poverty and social inequality. We, however, take heart from the growing strength in the organised expression of all those around the world opposed to militarism and corporate globalisation.
4. Conclusions on the current state of affairs in WTO: After our deliberations on the WTO Doha agenda and related issues, we concluded as follows:
a. The WTO has ignored the continued and growing opposition by popular movements throughout the world to its policies and methods, such as the illegitimate ways by which the Doha Agenda was imposed on developing countries in the 4th Ministerial of the WTO.
b. The failure of the WTO to meet agreed deadlines in various negotiations - notably Agriculture, TRIPS and Public Health, Special and Differential Treatment and the many Implementation Issues is primarily due to the refusal of the Quad (USA, EU, Japan and Canada) to accept the legitimate demands of developing countries.
c. These failures are merely an aspect of the double standards the Quad countries apply in international trade issues; marked by one set of rules for themselves and another that they impose on developing countries, exposing the WTO as a thoroughly undemocratic institution.
d. We particularly condemn both the EU and the US for their role in resisting the fulfilment of the deadlines and undertakings on Agriculture, and their refusal to honour the compromise consensus on TRIPS and Public Health.
e. On the Singapore or New Issues (i.e. Investment, Competition, Government Procurement and Trade Facilitation) we reiterate our total opposition to their inclusion in the WTO, or the initiation of discussions on modalities with a view to the launch of negotiations on these in Cancun. We stand by our demand that these issues should be removed from the WTO's agenda altogether.
f. It is clear that, as Cancun approaches, the Quad are accelerating the deployment of old and new undemocratic practices and pressures both in and outside the WTO so as to force their will on developing countries. In order to limit such illegitimate and underhand practices by the powerful, we endorse the campaign for internal transparency and participation in the WTO recently launched by many NGOs.
g. We note the opposition to the launch of negotiations on these issues expressed by African countries, especially the declaration by African Trade Ministers at the end of their meeting in Mauritius in June 2003. We also note a new initiative taken at the WTO on 13 August by a group of African countries to demand that the official WTO text that goes to Cancun includes proposals for improving the decision-making process in the WTO; as well as repeating their opposition to the new issues. We call on these countries to stand by these positions, as a matter of democratic principle, and also urge other African and developing countries to join them.
5. Call to Action: In the light of the above we have agreed and call on other African civil society organisations, labour unions and other social movements who share our views to join us to:
a. Mobilise the broadest possible sectors of African civil society to express their opposition to the continuing destructive role of the WTO in the lives of working people and the poor, and upon our countries' development aspirations and prospects;
b. Mobilise and sustain strong political pressure on our governmental representatives, in ways best suited to the specific conditions in our countries, before and during the Cancun ministerial meeting; actively holding our governments accountable for the positions they take in the Cancun Ministerial meeting, and expose any attempt to betray the best interests of the African peoples;
c. Pressure institutions of government, and our legislatures, and relevant public officials in our various countries so as to ensure the defence of our peoples' interests in the forthcoming Cancun ministerial meeting. Especially important are i) blocking the launch of negotiations on the Singapore issues and ii) rejecting any attempt by the Quad to manipulate developing countries into accepting negotiations on the Singapore Issues by linking these to issues of concern to developing countries;
d. Pressure our respective governments to endorse the two proposals tabled at the WTO by 11 African countries on 13 August 2003;
e. Be alert to, and therefore resist, the inevitable attempts by representatives of Quad countries and other governments who, between now and Cancun, will be visiting our national capitals under various guises, and contacting groups within our own countries to bully African governments to take positions detrimental to the African people on the issues on the Cancun agenda;
f. Launch an information dissemination campaign in our various countries to publicise what is happening in and around the WTO in the run up to and during the Cancun Ministerial meeting;
g. Mobilise a strong team of African activists to give voice to African perspectives in the activities of civil society organisations who will gather from around the world in Cancun;
h. Affirm our links with our partners in organisations of civil society outside Africa, including in the global North, to pressure their governments (especially of the Quad) in the interest of working people and the poor throughout the world, and in the interest of our planet;
i. Work together across Africa on the WTO, before and during Cancun, under the umbrella of the Africa Trade Network (ATN) to ensure common focus and strength in unity.
We issue this statement, and our call, as part of our commitment to the global movement against neo-liberalism and corporate globalisation, and the struggle for the establishment of alternative systems and institutions for all of humanity and the world. Another Africa is possible! Another world is possible!
Issued in Johannesburg, 17 August 2003
The two editorials in this months newsletter address issues that have significance to African health systems - medicines access and health worker migration. In the first, Germán Velásquez raises concern that the latest joint WHO, WTO and WIPO in its silence about health and access to medicines in the publication effectively subordinates the right to health to international trade rules. A more direct challenge to patent systems is argued for, and a further article in the newsletter from the Federal Reserve Bank of St Louis goes further to argue that the patent system suppresses innovation and should be abolished. In the second editorial, Yoswa Dambisya and colleagues raise concern about a different silence: They ask why African countries have become so silent on implementing the Code on International Recruitment of Health Workers, given their prolonged struggle to obtain it. Both raise questions about the effectiveness of global level diplomacy as a platform for addressing key issues affecting public health in Africa. A new working paper on the EQUINET website ("Concepts in and perspectives on global health diplomacy") explores this further, and invites views and perspectives on the questions raised.
Walk into many international meetings on health in Africa and you will hear discussion on development aid, and international support for programmes to respond to major diseases. The Global Forum for Health Research (Forum 2012) held in Cape Town had a different focus: it provided a platform for how countries across all income groups could invest in research and development (R&D) as a source of innovation to meet their health needs and as an investment in development and job creation.
Held under the title “Beyond Aid: Research and Innovation as key drivers for Health, Equity and Development”, Forum 2012 was organised by the Coalition on Health Research for Development (COHRED), which merged in 2011 with the Global Forum on Health Research (GFHR).
Dr. Francisco Songane, Chair of the Steering Committee for Forum 2012, reflected “There is a misconception that developing countries rely on international aid. National Governments may find it hard to meet targets for R&D spending, but they remain the major funders of research”.
Naledi Pandor, South African Minister of Science and Technology and co-host of the Forum confirmed this and the power of investment in R&D. She observed that “the ability to cycle between the laboratory, clinic and field site provides a very powerful platform for translational research”. Investing in this link in South Africa gave the country an advantage over countries that focused on the basic sciences or clinical research, but not both. According to Minister Pandor, this positions South Africa to respond to health need and to emerging markets in Africa, to advance African-led innovation in drugs, diagnostics, vaccine development and other product-oriented innovation, including in relation to gene therapy, cell therapies and tissue engineering.
Dr Songane, Dr Carel Ijsselmuiden, executive director of COHRED, and other speakers at the Forum raised that achieving these synergies between innovation and economic and social benefit means that “we, in the health sector, need to open the doors of our community, and actively work with the other sectors”. They proposed that we need to shift from an aid paradigm to negotiating investment in and benefit from R&D in health.
The Pharmaceutical Manufacturing Plan for Africa, adopted by the Summit of the African Union in 2007, was raised as a promising example, with its emphasis on a coordinated approach to local medicines production based on countries needs. The research agenda to support the plan seeks to produce evidence on the productive capacities, intellectual property, political, geographical, economic and financing issues that affect the manufacture of medicines, to inform the necessary interactions across multiple government ministries, regulatory authorities, financial investors and private and public research, development, teaching and healthcare delivery institutions.
The Forum also raised issues of equity, at both global and regional levels.
Firstly there are inequities in the current distribution of both capacities to invest and in the sharing of benefits from investments in R&D. For example, Carel Ijsselmuiden pointed to a recent report on the impact of sequencing of the human genome. This report demonstrated that the potential economic return on the initial investment had gone to the global north, rather than the south, where there was no capacity to build on knowledge produced by the project. "The south has to develop the capacity to compete in this type of domain," he said. "The continuing emphasis on aid may stop us seeing this new picture of the world that is emerging."
‘Beyond aid’ should be taken to not mean ‘beyond solidarity and fairness’. In the past the GFHR has drawn attention to the highly uneven distribution of resources for health research between high and low income countries. At regional level, Forum delegates in various sessions pointed, therefore, to the need for collaboration and pooling of resources and knowledge within and across regions, to avoid a widening gap. The technological possibilities for such collaboration are growing. As stated by Dr Songane, “new communication technologies are making up for a lack of infrastructure and resources. The possibilities are exciting – virtual collaboration, sharing of data, and the use of mobile health technology to reach even remote rural areas”.
At global level, a Consultative Expert Working Group on Research and Development: Financing and Coordination (CEWG) established by the World Health Assembly (WHA) has in 2010 been examining the current financing and coordination of R&D globally, particularly in relation to neglected diseases and the needs of developing countries. In its report (www.who.int/phi/CEWG_Report_Exec_Summary.pdf) the CEWG proposed minimum shares of gross domestic product to be set for government funded health research and a global convention to address issues of equity and sustainability in financing for R&D. Minister Pandor welcomed new models, like UNITAID’s patent pool for AIDS medicines, which allows generics producers to make cheaper versions of patented medicines by enabling patent holders to license their technology in exchange for royalties.
Raising a second dimension of equity, young researchers at the Forum raised in a communiqué that work on R&D must be framed as a public responsibility, given that health is a human right, and must thus reach and benefit all communities. Youth and other delegates raised that communities’ local or indigenous knowledge should be respected, protected and integrated within research and knowledge systems, and innovations developed in ways that ensure fair partnerships, sharing of evidence and benefit, and collective, social entrepreneurship.
Further, in a session on the Equity Watch work in EQUINET, presenters from research institutions, Ministries of Health, regional and international agencies in east and southern Africa pointed to the need to overcome inequities in access to already known technologies for health, including the housing, food, water, primary health care and other key social determinants of survival. Their country and regional analysis highlighted economic growth paths that raise inequity in access to these resources, such as through unplanned urbanisation, insecure employment, or poor investment in small holder farming. They also presented evidence of public policies and measures within the health system and in other sectors such as education that close the gap.
Forum 2012 called for a different mindset, for innovation and research to be given more attention, given their role as drivers of health, equity and development. Discussions in the Forum raised that equity in health, while desired, cannot be assumed to be an outcome of research and innovation. It is also not adequately addressed by aid. The policies and measures for ensure equity as an outcome- whether through fair sharing of benefits, solidarity and collaboration on capacities and resources, inclusion of communities and their knowledge, or equitable access to existing technologies for health - need to be explicitly negotiated, implemented and monitored.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: firstname.lastname@example.org. For more information on the issues raised in this op-ed please visit http://www.forum2012.org/presentations/ and www.equinetafrica.org
Archbishop Ndungane, president of the African Monitor, commented after the United Nations (UN) Summit on the Millennium Development Goals (MDGs) in September 2010 on the gap between the concrete commitments made and clear plans for how they will be implemented. A bottom line for this is money.
Even before the Summit the UN Secretary-General in his March 2010 report had observed that unpredictable and insufficient international financing was blocking progress on the MDGs. Health needs alone at global level have been estimated to cost up to US$76 billion annually by 2015. The UN Non government Liaison Service reported this year that the financial deficit on resources to meet the MDGs could reach between US$324 - $336 million in 2012-2017, including a shortfall of about US$168-$180 million in official development assistance (ODA).
Which country and community you live in and what income group you are borne into affects your chances for health and for accessing the resources for health. This leads to an unacceptable global inequity. African countries, with the highest rates of mortality and ill health globally, are also most disadvantaged by widening gaps between rich and poor countries, by diminishing commodity prices and by outflows of key resources, such as skilled personnel. The financial crisis triggered by the US and European banking crisis has exacerbated this shortfall, creating a budget revenue hole of $65 billion in low and middle income countries. According to Development Finance International, aid has filled only one-third of this hole in revenue.
So African countries and people have a significant interest in debates on how global commitments will be financed.
ODA has been one way of releasing immediate resources for global priorities. Almost all low income countries could absorb much more aid without negative economic consequences, whereas they have much less space to borrow or to raise taxes. Attention has thus grown on how far the international community has fulfilled long-standing aid promises and improved aid effectiveness. A 2009 Mutual Review by the UN Economic Commission for Africa and OECD noted the welcome increase in commitments made at G8 and other summits. These include commitments to 0.7% of Gross national income to ODA in 2002; to an increase of $25 billion annually in aid to Africa in 2005; to an additional US$60bn to fight infectious diseases and strengthen health systems in 2006; to US$22bn to raise productivity of smallholder farming and $30bn for climate change mitigation in 2009; and to support for Universal access to HIV prevention and treatment. At the 2010 UN Summit an additional $40bn was pledged for the Global Strategy on Women’s and Children’s Health. The UN ECA and OECD report also noted that while progress was being made to the target of 0.7% ODA, it was still at 0.43% of combined GNI, with improved ODA largely related to debt relief flows in 2005/6. OECD reports indicate that less than half the $25bn promised in 2005 has been delivered and shortfalls exist on other pledges made.
The UNECA / OECD report points out that the most significant source of development finance in Africa is domestic revenue, making up 75% of its development financing. It indicates therefore that for African countries to raise the domestic revenue to deliver on development commitments, multilateral trade negotiations need to yield more substantial and faster improvements in market access and returns, and progress needs to be made in investment in areas such as energy access, technology transfer, infrastructure and climate adaptation. A further response to the resource gap is to reverse the net transfer of financial resources out of Africa. For example, Global Financial Integrity (2010) estimated that between 1970 and 2008 the outflows from Africa due to trade mispricing alone were as great as ODA inflows.
Unpredictable, inadequate aid flows and the slow progress in improved returns from the global economy have raised doubt whether business as usual will be enough to raise the funds needed to meet global goals. President Nicolas Sarkozy of France and Prime Minister Jose Luis Rodriguez Zapatero of Spain both raised in their addresses to the 2010 UN Summit the need for new approaches to financing global commitments, especially through a new tax on international currency transactions. President Sarkozy stated in his address to the Summit: “We can decide here to implement innovative financing, the taxation of financial transactions. Why wait? Finance has been globalized. Why shouldn’t we demand that finance contribute to stabilizing the world through a minuscule tax on each financial transaction?”
When a similar call was made by Nobel prize-winning U.S. economist James Tobin in 1972, and by UN panel chair Ernest Zedillo in 2000, it met strong opposition. However since then, a range of innovative development financing options based on levies have been established: UNITAID, an international facility for the purchase of drugs to combat HIV/AIDS, malaria and tuberculosis launched by Brazil, Chile, France, Norway and the United Kingdom in 2007, has raised US$1.5 billion in three years, 65% of which came from a micro-tax scheme on air tickets. In 2009, as a result of a Task force in Innovative Financing, a number of new facilities were introduced, including a US$1 billion expansion of the International Finance Facility for Immunisation (IFFIm); a new mechanism for making voluntary contributions when buying airline tickets, expected to raise up to US$3.2 billion by 2015; US$360 million worth of debt conversions in the Global Fund's Debt2Health Initiative; a VAT tax credit pilot scheme called De-Tax, expected to raise up to US$220 million a year in VAT resources; and a commitment to explore a second Advance Market Commitment for life-saving vaccines. In March 2010, the UN with country partners and the American Society of Travel Agents, launched ‘MASSIVEGOOD’ an offshoot of UNITAID, that provides travellers in the United States the option of making a voluntary contribution of up to $50 when purchasing tickets, booking a hotel room or renting a car online. This is expected to bring in up to US$1 billion in four years to support treatment for children with HIV, for tuberculosis and insecticide treated bed nets. Such funds bring significant new resources, and raise challenges for how they support the financing of systems and improve the production of domestic revenue.
These financial innovations, the impending deadlines for action on global commitments and a funding gap that is not being met through current approaches has brought new demand for the introduction of an international multi-currency transaction tax. Sixty countries in the Leading Group on Innovative Financing for Development (LGIFD) support it, and the potential financial contribution is significant. Financial flows have increased sevenfold since 2000, with a volume of transactions worldwide of about $3.6 trillion daily for foreign exchange, of $210 billion daily for bonds and $800 billion for stocks. At a session on 21 September at the Summit, Bernard Kouchner, foreign minister of France, held up a five-cent coin saying: ‘This will be the tax on a 1000-dollar transaction. It is impossible not to accept that. Especially when you have in mind that the result of such a tax would be 40 billion dollars a year..'.
An approaching deadline to account for global goals and an economic crisis may be a challenging situation for global social commitments, but it may also be an opportunity to implement the possible - to advance sustainable and equitable ways of financing them.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: email@example.com. Further information on this issue and the UN 2010 Summit can also be found in the Health Diplomacy Monitor www.ghd-net.org.
In the wake of U.S. President George Bush's trip to several African nations, and after his State of the Union speech declaring $15 billion of spending for global AIDS prevention and care, American newspapers have rallied in support of the "compassionate conservatism" represented by Bush's "commitment" to anti-AIDS efforts. Certainly, the $15 billion number has turned out to be an inflated figure, as most of the money is recycled from existing spending and only $1.4 billion has been appropriated this year (with little indication of renewal in subsequent years) . But where the money is actually going has been left mostly unexamined. Not only is the funding circumventing the Global Fund for AIDS, TB and Malaria, being spent almost entirely through bilateral USAID initiatives known for their inefficacy (and diversion towards abstinence-only, anti-abortion initiatives), but more importantly the majority of funds are being spent in line with a common and fallacious public health dogma: that "information is everything", and preventing the spread of HIV means "promoting education" [1-5].
This "health belief model" seems intuitive and obvious: if people just know how HIV is transmitted (and stop being in "denial" about it) -- the rhetoric goes -- the transmission of HIV will diminish . Sounds credible enough; but this argument has been consistently promoted by a group of public health workers and international financial institutions who ignore most of the available data we now have on AIDS prevention initiatives . While the development banks and others have promoted the Ugandan case as a "model" (at one point claiming that effective "bereavement counselling" in the country was a reason for praise, rather than preventing the deaths to begin with ), the Ugandan "model" appears to be promoted without much examination of the data. Certainly, prevention initiatives in Uganda have reduced HIV prevalence in certain populations. But the prevalence rates have increased in some sections of Uganda while decreasing in others; in particular, the wealthier urban areas have seen a decrease in infection rates, while infection has rocketed upwards in the rural and poorer zones.
What is also often ignored is that even in sectors where prevalence has reduced, the reduction mathematically represents a decline in incidence well before the government's prevention initiatives began, and corresponds more to social demographic changes and economic reforms than "education" initiatives . What is perhaps most problematic about the Ugandan case is that the so-called "model" it offers makes several wrong assumptions. Given that the top epidemiological predictor for HIV infection around the world is not "risk behaviour" but rather a low income level, those most vulnerable to infection will not benefit from a model focused on "education" -- a model that assumes people in poverty have the agency to control the circumstances of their lives, even in the context of gender inequality or in environments without income opportunities other than trading sex for money [9-15]. As Dr. Paul Farmer and colleagues recently noted, "Their risk stems less from ignorance and more from the precarious situations in which hundreds of millions live" . And dozens of surveys support this fact, confirming that -- despite our presumptions -- those most at risk for HIV often do know how the virus is transmitted, and even in the highest prevalence areas have sex rates lower than in many regions of the U.S. and Japan [13, 16-20].
Sex is not as much the issue as the context under which sex occurs, yet several social scientists studying AIDS are guilty of trying to define an African "system of sexuality" and render sexual behaviour the problem rather than examining why sex among the poor seems to lead to HIV transmission so much more often than sex among the wealthy [21-24]. In interviews, those most vulnerable regularly discuss other concerns about life (access to clean water and food, gaining financial independence, and so forth) that take precedence over preventing HIV transmission [19, 25-30]. Yet the "targeted" public health rhetoric ignores these and even equates the concerns of the poor with the rhetoric of politicians by labelling both "in denial" [30, 31].
In the South African mining sector, for example, a recent group of surveys established that the "norm" of masculinity (expressed through soliciting prostitutes) in "South African culture" increases the risk of HIV transmission . To locate "culture" as the problem is to ignore the perspectives of the miners themselves (who, in fact, are from a variety of different locations as distinct as rural sectors of Malawi and Mozambique and urban areas like Johannesburg). As one miner put it: "Every time you go underground you have to wear a lamp on your head. Once you take on that lamp you know that you are wearing death. Where you are going you are not sure whether you will come back to the surface alive or dead. It is only with luck if you come to the surface still alive because everyday somebody gets injured or dies".
In the context of a 42% injury rate, it would be natural to think that catching a disease that could kill you ten years down the road might be less pressing than trying to gain some control over life -- or perhaps even enjoying life in some minor way (through alcohol or sex) before getting crushed by falling rock. But the psychologists who quoted this miner (and published their analysis in a top-ranked medical journal) labelled him "in denial," and claimed that his "low self-esteem" was the cause of his increased risk for HIV infection . A similar survey among prostitutes labelled them "liars" (in "denial" of their agency) when they attributed their prostitution to lack of opportunity and coercion .
"Culture" (whether a distant African one or a "culture of poverty" among the poor in wealthy countries) is often described as a barrier to effective intervention, assumed to be a fixed, unalterable thing defined by the dominant groups in power, while the marginalized have no culture themselves or are guilty of having a sub-culture that renders them vulnerable to HIV or promotes crime and delinquency [20, 21, 33-38]. Culture, denial, stigma and conspiracy theories are taken to be the causes rather than the effects of social and economic problems. At other points, culture is focused upon to devise "culturally-competent" solutions to change the low efficacy of HIV prevention initiatives [39, 40]. In both of these cases, "culture" is conflated with the structural violence of inequality and lack of access to resources -- and when these issues are un-addressed, even the most "culturally-competent" prevention initiatives still focus on merely co-opting local culture to suit the needs of "targeted" interventions . In this context, even after messages are adapted to "local norms" (ignoring the universal context of HIV-transmission, that of inequality and lack of access to resources), "providing information about health risks changes the behaviour of, at most, one in four people -- generally those who are more affluent and better educated" .
In response to accumulating data that the majority of education initiatives are failing, the public health community is now committing another behaviouristic mistake; instead of examining the political and economic contexts of prevention, it has now returned (unawares, I suspect) to a colonial rhetoric: claiming that the inefficacy of such initiatives is due to the individualistic nature of the interventions, ignoring the "collectivist African traditions" (thereby conflating all of the many social scenes in Africa into one "African system") [39, 42]. In colonial times, "venereal" syphilis among miners (which later turned out to be non-venereal syphilis and yaws) would be explained by the loss of "African traditions", which reportedly promoted female chastity by exerting group control over young women (paralleling the modern "revival" -- and partial invention -- of "traditions" like virginity testing in the context of AIDS ) [44, 45]. Mine workers were simultaneously taught to be individualistic and capitalistic in the mines, then returned to be collectivistic at their rural homes when they became ill (a very "cost-effective" strategy for mine owners to avoid paying for medical care) [18, 46]. The context of illness, and its relationship to their position in the economic field of relations, went unquestioned. Now, public health behaviourism aims to solve HIV transmission by holding "group rituals" for education -- so, perhaps, the "self-esteem" problems can be pushed aside as "traditions" solve all of the barriers to effective HIV prevention [39, 42].
What this rhetoric ignores and often disguises is that the background for increasing HIV transmission is a background of neoliberalism -- a context where the movement of capital is privileged above the ability of persons to secure their own livelihoods. Increasing migration is correlated precisely to the break-up of marriages as rural farms are destroyed after the liberalization of markets results in sharp drops in primary commodity prices; (mostly male) labourers travel to urban areas to work [13, 47, 48]. In vast sectors of southern Africa, miners are housed in all-male barracks for months at a time, worked six days a week, and given alcohol to "keep them happy" (or keep them from rebelling) on the seventh day -- when intoxication and depression lead to the solicitation of prostitutes. They are returned home to die, and find either their wives have left them to find a better source of income and support, or are waiting themselves to be infected with HIV . The "rural women's epidemic" of HIV -- that is the sub-epidemics of women in rural zones who have been infected by their migrant male husbands (most of whom have already died at the time of surveys) -- is not so "surprising" or "unusual" in this context .
AIDS, then, is a symptom as much as it is a disease. In the context of the new South African Customs Union (SACU) trade agreement with the United States, it will be a most severe symptom. The SACU deal promotes rapid liberalization and the movement of capital over the securing of stable employment and better livelihoods, privileging companies who wish to set-up base temporarily and shift the means of production at will. If similar deals in East Asia and the Caribbean are any indication, both TB and HIV will increase markedly in this context as migration and poverty render "monogamous marriage" a nonsensical idea and force both women and men in poverty to move constantly and find new sources of income wherever they can [13, 47].
The SACU deal also links this neoliberal context to the distribution of resources, particularly medicines, which are often discussed through a rhetoric divorced from the context of HIV prevention. The trade deal will render generic medicines extremely difficult to procure, providing a more than two-decade-long monopoly for patented medicines . Public health officials have not strongly voiced their opposition to this (leaving NGOs to take on the task), and have focused on the "cost-effective" prevention initiatives instead. The "prevention versus treatment" dichotomy should have been defeated by the numerous models indicating that access to vital health resources like antiretroviral drugs is part of the process of improving livelihoods, rather than being dichotomously opposed to effective disease prevention. Indeed, effective treatment provision often helps to reduce stigma, denial and blame, in addition to reducing HIV transmission [50, 51]. Brazil has certainly demonstrated this definitively, having reduced HIV prevalence (and incidence) after providing universal access to antiretrovirals. Despite being threatened by the US Trade Representative for producing generic medicines, Brazil has allowed the use of generic medicines, saving the country hundreds of millions of dollars and reducing HIV prevalence by over 50% .
The claim has been that such measures are not "cost-effective" in the manner of education initiatives (which themselves are declared cost-effective by predicting "high return on investments" in spite of the emerging data to the contrary). But "cost-effectiveness" is not based on a law of nature -- in its current form, the means for calculating such effectiveness assume that distinct health interventions are competing with one another, as if all health outcomes were pulling from the same pot of money, and the overall effect on society will be discrete, whether or not a plague is taking place [41, 52, 53]. The logic, like the "health belief model", seems intuitive, but it is notable that not all societies think this way; indeed, many assume instead that health is multiplicative -- that healthiness among some members of society contributes to healthiness among others as work-capacity and social esteem are promoted by the lack of disease . As WHO senior advisor Jim Yong Kim recently declared, "For years, we have assumed that health spending must be pulled from a fixed pot of money, without examining who determines how big the pot is or how ill health plays upon the maintenance of the economy and general society." Brazil decided to counter the World Bank claims about the "cost-ineffectiveness" of its programs by calculating the "cost-effectiveness" differently; when it took into account the cost of hospitalizations saved by properly treating AIDS patients and thereby preventing them from having recurring opportunistic infections (reducing hospital visits by 80%), and included the costs of mass death to the Brazilian economy, the cost of antiretrovirals suddenly seemed quite affordable .
Yet in this context, a new rhetoric against generic medicines was deployed to counter the idea that other countries could follow Brazil's path. The US Trade Representative threatened Argentina, Thailand, South Africa and other countries when all of them attempted to regulate the prices of pharmaceuticals or introduce competition into the monopolistic patent regimes . The USTR's claim was that generic drug use would reduce innovation, but like many claims about AIDS, this one ignored all available data. According to the industry's own tax records (obtained from the Securities and Exchange Commission), Merck this year spent 13% of its revenue on marketing and only 5% on R&D, Pfizer spent 35% n marketing and only 15% on R&D, and the industry overall spent 27% on marketing and 11% on R&D .
Most AIDS drugs were produced under significant public funding, and 85% of the research (including clinical trials) for the top five selling drugs on the market were produced through taxpayer funding . Meanwhile, all of sub-Saharan Africa constitutes only 1.3% of the pharmaceutical market, so as one former pharmaceutical executive put it, providing generics to this market would result in a profit loss equivalent to "about three days fluctuation in exchange rates" [58, 59]. But the drug industry's fight for this market and middle-income country markets is serious, as the growing inequality in poor countries under the context of neoliberalism manufactures a new market among the wealthy and a sector for industry expansion .
Realizing the problems with claims about patents and pharmaceuticals, developing country trade ministers pushed through a deal at the November 2001 trade conference in Doha, Qatar. The resulting "Doha Declaration on TRIPS and Public Health" (referring to the Trade Related Aspects of Intellectual Property Rights, or TRIPS, Agreement) would allow poor countries to import generic medicines, especially if they lacked the capacity to produce such medicines themselves . Although it passed unanimously, the US Trade Representative managed to become the only trade minister out of the WTO's 145 member country ministers to block the implementation of the Doha accord . A deadlock still exists as the US insists upon limiting the scope of countries eligible to import generics. The US has once again co-opted the public health rhetoric, claiming that only a few iconic, extremely poor countries should be the focus for the deal . Such an exclusionary policy would not only violate the Declaration itself (which claims that the WTO will promote "access to medicines for all" ) and deny medicine access to the majority of people who need it, but would destroy economies of scale and other necessary means to build efficient and effective generic drug production facilities, and prevent competition to lower prices and increase quality [63, 64]. Such is the nature of "free trade".
The "culture" rhetoric also re-appears in this framework. U.S. presidential candidate Howard Dean, claiming to be the "Democratic wing of the Democratic party", has argued that antiretrovirals are of humanitarian importance but should not be emphasized because they are not as "culturally appropriate" as prevention initiatives. Culture once again becomes the basis for justifying inequality. And it is simultaneously blamed as reports are produced about the increasing prevalence of drug resistance in the U.S. and Europe. Drug resistant strains of viruses emerge when patients intake medicines irregularly, and while the reports of resistance are all from Northern countries, they have been projected onto the South under the assumption that "if drug resistance emerges here, it'll emerge there", particularly in the "cultures of denial" (as The Boston Globe put it) [65-67]. Some public health workers have even suggested that antiretrovirals should only be accessible to those patients "most likely to comply", yet what this denies is that those most likely to comply are those least likely to have HIV -- they are the wealthy and the people with resources needed to control the circumstances of their own lives.
Drug resistance can be more effectively countered by scaling-up antiretroviral treatment and providing sustained and equitable distribution; resistance propagates most often because people who are denied medicine are desperate to get it, so a black market flourishes, allowing people to trade medicines and take improper regimens . The drug resistance excuse is, like most excuses about AIDS, a vestige of past public health excuses, first deployed to suggest that persons with drug-resistant TB should not receive treatment (resulting in multi drug resistant TB as those people -- fated to die -- struggled to survive and receive pills wherever they could). Only when multi-drug resistant TB hit New York City populations did treatment for it suddenly become "cost-effective" .
Yet the public health community uses examples like these to suggest that they have no options besides meagre education-based interventions. As one group of health workers put it, "as ordinary citizens, we are not in a position to change the political and economic system" . While such an analysis effectively loses the marathon before the race has even started, it also ignores the numerous health models (often constructed by activists rather than public health programs) that have effectively changed political and economic contexts for HIV transmission rather than subscribing to fatalism. In the context of the poorest location in the poorest country in the Western hemisphere (the central plateau of Haiti), public health workers have managed to provide free antiretroviral treatment without producing primary resistance and have effectively begun to stem HIV transmission by providing new models for food provision, income generation and continuity of health care distribution [7, 50].
In the context of southern Africa, campaigners have forced the Coca-Cola company to change its labour policies and provide family housing, reduce migration-based networks of product distribution, and provide complete health packages including antiretroviral drugs (www.treat-your-workers.org). So the fatalism must be tempered by an awareness of such models, which are now abounding as those infected and affected by AIDS refuse to sick back and watch the inefficacy and behaviouristic prevention initiatives produced by the public health community.
What the health community ignores is that that public health must be less about coercion and more about facilitation. In addition, there are many campaigns focused exclusively on inequality between countries -- but these often present the idea that "Third World" starvation will be solved when "First World" people eat less ice cream. Indeed, between country inequality is tremendously important. But increasingly the First vs. Third World rhetoric produces claims that public health work has competing interests -- for example, between lowering prescription drug costs in wealthy countries and lowering them in poor countries (although the data indicate that the pharmaceutical industry can easily afford both) -- instead of questioning the rhetoric of "cost-effectiveness" and the zero-sum approach to health provision. We must increasingly focus on the inequalities that take place within countries, as these point us toward routes to facilitate better health rather than attempt to coerce people whose life circumstances render the rhetoric of hygiene ineffective and often ridiculous [70-75].
When we examine within-country inequalities, we begin to see the major trends -- that the poor (even the relatively poor in wealthy nations) are consistently those marginalized in the context of AIDS, whether they are located in the poor neighbourhoods of Washington D.C. or the mining fields just outside of Johannesburg; that the wealthy in both rich and poor countries use migrant labour and threaten the health of the poor to increase their share of capital; and that AIDS is a symptom of the breakdown of social relations that occurs in the context of growing inequalities [12-14, 20, 25, 26, 28, 38, 41, 47, 48, 50, 53, 76-81]. AIDS is effectively a symptom of Empire, which operates by producing inequalities everywhere, keeping resources inequitably distributed so that they may be accumulated by a few, and rendering problems like disease a side-effect of capital accumulation .
Empire is threatened not simply by local resistance but by resistances that occur when people in similar circumstances between different nation-states -- people in both poor and rich countries -- realize that inequality is central to this issue. Anti-AIDS efforts are funded currently to increase labour potential and prevent economic collapse by keeping workers economically productive, or by focusing so much on "behaviour" and "culture" that the context in which "behaviour" occurs is rendered unproblematic [82-84]. Therefore, the current anti-AIDS efforts bolster and disguise the mechanisms of Empire. AIDS becomes the product of individual irresponsibility and anonymous Third World destitution -- the plague captured in pictures of dying babies and public health saviours desperate to convince the natives to adopt better hygiene practices. To expose this rhetoric's basic fallacy will require serious questioning of public health's behaviouristic trends, as well as the dominant economic and political themes that render HIV a plague of the poor.
* For a list of the references used in this article please click on the link provided.