Build Universal public health systems as a path to the right to health
Latin American Social Medicine Association (ALAMES) and CEBES (Centro Brasileiro de Estudos de Saúde/Brasilian Centre for Health Studies/), Brazil

ALAMES and CEBES, in the framework of the Second Brazilian Congress of Policy , Planning and Management in Health of the Associacao Brasileira de Saúde Coletiva (ABRASCO) affirm that the path to full exercise of the right to health for the peoples of Latin America involves building, strengthening and developing universal public health systems (the ‘SUS’), as opposed to the campaign launched by international financial institutions and neoliberal governments around ‘universal health coverage’ based on the expansion of different forms of insurance, with a limited package of services for the poor and through promoting private investment in health.

This position is based on the following considerations:

• Universal health care systems are expressions of public and social commitment in each country to implement the principles of universality, equality, integrity and non-discrimination in relation to peoples’ health needs. They are part of state policies aimed at ensuring social rights.
• A single universal and public health system (a national health service) contributes to the implementation of universal policies, in the context of social and human development, that break with the social inequalities and inequities that are inherent in the logic of the market. Their management and financing can be sustained through fair tax policies that promote a fairer distribution of wealth.
• The neoliberal reforms in various countries in the region to date demonstrate that systems of health insurance based on targeting and limited service packages have deepened social differences in care by placing at the core of their design alleged financial constraints and greater private sector roles in health services.
• The momentum that agencies, foundations and corporations are giving to the debate and implementation of so-called ‘universal health coverage’ is an expression of an interest in locating health as a key field of capital accumulation. This can rob countries of resources that are vital for health and reproduces injustices and inequities in health care.

We should be alert to the efforts being made to deepen exclusionary insurance systems and loss of health rights in Peru, Colombia and Mexico.

We call on the Latin American and global movement for the right to health to express their rejection of deepening processes of market insurance and privatization that are advancing right now in Peru, Colombia and Mexico.

• In Peru, using a questionable granting of legislative powers to the Executive Branch to drive the process that bypasses the Congress, the Ministry of Health and Ministry of Finance intend to introduce new laws that seek to deepen market participation in the health sector through the promotion of public-private partnerships, contracting of services and deregulated insurance. This lowers the possibility of equalizing the access to comprehensive health care and social security that only a third of Peruvians currently enjoy. The first laws passed under these legislative powers have violated the labour rights of health workers, undermining their security of pay, with further uncertain implications. This is despite a constant demand from social movements and professional associations in health in most parts of the country to build a reform based on universal principles.

• In Colombia, universal coverage based on insurance has had disastrous consequences, with the collapse of national insurance funding declared by government itself to be a national health emergency. Despite this, the reform initiated today merely changes names on the same entities and processes that have for twenty years undermined access to health, blocked avenues for claiming the right to health and subordinated claims on the right to health to macro-economic considerations. The reforms do not address any of these underlying factors and despite the flow of funds, the health system is literally dismembered. The fact that health is only a business for insurance companies has been associated with a rise in corruption and paramilitarism in the sector.

• Mexico is currently presented as a promising example of neoliberal reform. However, claims in the reform of having achieved universal coverage hide the fact that a significant share of the insured population has no real access to care, that there has been a reduction in benefits covered by insurance, and that the introduction of private insurers seeking to make profits in the sector is raising the risk for millions of people of losses in social security health benefits.

All countries need universal health systems.

• Recognizing the complexities and particularities of each country, it is urgent that social movements drive and ensure the formation of Universal Health Systems, understood as an inalienable responsibility of the state and society, to build institutions that guarantee the right to health universally and equally outside the logic of the market and profit. This requires progressively overcoming the fragmentation of sub-systems through innovative management and through a commitment to sustainable financing.
• We recognize the national health system (the ‘SUS’) in Brazil as an example of social momentum based on universalist principles, and call for its defense and for deepening it in all necessary areas. We especially support popular demands to allocate 10% of the gross federal revenue to support the expansion of the SUS and to limit the growth of private services. We defend Brazil's SUS as a source of inspiration and an example of the real possibility of reversing the expansion of an individualist model of health insurance that breaks the concept of and responsibility for public health.
• In this regard we urge the Brazilian government to publicize and defend the SUS internationally, presenting it as an alternative to guarantee the right to health of the people.

For the right to health, universal public health systems for all countries of Latin America!

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For the original declaration in Spanish see http://www.alames.org , entry two for October.

Building a healthy society in South Africa: perspectives and actions
Editor, EQUINET newsletter

When the first Global Symposium on Health Systems Research, held under the theme "Science to Accelerate Universal Health Coverage" ended a week ago, after hearing the concluding statement (included in this newsletter), many people went back to heavily fragmented health systems with very different experiences of access and service for different social groups. The two editorials in this newsletter take the issue of universal coverage to the real time of the policies and interests being negotiated at country level in South Africa. The discussion by Di McIntyre on national health insurance in South Africa points to the importance of perspective and clarity on the long term implications of choices being made in the current debates on national health insurance; while the report by Jacky Thomas of SANGOCO points to the measures civil society are taking to move from issue specific to common platforms, to challenge unhealthy divisions in systems and in society. Together they raise the challenge of twinning perspective with knowledge, and knowledge with organisation, to build universal, integrated health systems.

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

Call Closes On January 7 2005

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

The call:

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

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

The programme

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

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

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

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

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

Call for participation and applications:

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

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

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

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



This briefing describes the new programme of student research grants in
EQUINET and invites applicants for the first round of grants.

The Regional Network for Equity in Health in Southern Africa (EQUINET)
promotes policies for equity in health across a range of priority theme
areas (See www.equinetafrica.org) EQUINET has over the years, organized its
work in various theme areas, including: economic and trade policy and
health; human rights, governance and participation, equity in health sector
responses to HIV/AIDS, human resources for health; monitoring and
surveillance and others. Within these areas of work EQUINET aims to
identify, recruit and build capacity and analysis. After a successful
pilot initiative in 2003 in co-operation with the Malawi Health Equity
Network member in the EQUINET steering committee, EQUINET has now launched a
programme of student research support that provides small research grants
for students at college or university in various programmes in east and
southern Africa. The programme will give priority to student research
applicants who propose projects in areas of research relevant to EQUINETs
priority areas of theme work, and who provide evidence of supervision from
expertise in these areas.

This first round of the EQUINET student research grant programme (SRGP) is
being implemented in February 2004. EQUINET will award a number of small
grants to post graduate students and undergraduate students in East and
Southern Africa for research proposals in the areas of
? Equity in Human Resources for Health
? Equity in health sector responses to HIV/AIDS and treatment access
? Using health rights as a tool for equity in health
? Health equity in economic and trade policies
? Fair financing in health
? Governance issues in health equity
? Understanding and analyzing policy processes
? Equity issues in food security and nutrition

The grants are for students to carry out supervised, small research projects
in the course of their studies and are set at a maximum of $750. Applicants
are requested to provide brief information in 2-3 pages on
? The name, institution, course and year of study of the student
? The name, department and institution and contact email/fax for the
proposed supervisor for the study
? The theme area of the proposal
? The hypothesis, research question or research objective(s)
? The methods to be used, and indicators / (quantitative, qualitative
information) to be collected and the intended analyses to be carried out
? The time frames and budget
The application should be made jointly by mentors / supervisors and their
students. The grants will be open to all EQUINET members, undergraduate
and postgraduate students, students from all disciplines. Applications
should be submitted to admin@equinetafrica.org with STUDENT GRANTS in the
subject line or by fax to 263-4-737220 by March 30 2004.

In this round the student providing the project proposal rated highest on
grounds of analytic and technical quality and relevance will qualify to be
supported to attend the EQUINET conference in Durban South Africa, June 8-9
2004 (see www.equinetafrica.org) and formally granted their award at the

The selection of grants will be made on the basis of relevance of subject
area and quality of proposal but with some attention to ensuring equity in
the distribution of grants across countries in the region. Applications in
French or Portuguese will be considered.

EQUINET web based resources, newsletter and expertise in the theme areas
will be available to the students. The reports of the research projects
will be made available on the EQUINET website. Publication from the research
is encouraged, with acknowledgement of the support from EQUINET. EQUINET
will also have the right to use the research in its theme work and will
encourage the students participation in future EQUINET activities and
information exchange.

Focal points for queries on this programme are Dr R Loewenson/G Musuka at
the EQUINET Secretariat (TARSC) and Dr A Muula at the Malawi College of
Medicine/ Malawi Health Equity Network. Please send queries through
admin@equinetafrica.org. For general information on EQUINET and its work
please visit our website at www.equinetafrica.org or email the secretariat
at admin@equinetafrica.org.

Can essential benefit packages be a lever for universal health systems?
R Loewenson, M Mamdani, EQUINET

Current policy agendas raise an impetus for countries in east and southern Africa to be clearer with the public on what health care services they can expect to access. Commitments made to universal health coverage (UHC) and equity in health care point to a need to define the entitlements or service benefits that will be provided universally to respond equitably to population health needs. Constitutional provisions on the right to health care raise a demand to clarify what services people should be legally entitled to. Yet the gap between demand and resources suggest a need to clarify what can be funded and provided universally, taking costs into account. The diversity of funders and providers in most health systems in the region call for funders and providers to be aligned around these entitlements while social demand for public accountability calls for transparency on how resources and capacities are being used to deliver these entitlements.

As one response, many countries in east and southern Africa (ESA) have developed essential health benefit packages (EHBs) in order to define service benefits, to direct resources to priority, relevant and effective areas of health service delivery. EQUINET research in 2015-2017 through Ifakara Health Institute and Training and Research Support Centre working with ministries of health in Swaziland, Tanzania, Uganda and Zambia found that of the sixteen countries in the ESA region, thirteen had an EHB in place by 2016, albeit with different names and at different stages of design and implementation.

There was much in common in the way these EHBs were being developed and what they covered. The EHBs in the region cover similar services for communicable and non-communicable diseases, maternal and child health and public health. They generally combined an analysis of health burdens and cost-benefit or value-for-money to identify what services to include, taking on board policy goals and commitments. In some cases they took into account the priorities reported by stakeholders and external partners and, to a more limited extent, communities and parliamentarians. When countries used consultative, consensus-building design processes with wider stakeholders they widened awareness and debate on the choices to be made in what services to include, on the cost of care and on the entitlements included.

It would appear that the process for defining, costing and clarifying service benefits could be a key entry point for policy dialogue across stakeholders and an important basis to build an operational strategy for realising UHC in an equitable manner and for making clear the deficits to be met.

Indeed, ESA countries report a range of ways they are using their EHBs: They are being used as a tool for budgeting and planning at local government level; to guide priority setting and budgets; to purchase services from private, not-for-profit services and to monitor service performance. These areas of practice depend on quality system data, including from the from the private health sector, good population health information and data on the costs of services to both design, purchase and be accountable for delivery of the benefit.

While there are shortfalls in some of these areas of data, the funding gap has presented perhaps the greatest challenge in delivering on the EHB. ESA countries face clear challenges in reconciling the services they should provide to respond to population health need with the resources they have to do so. The estimates ESA countries calculated for what their EHBs would cost varied widely, from $4-$83/capita at primary care level to $22-$519/capita for referral services. In part this reflects differing assumptions and methods used for capital and recurrent costings. At the same time, in most ESA countries these figures point to a gap between the cost of a benefit package that responds to health needs, and the funds available for it, particularly in the public sector. Having these costs of the EHB raises a question for national and global levels of how, in the face of commitments to UHC, these costs will be met to turn the talk into action.

In the face of this funding gap, some countries have begun to explore new revenue sources from innovative financing, linking the EHB to policy dialogue on health financing. Resource constraints and vertical financing have, however, also motivated rationing of scarce resources, reducing the benefit to a smaller subset that can be funded from current budgets. This may focus resources on what is possible and avoid the frustration generated by the gap between aspiration and delivery. However, it also raises concerns on how to ensure fairness and public health effectiveness in the decisions on what services are covered and what is excluded. How should services treat people who present with a combination of conditions, one covered and one not? How to ensure the integration across services when some are funded and others not? How to avoid ‘minimum’ benefit packages becoming the ‘maximum’ provided? How to ensure that the poorest in the population get all their health needs addressed without costs that impoverish them?

In a regional dialogue within the countries involved the research, the EHB as a universal benefit was seen to be consistent with policy goals to build universal equitable health systems. It was seen to be a potentially useful measure to engage and build support from high-level political actors, funders, providers and communities on the different challenges that need to be addressed in implementing UHC, and to align public and private actors around national goals.
In facing the financing challenges given the desire to ensure universal provision of the benefit, it was felt that the EHB would be best funded through progressive tax financing and pooling of other social insurance, earmarked tax and private sector contributions to avoid segmentation and to ensure the universality of the benefit. At the same time it was felt that funding constraints not present a pressure to limit to curative services, and that the EHB include health promotion, public health and prevention measures, as both value for money, important for service integration and key for health sector engagement on inter-sectoral action for health.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. More information on the issue can be found in the regional meeting report at
http://www.equinetafrica.org/sites/default/files/uploads/documents/EQ%20Regional%20EHB%20Mtg%20Rep%20Nov2017.pdf , the country case study reports on the EQUINET website and synthesis paper at

Can Ugandans get to “prosperity for all” without addressing “health for all”?
Charlotte Muheki Zikusooka, HealthNet Consult, Uganda

As we turn the corner of 2010 and make our personal plans for 2011, it’s also appropriate to think about the plans and actions we will take to improve our lives as a nation. With election fever raging in my country, Uganda, there are more than enough promises on how to make Uganda a better country. However, some questions remain unanswered. For me, and possibly for many others, one area we need to give more attention to is the current and future health of our population. The question I pose is: are we heading towards “health for all”? Are we taking steps to achieve health care for all, more recently referred to as “universal health coverage”?

The World Health Organisation defines universal health coverage as “securing access for all to appropriate promotive, preventive, curative and rehabilitative services at an affordable cost”. In 2005, the World Health Assembly adopted a resolution urging its member states to work towards universal coverage and to ensure that their populations have access to the health interventions they need without the risk of financial calamity. This means that people should be protected from the costs of health care when they fall ill, that all people should access the services that are available to meet their health needs, and that services should meet conditions of quality and dignity, regardless of people’s ability to pay.

The goal for universal health coverage is; ‘No one should die because they cannot afford health care, and no one should be made poorer because they get sick.’ The questions we should grapple with are: how far has Uganda moved towards achieving this? And what specific plans are being laid for gradual movements towards achieving this?

It’s surprising to find that preventive and public health and health care were conspicuously missing from the principles and pillars of Uganda’s poverty reduction strategy of “Prosperity for All” (Bonna Bagagawale). For a long time, wealth creation and health have been considered to be inextricably inter-linked. People with ill-health cannot produce at their most desirable abilities, and poor people face many threats to their health. It can be a vicious cycle. Health or lack of health can be the difference between wealth and bankruptcy, especially when we consider the fact that one of the most common causes of poverty can be health care costs. In Uganda, households contribute about 49% of total health expenditure. We need to better understand the impact our health systems are having on people's health and wealth, and therefore on our economic growth as a nation.

In pursuing the goal of universal coverage for health, we should also look at how our health services are financed. In 2001, government officially abolished fee payment at public health facilities. This is one of the most commendable steps in moving towards achieving universal coverage. However, such an action would have been even more beneficial if was followed by additional actions that enhance faster movement towards “health for all”. Uganda spends about $27 per person on health per year, which is below the $40 per person recommended by the World Health Organisation for provision of a basic package. A significant proportion of the $27 spent on each person comes from external sources that are sometimes unsustainable. Sadly, even though fees have been lifted, about half of our total health funding still comes from direct cash spending by households at private health providers whose services are usually viewed to be a relatively better quality than those provided in government facilities.

This financing situation poses two problems. The first is obvious; our health sector is severely under-funded. Ministry of Health estimates current expenditure per person on essential medicines as only US$ 0.87 against an estimated requirement of US$ 10 per person. It is therefore not surprising that only 35% of the health facilities have six tracer medicines and supplies. The second is less obvious: financing a health system from people’s cash payments (out-of-pocket) is the most unfair, fragmented and least likely approach to take us towards “health for all”. Experts in health financing, in Uganda and the world over, acknowledge that universal health coverage cannot be achieved in contexts were countries have not effectively addressed the issue of equitable health financing.

So what do we need to do? Equitable financing is based on set of principles, namely: financial protection (no one in need of health services should be denied access due to inability to pay and households’ livelihoods should not be threatened by the costs of health care); progressive financing (contributions should be distributed according to ability-to-pay, and those with greater ability-to-pay should contribute a higher proportion of their income than those with lower incomes); and cross-subsidies (from the healthy to the ill and from the wealthy to the poor). Uganda’s current financing systems may still be far from what we need to achieve “health for all”, but it is also possible for us to take the necessary steps to achieve it.

As Uganda turns a new corner into 2011, hopefully we can start building the road map and taking these steps to move towards “health for all”.

This editorial first appeared in New Vision Uganda on 4th Jan 2011. 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.

Can victory on AIDS medicines catalyse wider change?
Patrick Bond (http://www.zmag.org)

A rare activist-driven win for some of Africa's wretchedly poor women, men and children leaves me humbled. In June 2002, I wrote a Znet (www.zmag.org) column-'Corporate cost-benefit analysis and culpable HIV/AIDS homicide'-in which the main prediction proved partly wrong within a few weeks. I have been waiting for a chance to correct the mistake. My error, excessive pessimism, was compounded by another event I would not have considered possible: the November 19 announcement that the South African government will now finally begin providing anti-retroviral (ARV) medicines to hundreds of thousands of people who are HIV+.

Activists hope that five million infected, who now account for more than a quarter of South Africa's adult population, will eventually get the desperately needed medicines, notwithstanding some practical barriers to implementation. Exultant relief was expressed by South Africa's Treatment Action Campaign (TAC), along with allies including ACT UP, Oxfam and Medicins sans Frontiers, which is running successful treatment pilot projects in Cape Town township clinics, where compliance with treatment regimes is higher than 90%.

TAC also restrained itself from launching protests against president Thabo Mbeki's extraordinary comment in late September to the New York Times: 'Personally, I don't know anybody who has died of AIDS.' In mid-November, the hated health minister, Manto Tshabala-Msimang, also revealed her reluctance to attribute AIDS to the HI Virus, just as she announced the medicines roll-out. In previous statements, she has termed ARVs 'poison.' Given such attitudes, I didn't think Pretoria or its corporate friends would get this far along the path to civilised behaviour, this fast. For the chance to commit these errors, I am delighted, because far worse would have been to claim deadly accuracy.

My prediction was that at least three structural forces in South African capitalism would overwhelm the struggle capacity of AIDS treatment activists. Structure/struggle is always a dialectic, but it's wonderful to see history written from the bottom up, for a change. I will briefly rehearse the argument that I confidently made in mid-2002; some of that analysis is still valid, even if my main point-that the dynamics of state power and corporate profits tend to overwhelm progressive resistance-must be revised.

The first factor is the pressure exerted by international and domestic financial markets to keep Pretoria's state budget deficit to 3% of Gross Domestic Product. This pressure led Mbeki's spokesperson Parks Mankahlana (who died of AIDS three years ago) to remark to Science magazine in early 2000 that pregnant, HIV+ women would not be receiving Nevirapine to prevent mother-to-child transmission, because 'That mother is going to die and that HIV-negative child will be an orphan. That child must be brought up. Who is going to bring the child up? It's the state, the state. That's resources, you see.' Second is the multinational pharmaceutical corporations' interest in maintaining exclusive patents on ARVs so as to monopolize profits, profits which come from sales to wealthy markets, not low-price deals for Africa. As the actions of US Trade Representative Robert Zoellick prove, pharmacorp pressure remains intense, although some firms have offered cheap drugs, but mainly so as to head off the possibility of mass imports (or local production) of generics. To illustrate, staff at the Bill and Melinda Gates Foundation, which provides medicines to some African countries, certainly don't want to see the World Trade Organisation's protections on 'Trade in Intellectual Property Rights' undermined, for obvious reasons.

Third, South Africa's huge unemployed labour pool-more than 40% of the potential workforce-means that local capitalists can readily replace unskilled workers who start developing AIDS symptoms with desperate, jobless people. This is less expensive than providing medicines, with Anglo American Corporation's 2001 cost-benefit analysis demonstrating that only the highest-paid 12% or so of employees justified receiving AIDS medicines, given the cost of recruiting and training replacements at the higher end of the spectrum.

But within a few months, the calculus changed sufficiently for two of the largest employers in Africa, Anglo and Coca Cola. The main ingredient was protest-and in Anglo's case, I was reliably informed by insiders, the prospect of demonstrators at the August 2002 World Summit on Sustainable Development dragging up many other bits of dirty laundry. Coke's main bottler in South Africa has failed to insure two-thirds of its 4,000-strong workforce at a sufficient level to allow the HIV+ workers access to ARVs, and it too was subject to international protest over African AIDS policies.

However, even though the costs of HIV/AIDS-absenteeism, declining productivity, payouts for early death-have soared to as high as 25% of payroll, according to the Financial Times in a September 18 report this year, most employers are still hesitant to provide ARVs: 'Untreated, HIV typically takes four to five years to manifest itself as full-blown AIDS, and companies are reluctant to pay for a risk that they cannot see. Persuading managers to part with fees [AIDS treatment programmes] today for costs that will hit company earnings years down the line has been a hard sell.' In sum, all three structural factors are still deterrents to provision of treatment, though each has been mitigated recently. The budget deficit will climb this year from just over 1% of GDP to nearly 3%, allowing extra leeway for AIDS spending. Pharmacorps are cooperating with the World Health Organisation, Clinton Foundation and governments to lower prices for Africa, in part because Canada's outgoing prime minister Jean Chretien-spurred by UN advisor Stephen Lewis-has introduced legislation to promote generics. And employers are waking up, in part because of the dramatic rise of AIDS-related disability claims as a percentage of all disability claims, from 18% in 2001 to 31% last year.

What, specifically, was behind the November 19 Cabinet statement? Pretoria cited factors which included: 'a fall in the prices of drugs over the past two years; new medicines and international and local experience in managing the utilisation of ARVs; [sufficient] health workers and scientists with skills and understanding; and the availability of fiscal resources to expand social expenditure in general, as a consequence of the prudent macro-economic policies pursued by government.' However, these factors are, in my view, minor compared to intensive activist pressure, which Pretoria did not dare mention lest it encourage further protests. TAC's victory statement was explicit: 'The combination of the Constitutional Court decision on mother-to-child transmission prevention, the Stand Up for Our Lives march [of 15,000 people on parliament] in February, the civil disobedience campaign and the international protests around the world have convinced Cabinet to develop and implement an ARV rollout plan.' Another factor, of course, is the 2004 presidential election, which Mbeki is expected to win easily but which will be characterised by high levels of apathy and no-vote campaigning by the Landless Peoples Movement. An AC Nielsen survey in November confirmed that Mbeki's AIDS policy is hurting the ruling African National Congress' chances of turning out the vote.

High visibility is an important antidote, and the Cabinet promised that 'within a year, there will be at least one service point in every health district across the country and, within five years, one service point in every local municipality.' In addition to medicines, the state will provide an education and community mobilisation programme, promotion of good nutrition and traditional health treatments such as herbal remedies, support for families affected by HIV and AIDS, and funds for upgrading health infrastructure. The current health system is massively overextended, with far too few essential medicines, much less ARVs, available in South Africa's underfunded rural clinics.

The programme's resources-US$40 million through March, rising to US$680 million per year in 2007-are all new (not drawn from existing allocations to social programmes. The cost of medicines will rise from 20% to 33% of the programme budget.

Will ARV availability generate negative unintended consequences? One would be noncompliance with treatment regimes by poor people, and the concomitant emergence of drug-resistant strains. Another would be the black-market smuggling of cheap drugs to Europe and North America which would reduce access in Africa. Another is that although stigmatisation will decline given the availability of hope-giving drugs, so too might the practice of safe sex. These are all major challenges to TAC and other health-sector groups.

The Cabinet also repeated one of Mbeki's tired truisims, namely that immune systems in townships and villages are 'assaulted by a host of factors related to poverty and deprivation.' In spite of a recently-published ten-year government review aiming to show increased delivery of old-age pensions and child support grants, there is no disguising the role of the allegedly 'prudent macro-economic policies pursued by government' in creating poverty and inequality.

The conflict between neoliberalism and life was rarely as explicit as in the case of AIDS medicines, and was compounded by patriarchy, traditional and modern sexual practices such as multiple partners for men, and domestic violence against women. Rape continues at scandalous levels. The TAC leaders, some of whom (like the brilliant activist Zackie Achmat) learned politics in highly vulnerable Trotskyist cells within the ruling party, are more than capable of simultaneously fighting capitalism, racism and sexism together. But a few other political choices may also become more urgent.

One relates to their alliances within South African politics, which have been effective in attracting the most forward-looking trade unions, the SA Communist Party, churches, NGO activists and technical supporters (lawyers, healthworkers, academics, journalists). Yet these alliances have not strayed far from the African National Congress.

Does TAC have sufficient linkages to non-ANC communities (especially those devoted to building the new independent left)? Will the myriad of problems that cause AIDS opportunistic infections-especially dirty water and air (thanks to coal/wood/paraffin)-also be addressed? At a time that the South African government is disconnecting water and electricity at a lethal rate, alongside evictions for those who cannot afford expensive rental and mortgage payments, addressing links between AIDS and diseases of poverty/homelessness are crucial.

This leads to another problem: will TAC and its allies make the case that access to ARVs is a human right and that people should not pay user-fees or partial cost-recovery for the medicines? They do make this case, but only in the event that people are too poor to pay for medicines. Yet 'means-testing' of black South Africans with irregular informal incomes is notoriously difficult. TAC may need to consider a more explicit 'free lifeline' strategy, as the water and electricity campaigners have done, partially successfully. After all, I see TAC as integral to the overall politics of 'decommodification' and 'deglobalisation' that are so crucial to social progress across the world. To decommodify is to take that which is life-giving-our medicines and healthcare, water and a decent environment, clean energy, education and childcare, support for the elderly, even food and culture, as well as employment-and remove them from the market, as much as is required to ensure a lifeline access to all, on a universal basis.

Such socio-economic human rights can be won, in my view, only through deglobalisation, namely the delinking of countries and regions of the world from the bureaucratic straightjackets designed in Washington and Geneva-structural adjustment, TRIPs, etc-on behalf of corporate interests.

Nevertheless, whether or not TAC continues to tackle the three structural impediments to ARV access-neoliberal fiscal policy, pharmacorps and corporate control of health perks-the immediate victory will make a huge difference. For the half million South Africans who are symptomatic with AIDS or who have a CD4 blood count less than 200, there is now hope. Across the world, for three million people who died this year of AIDS, this breakthrough has come too late. But for 40 million others infected, the treatment activists and their international allies deserve a standing ovation. Those who help Washington-based Africa Action protest Bush health policies on December 1, World AIDS Day, will gather strength from the South African breakthrough, and they will be louder and prouder than ever.

Can we better support parliaments to turn protocols into practice for equity in health in southern Africa?
EQUINET Secretariat, TARSC

The SADC Health Protocol came into force at the 2004 SADC Mauritius Summit and now applies across the region. It outlines the priorities and mechanisms for regional co-operation in health. We look forward to the protocol being raised and discussed within the parliaments of the region to see how far we are making progress in the regional priorities and approaches signed on to by the heads of state in Mauritius.

Why should parliaments be important to struggles for equity in health? Parliaments are a watchdog of public policy and consolidate this policy in law. In their legislative role they are able to transform social norms and values into binding legal entitlements. Their oversight role on the budget and on the actions of the executive provides an important opportunity to ensure that these legal entitlements are realized in practice. For example parliaments are an important watchdog of the government Abuja summit commitment that at least 15% of government budgets are invested in the public health sector. They can give voice through various processes of debate, inquiry, public hearings and consultation to public views, including the views of those areas and groups where such voice may be weaker or less articulate.

In an EQUINET, GEGA and SADC Parliamentary Forum regional meeting in South Africa in August 2003, it was recognized that parliaments are uniquely placed to build alliances with the Executive branch of government, across political parties, between different portfolio committees and with civil society, health sector and other agencies at national and regional level in support of health equity. (The report of this meeting is found at www.equinetafrica.org) The parliamentary reforms taking place in the region provide an enabling environment for this. At the August 2003 regional conference, delegates agreed that the establishment of parliamentary committees on health provided a forum for deeper review, policy monitoring and analysis, and noted that a range of health related activities were already taking place. These committees have held public hearings on laws and policies, visited and investigated conditions in the health system, held systematic hearings on the national budget and its consistency with national health policies and promoted public awareness on key areas of social norms and action in health, such as HIV and AIDS. In Zambia, South Africa and Zimbabwe, for example, with support from institutions in EQUINET and GEGA, parliamentary committees on health have analysed and made input on equity issues in the health budget and have visited districts to follow up on the equity issues raised. In Tanzania the parliament has established a parliamentary forum on AIDS at which key issues such as equity in access to Antiretroviral treatment have been debated. In Malawi parliaments have raised and promoted debate on issues of migration of health personnel and on the quality of health services at the district level.

In June 2004, during the EQUINET regional conference on equity in health, parliamentary committees and organisations working on health equity agreed that these critical areas of work needed more consistent regional exchange of information and good practice, support and activity. They would also benefit from longer term co-operation with state, academic and civil society institutions working on health equity. How can this be achieved? Is a more regular forum of health committees needed, within the SADC framework? How can the current work and institutional partnerships with parliaments be better networked and more consistently supported to ensure greater exchange of information, learning and good practice? These issues were raised as matters of concern to organisations like EQUINET working with parliaments and we invite readers and institutions working with parliaments to give feedback to these queries. What experiences exist in the region of work with parliamentarians on equity in health? How can we better strengthen and support such parliamentary roles, particularly if we are to achieve our goals of equity and social justice in health, and the policy commitments expressed in the SADC Health Protocol?

This briefing is produced by the EQUINET secretariat at TARSC. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat email admin@equinetafrica.org . Reports cited are available as a downloadable pdf file from our website at www.equinetafrica.org

Case studies of experiences of mechanisms for social participation in health services

This month's editorial presents one of the many experiences of the mechanisms that exist at primary care level for community participation in health services and for communication between services and communities. A series of case study briefs have been produced on these experiences, highlighting their contribution to people centred health systems, but also their challenges. As noted by those working with health centre committees in the region, if the intention is to build PHC-oriented, people-centred health systems then these mechanisms need skills for activism and transformation to help build social participation and power and a range of capacities, tools and processes that support this. The case study brief on experiences in South Africa is included in this newsletter and we will include further case study briefs in forthcoming newsletters.

Change agents, substitutes or scapegoats for crumbling health services – What roles can communities health workers play?
Uta Lehmann, School of Public Health, University of the Western Cape

“I started volunteering [as a community health worker] in 1996. During that time, the most common disease in my village was tuberculosis (TB). We worked together and visited those who were infected with TB. We also went to fetch their pills from hospital and distributed them accordingly. We were to ask the sick people to cough out the sputum and save it inside specimen bottles that we took to a certain sister at the hospital.” (Eastern Cape community health worker)

Community members have been rendering certain basic health services to their communities for at least 50 years. All over the world, but particularly in countries in Asia, Africa, and Latin America community or village health workers (CHWs) have been providing health education to their communities, helping pregnant mothers and new-born babies and treating basic illnesses. They are often mature women, with little formal education. The quotes from CHWs in Eastern Cape South Africa highlight this experience.

“My first encounter with the health programmes was in 1986. Our training was to help people who had been swept by the river waters and nearly drowned. ….We went to all the homes teaching people about TB and how to avoid it. To those who had it already we continued to train them on how to take care of themselves and prevent further spreading of the disease. We encouraged people to have toilets, to build chicken runs and pig sties and avoid animals running loose all over the place to keep ourselves in good health.” (Eastern Cape community health worker)

Since the arrival of HIV, community health workers have also been counselling community members, providing peer support and home-based care and ensuring that people on antiretroviral therapy take their treatment. In some countries they have also been involved with HIV testing.

In the past CHWs have been seen as advocates for health in their communities and agents for social change. This made them central to comprehensive primary health care. In recent years a much more technical understanding has taken hold, which views CHW programmes as a strategy to address health worker shortages in most countries. This view is reflected in the 2006 World Health Report which advocates the delegation of tasks to lay health workers.

The renewed enthusiasm for community health workers presents great opportunities to seriously review how community health is organized and rendered and to empower communities. However, questions have to be asked about the rationale and intention of this enthusiasm:
• Is it realistic to expect commununity members from invariably impoverished communities to take responsibility for what in effect are essential health services, often with very little training and hardly any supervision?
• Are governments in fact not abdicating their responsibility for ensuring appropriate health care for their citizens, in particular the most vulnerable ones?
• Under what circumstances are CHW programmes empowering communities and under what circumstances are they shifting the burden of health care to those most vulnerable in society?
• What roles can CHWs realistically play?

There is ample rigorous evidence from different parts of the world that CHWs can play a crucial role in broadening access and coverage of health services in remote areas and can undertake actions that lead to improved health outcomes in a range of areas, including child health, TB and HIV/AIDS care. CHW programmes hold the potential of enabling countries to build sustainable, cost-effective and equitable health care systems, thus contributing towards moving closer to achieving the Millennium Development Goals. However, the challenge of achieving success cannot be underestimated. Programmes need careful planning, secure funding and active government leadership and community support. To render their tasks successfully, CHWs need regular training and supervision and reliable logistical support. Importantly, governments have to retain their responsibility for essential health services at all levels, including for CHWs programmes. It is their responsibility to ensure that CHWs are, in fact, appropriately and adequately trained and supported by health service staff and communities and that their roles are clearly understood by all role players. This requires political leadership and substantial and consistent resourcing.

Given present pressures on health systems and their proven inability to respond adequately, the existing evidence strongly suggests that, particularly in poor countries, while CHW programmes are not easy, they are a good investment. This is particularly true given that the alternative in reality is NO care for the poor living in geographically peripheral areas.
They represent far more than improved service provision and access, however.

The continued testimony from the community health worker in South Africa’s rural Eastern Cape province demonstrates the personal and social dimensions of health actions that CHWs bring:
“Then the disease called HIV/AIDS started attacking people till it came to my house and attacked my own son. I could not understand this disease which he came with from Cape Town, but I took him to hospital. I was very hurt and heartbroken to see how his whole body was covered with sores, from head to toe, even the softest parts. I took him to hospital. At the hospital I was not told that it was HIV/AIDS, I was told he had TB. After reading his forms carefully, because I could read a little, I discovered that they had diagnosed him with thing [HIV/AIDS]. My frustration worsened, and that is when I decided to give myself to the whole of the village to help other people, especially that I had this bad experience firsthand. I went up and down the ravines of the village working. Many more people were discovered to be infected till this day. I worked harder and harder though, unfortunately, some of those I tried to help could not make it, they died. Some had very bad sores and we frequently washed them. I would take a flask from home and boil water for my patients to keep in it so I could prepare something to eat for them before taking their medication. For some, I would get there and start making fire with wood as we normally do in the rural areas, and warm water to use for his bath. They looked very bad during those days but today you wouldn’t think it’s the same person that I had nursed to recovery” (Eastern Cape community health worker).