IMF policies are blocking the scale of public spending and hiring of doctors, nurses and teachers African countries need to meet health and development goals. Three recent reports respectively by the IMF’s Independent Evaluation Office (IEO), the Center for Global Development (CGD) and ActionAid International’s Education Team suggest that IMF policies place unreasonable limits to spending of available aid and to scaling-up public spending through overly austere policies that lack empirical justification.
The IMF's mission is to keep inflation under control and promote “macroeconomic stability”. Country access to World Bank aid and other bilateral foreign assistance is contingent upon “thumbs-up” approval from the IMF on macroeconomic policies. The multiplier benefits of major investments in public health and education can take 15 to 20 years to appear in the form of higher GDP growth and productivity rates. Each macroeconomic policy option has its own short-term and long-terms costs and benefits, but because the IMF is always demanding short-term fiscal solvency at any given time, many reasonable alternative macroeconomic policy options for hiring more doctors, nurses and teachers or making long-term investments in the health or education systems are not even being allowed for consideration or debate. So are IMF demands blocking the scale-up of public spending needed to fight AIDS and achieve the Millennium Development Goals (MDGs)? The three reports examine these issues.
The IEO report “The IMF and Aid to Sub-Saharan Africa,” available at http://www.ieo-imf.org/eval/complete/pdf/03122007/report.pdf, examined IMF loan programs to 29 Sub-Saharan African countries from 1999-2005 and found significant percentages of foreign aid were not programmed to be spent because:
* about 37 percent of all annual aid increases were diverted into building international currency reserve levels. Even in countries with sufficient currency reserves, only about $3 of every $10 in annual aid increases was programmed to be spent; the IMF redirected or diverted the remaining $7 out of every $10 into paying domestic debt, building international currency reserves, or both. Having so much new aid not being spent was certainly not the intention of the donors, or citizens in donor countries.
* aid spending was curtailed due to the IMF’s insistence on very low inflation levels. Countries that failed to achieve to 5-7 percent inflation a year were only allowed to spend 15 percent, or just $1.50 of every $10 of their annual aid increases. At a seminar in London in April 2007, Joanne Salop, lead author of the report, said the IEO report team recommended that as the 5-7 percent threshold was the operative IMF policy, it should be publicly stated and clarified - but the IMF Executive Board and management rejected the recommendation.
The IEO report found the IMF Executive Board and senior management were not enthusiastic about donors' emphasis on “poverty reduction” or new efforts to scale-up aid and spending for the MDGs. Without strong leadership directing real policy changes in this regard, the report found, staff simply reverted to prioritising macroeconomic stability over other goals. Yet IMF leadership is overly cautious about deficit spending “crowding out” available credit for the private sector, despite mounting evidence for the reverse, as noted by IMF’s Sanjeev Gupta in a 2006 IMF report (“Macroeconomic challenges of scaling up aid to Africa: a checklist for practitioners,” IMF, 2006. p.26).
The CGD report “Does the IMF Constrain Health Spending in Poor Countries? Evidence and an Agenda for Action,” available at http://www.cgdev.org/doc/IMF/IMF_Report.pdf further explores the implications of this IMF austerity. Produced by fifteen experts from policy-making positions in developing countries, academia, civil society, and multilateral organisations, it reviews experience from Mozambique, Rwanda and Zambia. The report found that: “IMF-supported fiscal programs have often been too conservative or risk-averse”, and have led to underspending of development aid, as they have “not done enough to explore more expansionary, but still feasible, options for higher public spending.” The report calls on the IMF to “explore a broader range of feasible options,” with “less emphasis on negotiating short-term program conditionality.”
The ActionAid International Education Team report “Confronting the Contradictions: The IMF, wage bill caps and the case for teachers,” (http://www.actionaidusa.org/imf_africa.php), found that IMF policies - by varying degrees of influence in setting the level of funds available public sector employees' wages or “wage bill ceilings" - require many poor countries to freeze or curtail teacher recruitment. This leads to persisting chronic and severe teacher shortages. In all three countries studied, inflation-reduction and deficit reduction targets and the wage bill ceiling is too low to allow governments to hire enough teachers to achieve the 40:1 pupil-teacher recommended by the Education for All-Fast-Track Initiative, thereby compromising the quality of education in these countries.
For health and education advocates who are trying desperately to maximize budgets, wages and get every last doctor, nurse and teacher hired, such empirically unfounded economic policy-making is totally unacceptable. An array of reasonable alternative policy options for increasing public spending is being unnecessarily omitted from consideration.
The ActionAid report calls for IMF advice to provide a range of policy options so that governments and other stakeholders – including parliaments and civil society –can make informed choices about macroeconomic policies, wage bills and the level of social spending.
The report also highlights the growing policy contradiction in the foreign aid system: as the richest donor countries try to scale-up spending and foreign aid, they also block the ability of many poor countries to spend that aid because of the IMF loan programs they have approved. A July 4, 2005 New York Times editorial appropriately summarized this current contradiction in donor policies: “There is a desperate need for greater policy coherence in a period when many national governments, including Washington, are sensibly exhorting African governments to spend more on primary health care and education, while international financial institutions largely controlled by those same Western governments have been pressing African countries to shrink their government payrolls, including teachers and health care workers.”
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat firstname.lastname@example.org. For further information on this issue please visit www.actionaidusa.org.
From the 1-3 July 2007, African leaders will meet in Accra, Ghana at the 9th Ordinary Session of the Assembly of the African Union. The major agenda item is the proposal and plans for the United States of Africa. Africa’s Under-development as manifested in its public health catastrophe is not on the AU summit agenda. This raises the crucial question of the kind of unity African leaders wish to achieve. Significantly the debate about the proposed union has revolved mainly around political issues without commensurate attention to the development issues which were no less important to the founders of the Pan African movement.
It is now six years since Heads of State of African Union member states pledged in Abuja in 2001 to commit at least 15% of national budgets to health. To say it is tragic that in 2007 only two out of fifty three AU member countries (Botswana and Seychelles) have clearly met that pledge does not even begin to describe the situation. It is beyond tragedy.
In these past few weeks, all roads led to the G8 Summit in Germany. In what has become an annual ritual since the turn of the century, international campaigners Bono, Bob Geldof and an impressive assortment of Development and AIDS related organisations led the calls for more aid to Africa, and for Africa not to be forgotten in the clamour over climate change. As usual, selected African leaders turned up with begging bowls and for photo calls. Leading international campaigners have since described the aid pledged by the G8 this month as 'a farce' and 'grossly inadequate'.
We know that many of the more developed countries have played historical roles in under developing Africa. 400 years of industrial scale slavery, in addition to colonialism, ruthless exploitation of Africa’s resources, cynical ‘interventions’ and the debt burden have cost Africa dearly. The ‘foreign’ aid to Africa is a percentage of what has been taken out in human and natural resources, and is but a small step towards repairing the damage done to Africa.
But we also know that African leaders cannot seriously expect other countries to commit to, or meet pledges to ‘save’ Africa when they themselves appear indifferent to Africa’s future. To be going forward with plans for African unity without simultaneously meeting the most fundamental commitment to African development – that of health - is misguided to say the least.
It is comical for us to be calling on the G8 countries to meet the recent Gleneagles pledges when the vast majority of AU member states have not met their own Abuja 2001 pledge. This is not a pledge we can afford to pass unfulfilled. The Africa Public Health Rights Alliance (APHRA) and its '15% Now!' Campaign revealed on Human Rights Day (December 10) 2006 that by crossing continental, sub regional, country, health, disease specific and development information from a wide range of agencies and institutions we computed that an estimated 8,000,000 Africans are dying annually from preventable, treatable and manageable diseases and health conditions – mainly Malaria, TB, HIV, child and maternal mortality. This figure does not include organ related disease (heart, liver, kidney and lung diseases), an assortment of cancers, vaccine preventable diseases and so forth which could very easily add another million – or more. The consistency of these figures over the past six years alone means that Africa has suffered an estimated 48,000,000 preventable deaths since 2001.
By coincidence, the dream of the United States of Africa is planned to be actualised by 2015, the same year the Millennium Development Goals are to be met. If Africa’s health catastrophe continues unabated we could loose another 72,000,000 lives by then. This is the equivalent of whole nations dying out within a year or a decade. Many African countries (such as Botswana, Burundi, Eritrea, Gambia, Lesotho, Liberia, Libya, Namibia and
Swaziland) have populations of between 1-8,00,000. Most of the island countries have populations of less than a million. Even Africa’s most populous countries (DRC, Ethiopia, Kenya, South Africa, Sudan - with the exception of Nigeria at 130,000,000) all have populations of between 30-80,000,000.
It would therefore not be an exaggeration to describe over 120 million preventable deaths between 2001 and 2015 as genocide – by inaction. In this case and for every life lost, government indifference to Public Health is the equivalent of an Interehamwe machete or Nazi gas chamber. If we were set up memorials to the preventable deaths from one year alone, we would need 100 stadiums in Africa with the capacity to each host 80,000 skulls – each a stadium of shameful silence, and a monument to government without responsibility.
Africa Must Unite! But for it to be a meaningful unity it must not be a unity of the dead. It must not be unity as a continental graveyard.
Meeting the 15% pledge will be a significant indication that African leaders care for their countries and are prepared to live up to their primary responsibility of keeping their citizens alive and healthy. No meaningful and sustainable development of Africa can happen without sustainable financing for health care. Indeed the status of public health is the most significant indicator of social and economic development. This is why the Right to Health is the most crucial Right of all – we all have to be alive and well to exercise any other Rights. The dead have no Rights – except perhaps the ‘Right to a decent burial’.
To postpone the meeting of the 15% pledge to the future is to accelerate the death of Africa. We call on the African Union to place the 2001 15% pledge on the July 2007 summit agenda and at the very least to introduce it as urgent business [under item vii, AOB]. We further call on them to make it a major agenda item of the next summit or to call a special summit dedicated to meeting the 15% pledge. This should be preceded by a special summit of Finance and Economic Development Ministers
To further illustrate the full scale of Africa’s health disaster, it is not enough to demonstrate only the unprecedented scale of preventable death. It is also crucial to demonstrate the scale of Africa’s impotence and one example will suffice.
Without health workers, no amount of free medicines can be delivered to citizens, and all ‘foreign’ AID is meaningless. Yet many African governments have no clue how close to death their countries are due to shortage of health workers of all categories.
The DRC with a population of 57 million, roughly equivalent to the populations of UK, France and Italy has only 5,827 doctors compared to the
France’s 203,000, Italy’s 241,000 and the UK’s 160,000. But it is not just a case of the most developed countries being able to train more health workers, or to poach from Africa to make up their shortfalls. Cuba with a population of about 11 million has roughly the same population as Malawi, Zambia or Zimbabwe. But Cuba has 66,567 Doctors compared with Malawi’s 266, Zambia’s 1,264 and Zimbabwe’s 2,086. Not surprisingly, Cuba has roughly the same life expectancy (77 years) as the G8 Countries, the Scandinavian and other developed countries while the average life expectancy for African countries compared to it here is 37 to 40 years. The success of Cuba in the areas of health care and education demonstrates it can be done. Despite issues with the Castro government, western countries have visited Cuba to study how they have achieved their health success. To come anywhere near meeting the World Health Organisation recommended health worker’s to patient ratio or meeting the health based MDG’s these African countries compared to Cuba will need to train and retain roughly 59,000 Doctors each in 8 years. The DRC will need to train and retain at least 150,000. The numbers for nurses, pharmacists and most categories of health workers are comparable across board. This should be Africa’s priority.
In other words, there is no alternative to long term in country sustainable financing to rebuild Africa’s Public Health systems including health workers and improved working conditions and remuneration for them, adequately equipped clinics and hospitals, improved sanitation and environmental health, clean drinking water and so forth. Without these Africa may achieve its dream of continental unity, but it will be a fools paradise.
We are for a United Africa. But it must be a unity of the living, and of a healthy African people – able to enjoy full civil, social, economic and political Rights - not a unity of the diseased, dead and dying.
Successfully unity can only be based on successful development of which health is the corner stone.
The Africa Public Health Rights Alliance and its 15% Now campaign call on you to join the undersigned below in signing the petition calling
on AU member countries to fulfil their 15% Abuja pledge as the first genuine step towards a healthy United States of Africa.
You can sign by sending your name, position, organisation and country to
email@example.com - Also stating if signing in a personal or organisational capacity.
*Signatories to the petition do not necessarily endorse the views expressed in this article.
Article originally published by Pambazuka News, 21 June 2007: http://www.pambazuka.org/en/category/comment/42108
EQUINET calls for Abuja PLUS! EQUINET advocates for governments to meet their Abuja commitment to 15% government spending on health, excluding external funding, PLUS debt cancellation and international support to meet at least US$60 per capita on health systems. Information and publication on EQUINET work on health financing is available at the EQUINET website at www.equinetafrica.org.
We are African organisations deeply committed to improving the health of the people of our continent. Yet we are deeply concerned about the lack of progress, and in some countries reversal of progress, resulting in millions of preventable deaths that continue to burden our countries each year. It is clear that as long as our health systems remain weak in many dimensions and our countries face a health workforce crisis, the current unacceptable trends will persist.
In spite of this slow progress, we remain optimistic. We have observed progress in some regions and countries, and identify with the deepening commitment to the health of many of our Government and institutions. Our Regional Economic Communities have assumed an important leadership role within the continent in catalyzing actions required to strengthen health systems and achieve health MDGs. We are convinced that the engagement of our partners locally and globally can translate into the political will, resources, and efficiency required to transform health on our continent. With so many lives at stake, our neighbors, our children, and ourselves, we must succeed.
Cognizant of the continuing intolerable burden of disease, African Union ministers of health have developed an Africa Health Strategy 2007-2015 that seeks to “provides a strategic direction to Africa’s efforts in creating better health for all.” At the core of the Africa Health Strategy is the strengthening of health systems based on carefully costed National Health Plans that incorporate the commitments made by African governments, including achieving the Millennium Development Goals and universal access to HIV/AIDS treatment, care, prevention, and support by 2010.
The chief responsibility for the success of these plans lies with our own governments. We will hold our governments accountable. We will insist – and are demanding – that they take the necessary steps to achieve the promises of good health, a foundation of healthy societies. Collectively, we will hold our governments accountable to increasing health sector investments to at least 15% of the national budget, improving the efficiency in allocation and application of these resources, and the implementation of health workforce and systems strengthening strategies capable of providing quality health care to all people. We further commit to work with our governments to identify sustainable financing strategies that can replace point-of-service payments (i.e., user fees) for essential health services and to meet their other commitments and responsibilities including as part of the human right to health.
However, the successful implementation of the National Health Plans requires support from Africa’s development partners, especially from the nations that comprise the G8. Even if African governments significantly increase their own funding for National Health Plans, these plans will have significant financing gaps. Many of the actions required for these plans to succeed will require solutions and expertise that crosses national and even continental boundaries.Building health systems must include building partnerships between health care providers and the communities that use those services. It requires donors to listen to African communities to find out what their needs and concerns are, so that services are tailored to those needs, as opposed to imposing systems that may be effective elsewhere but not in Africa. It is about using the opportunities that exist within communities to advance health care, by harnessing the knowledge, resources, and energy in the community and applying it to work together with the formal health system.
We call upon the upcoming G8 summit in Germany to recognize the Africa Health Strategy developed by our health ministers and to engage in substantive dialogue with communities, civil society, governments, regional economic communities, and the African Union.
This dialogue should be backed by firm commitments about steps that we know will be required of wealthy countries if African National Health Plans are to succeed. We call upon the G8 countries to fulfill existing pledges, including the commitment of 0.7 per cent of their own Gross National Income (GNI) to Official Development Assistance (ODA), the doubling of aid to Africa by 2010, and to adhere to the commitments of the Paris Declaration on Aid Effectiveness, including those that relate to alignment and harmonization of aid investments with country plans and leadership.
We ask that this G8 summit also make the following commitments, which are required for African National Health Plans to succeed:
1. Provide long-term, predictable funding to cover financing gaps identified in National Health Plans and plans for universal access to HIV/AIDS treatment, care, prevention, and support, and harmonize health assistance with country-driven National Health Plans.
2. Work with International Financial Institutions and developing country governments and civil society to ensure that fiscal and monetary policies are aligned with the best estimates of the fiscal space required to achieve the MDGs and other human development goals and commitments.
3. Accelerate debt cancellation and ensure that debt cancellation supplements rather than displaces aid.
4. Provide the needed financial and technical support to developing countries to design and implement sustainable financing schemes that can support the elimination of point-of-service payments (user fees) for essential health services and that are designed to enable all people, including the poor, access to quality health services.
Health Systems and Workforce
5. Work with the AU and other continental partners to identify a basic package of health systems interventions, implemented at the community and district levels, that can provide the backbone for the delivery of health service packages required to achieve the MDGs and universal access to the best attainable health care.
6. Support the development and implementation of inter-sectoral and comprehensive health workforce strategies that are integrated with a broader health sector response and public service reforms to address numbers of health workers as well as other variables such as internal distribution, skills mix, work environments, productivity, and management capacity.
7. Engage developing countries to formulate a comprehensive strategy to address health worker migration that emphasizes co-development, including by adopting policies to develop self-sustainable workforces within OECD countries and to follow ethical recruitment practices.
8. Increase support to developing countries to fully utilize TRIPS flexibilities to improve access to medicine, including by helping build capacity to utilize these flexibilities and by avoiding any restrictions to such flexibilities – or any other provisions that may be detrimental to health – in trade agreements.
9. Support initiatives and programs that promote peer and independent mechanisms to track the progress of our governments and their partners to the commitments and declarations made at global, continental, and regional fora.
10. Through diplomatic levers, technical assistance, and other strategies, support African civil society efforts to hold our own governments accountable to their commitments and responsibilities.
Signed by 82 organisations and individuals.
The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET. Please send feedback or queries on the issues raised to the EQUINET secretariat firstname.lastname@example.org.
"Universal access to antiretroviral treatment in SADC remains elusive... Of the 13 SADC states for which information is available, only two countries, Botswana and Namibia, had achieved antiretroviral treatment coverage of more than 70% of those who needed it by December 2005."
Evidence of commitment and action, but also lack of progress on universal access to AIDS treatment, care and prevention, and thus on realising the right to health for people living with AIDS and vulnerable communities. These were key findings of an ARASA report released in April 2007 entitled: 'HIV/AIDS and Human Rights in SADC: An evaluation of the steps taken by countries within the Southern African Development Community (SADC) to implement the International Guidelines on HIV/AIDS and Human Rights'.
This ground breaking report is the first in the region to attempt to measure the successes and failures of SADC countries in responding to HIV in a human rights based framework. Given that sub-Saharan Africa has just over 10% of the world’s population but is home to more than 60% of all people living with HIV, HIV and AIDS is a key human rights issue with tremendous civil, political and socio-economic implications.
Many countries in the region have risen to the challenge of responding to the HIV epidemic but are confronted with financial, structural and political barriers to the implementation of law and policy reforms and the establishment and scale-up of programmes to effectively address the epidemic.
Although respondents interviewed in thirteen of the fourteen SADC countries felt that there was political commitment to addressing HIV and AIDS (evidenced by the declaration of HIV and AIDS as a national emergency or by politicians being open about their status) only six countries passed muster in terms of translating commitment into action, particularly in the area of human rights, civil and political rights, and social and economic rights.
One overarching problem identified was lack of commitment to implementation. Although Swaziland, Tanzania, Zimbabwe and Zambia declared HIV and AIDS a national disaster, they were reported to have made little significant progress in the review or reform of laws to ensure the protection of basic human rights so critical to the success of national responses to HIV and AIDS. But even if laws and policies exist, alone they do not solve the problem: 50% of SADC countries have less than 15% antiretroviral treatment coverage and similarly dismal figures for coverage of mother-to-child-transmission treatment and other key HIV and AIDS interventions.
Therefore, resources are needed to implement existing laws and policies if people are to be enabled to enjoy their right to the highest attainable standard of health. Access to resources at individual, community and national levels poses a barrier to access to prevention, treatment and care programmes and requires urgent attention at government, regional and international levels.
Although eleven SADC countries have laws or policies prohibiting unfair discrimination on the basis of HIV status, human rights abuses hamper the implementation and utilisation of existing prevention, treatment and care programmes for people living with HIV and AIDS. The prevalence of gender-based violence and inferior treatment of women and children continues to fuel the epidemic. Much of this can be ascribed to individual attitudes and beliefs, which laws and policies alone cannot change. Changing these social norms is made even more difficult when political commitment is superficial.
If we are to make progress on HIV and human rights, on HIV treatment and prevention, tokenistic commitment must be replaced with true leadership - leadership not only within governments but at every level of civil society as well. This requires the engagement of our leaders, from the village chiefs up to the offices of presidents and prime ministers. Political rhetoric is no substitute for leadership that translates into action.
The views expressed in this newsletter, including the signed editorials, do not necessarily represent those of EQUINET. Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat email@example.com. For further information on the issues raised or to access the full report referred to, please visit ARASA www.arasa.info or EQUINET www.equinetafrica.org.
Amekwi Lokana, a mother of six from Kenya, said some years ago 'These days, if you are without money, they leave you to die. If my children are ill, and I have money from selling sisal and firewood, I take them to the nearest town. If there's no money, I use herbs … if God takes them, we have done our best.'
It should never be the case that those without money cannot access health care. The most basic obligations that governments have are to respect and protect the survival and health rights of citizens. For governments in east and southern Africa, this is done in a context of the greatest intensity of AIDS globally, high levels of poverty and many other health challenges.
Meeting this obligation is not simply a matter for Ministries of Health. Increasingly finance and trade sectors are having a powerful bearing on health through the agreements they make. Most recently this issue has emerged in the Economic Partnership Agreement (EPA) currently being negotiated between east and southern Africa (ESA) and the European Union (EU), with the aim of signing a final agreement in December 2007.
The "Cotonou Agreement", signed between the EU and African and Caribbean countries in June 2000 makes clear the two central objectives of EPAs: to eradicate poverty and to enhance global integration. The challenge ESA countries face however is that the “global integration” pursued is through liberalisation and commercialisation measures that threaten poor communities' access to the goods and services essential for their health. In past experience this has increased - not reduced - poverty and poor health outcomes, particularly in an international trading system heavily stacked against African countries.
An EQUINET / SEATINI report released earlier this year points to a number of areas in which the EPA currently under negotiation can affect health and health care, unless specifically dealt with.
Firstly the EPA can affect access to essential medicines. It does not yet clearly make a commitment to give ESA countries rights to make maximum use of flexibilities in the WTO TRIPS agreement. These are essential to ensure access to medicines and medical technologies. Although this commitment has been verbally stated by the EU, it is not yet reflected in the EPA. Prior experience of EU free trade agreement (FTAs) with South Africa on this issue suggests that ESA countries and their parliaments and civil societies need be vigilant. The draft text put forward by ESA countries to provide full TRIPS flexibilities and capacity support for their implementation needs to be written into the EPA before it is concluded.
The EPA has not yet specified provisions for trade in health related services. Although most EU countries rightly protect their own public sector as the major provider of health services, there is pressure for service liberalisation in the EPA. ESA countries may thus be put be under pressure to make commitments to liberalise their health services. However for countries in the region to ensure that the poorest draw an equitable share of resources to meet health needs, governments need to regulate health service provisioning and to redistribute funds for health through public sector services. This contradicts commitments to liberalisation of health services. The EPA should exclude any such commitments to liberalise health care services, and should further include health impact assessments in other sectors prior to commitments being made, where these may have an impact on health.
The EPA promotes market access and reduced tariffs and subsidies in agriculture. In a region where undernutrition is high and increasing, all trade policies in agriculture need to be scrutinised for their health impact. In the context of the extreme and longstanding inequalities between EU and ESA agricultural production systems, it is likely that local and smallholder producers will not benefit from the current proposed measures, unless they are deliberately recognised and invested in under the EPA. Until all subsidies on agriculture in the EU are removed, it would not make sense for African countries to lift their own protective subsidies, particularly if this will lead to a further increase in food imports, further undermine local producers and further increase undernutrition.
The EPA raises a more fundamental issue. In the trade agreement, health and health care are put in the context of tradeable goods and services and treated under the aim of enhancing global integration, rather than as key contributors to the stated priority of poverty eradication. We argue that:
• the health implications of the EPAs need to be explicitly recognised
• health officials should be included in negotiations
• health impact assessments should be carried out where relevant, such as in any areas where service liberalisation may impact on health; and
• EU and ESA countries ensure that the EPA is fully compliant with all regional and international health protocols and conventions before it is concluded.
These calls were also made by Zimbabwe civil society in April this year as part of a wider process of Africa and Europe wide activities on the EPAs on April 19. One recurring point of these events was that EPAs as currently constituted would disadvantage developing countries. The EU negotiates as a bloc, with a powerful functioning bureaucracy and a team of skilled negotiators who will speed the pace of the negotiations. However at stake for ESA countries is a deeper bottom line – the health and survival of their people. ESA states thus have an obligation to apply the “precautionary principle” in the EPA negotiations where potential health impacts exist: countries need to be satisfied through evidence produced that the measure negotiated provides greatest possibility, authority and policy flexibility for protecting health and access to health services, and does not lead to negative health outcomes.
Addressing these issues will surely begin to meet the stated joint commitment to poverty eradication. Alternatively, with people's health at stake, the precautionary rule surely applies: No deal is better than a bad deal!
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat firstname.lastname@example.org. For further information on this issue or the full report referred to please visit SEATINI (www.seatini.org) or EQUINET www.equinetafrica.org.
What can Africans expect from the World Health Assembly (WHA) on 14 May 2007? Judging from past experience, the Assembly will be a forum where African countries will find issues critical to public health being raised, but not resolved without a struggle.
Kenya, supported by other African countries, proposed in a resolution on Malaria that, countries’ provide legislation to use “to the full” the flexibilities allowed under World Trade Organisation (WTO) agreements to increase access to anti-malarial medicines, diagnostics and technologies for prevention. The US has strongly opposed this. The WHO Executive Board therefore decided in January 2007 to send the draft resolution to the WHA with both the alternate US and Kenya proposals in bracketed text, indicating a lack of consensus. Inexplicably, the draft resolution posted on the WHO website did not reflect the Kenyan proposal and it took many days before it reflected the decision of the Board. The Kenya proposal needs to be supported to protect the legitimate legal rights that countries have under WTO.
Despite the negative US position, at the 2006 WHA many countries recognised that the current intellectual property rights system does not adequately provide for research and innovation on treatments for diseases that disproportionately affect developing countries. To address this, an Inter-Governmental Working Group on Public Health, Innovation and Intellectual Property was established to prepare a global strategy and plan of action. This Working Group will table a report at the WHA.
A resolution will also be tabled on the rational use of medicines, in light of a finding of irrational drug use in over 50% of medicines in developing countries, with weak application of essential medicines, particularly in the private sector. African countries could potentially treat double the number of people within the same budget if this were addressed. The issue of rational use of medicines has been discussed at the WHA since 1985, and countries have urged greater leadership, evidence based advocacy and support from WHO to advance implementation of rational drug use.
While these issues are on the WHA agenda, there is concern about what is happening in practice on intellectual property rights and health. In research on the small pox vaccine, WHO’s relatively open approach to ownership of the research outcomes has enabled private companies to derive exclusive patent rights from such research, such as the US patents have been registered on treatments by the University of California in April 2004 and April 2006. Such patenting could hamper access to vaccines for many countries in the future.
While small pox was eradicated in 1977, many countries still hold unofficial stockpiles of the small pox virus, with only the US and Russia holding official stockpiles. Backed by recommendations of the Committee on Orthopoxvirus Infections, in 1996 African countries pushed strongly for the destruction of the remaining stocks of the virus, given that the risk posed by deliberate or accidental release outweighed any benefits from retention. In a counter initiative, several developed countries including the US and Canada, drawing on recommendations from a new and differently constituted Advisory Committee on Variola Virus Research, are seeking to block the destruction dates so as to retain the right to seek approval for "scientifically interesting" research, including genetic modification of small pox.
WHO is now applying the same open approach to the Avian Flu virus, i.e. sharing specimens without ensuring provider and other countries have adequate access to treatments and vaccines. Countries like Indonesia, who share viruses, have found that they either cannot afford or cannot secure access to the vaccines because of limited production capacity, leaving their citizens vulnerable to infection. The WHO Guidelines (March 2005, listed but not available on the website) state that WHO Collaborating or Reference laboratories will neither share viruses or specimens, nor publish research results without permission from the originating country. Yet the sharing of specimens has not followed these guidelines, allowing private appropriation of the research outcomes.
Indonesia stopped sharing its viruses with WHO in 2007 even though sharing facilitates research into treatments and vaccines. Indonesia took action, not for commercial interest, but because it could not secure adequate access to vaccines for its people, who were offered vaccines at a prohibitively expensive US$20 per dose. Indonesia did say it was willing to share the viruses on more equitable terms, but WHO has thus far not been able to create equitable conditions for either virus sharing or access to Avian Flu treatments for countries in need (in Africa, Nigeria, Djibouti and Egypt have reportedly experienced Avian Flu). These cost barriers to access vaccines or treatment carry massive risk for the countries concerned: according to the US Centre for Disease Control (http://www.cdc.gov/flu/avian/gen-info/facts.htm) the Avian Flu mortality rate can reach 90 to 100% in 48 hours. In 2005, Indonesia experienced this problem when Roche refused to supply Tamiflu because of advance orders from other countries intent on stockpiling, even while Asian countries were experiencing an outbreak. Roche has sought to remain the sole producer of Tamiflu, despite donating some medicine to WHO.
Access to vaccines by developing countries may be further compromised by the limited global vaccine production capacity. Vaccine producers have taken advance purchase orders for vaccines. The resolution on Avian Flu to be considered by the WHA provides an opportunity for countries in Africa and elsewhere to ensure that access to vaccines is not a privilege primarily for wealthy countries, and that WHO facilitates wide access in response to need.
These upcoming issues at the WHA signal both the continued importance of international collaboration on health issues, as signified in the WHO constitution, as well as the need for constant pressure for and vigilance over its practice.
This editorial reflects the author's individual views. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at email@example.com.
There is a dire shortage of professional health care workers to deliver essential health services in sub-Saharan Africa, including life-saving antiretrovirals (ARVs) for people living with HIV and AIDS. Donor support for disease-specific interventions for AIDS, tuberculosis, and malaria has increased markedly in recent years. However, funding for recurrent costs for these interventions, such as increasing salaries and creating new posts, has remained taboo.
The Global Fund to Fight AIDS, TB and Malaria (GFATM) was created largely due to pressure from activists and non-governmental organisations (NGOs) who fought to have a global financing facility that would pay for ARVs – something that was considered off-limits to donors before 2002. In 2005, a specific "window" of funding was created to support health systems, including human resource costs. Since then the option has been integrated within specific disease components.
Although there is some degree of uncertainty about the scope of GFATM support for human resource costs in future rounds, country applicants have an opportunity to request such support in Round 7. The GFATM should provide unambiguous and continued support for funding salaries and other "recurrent" human resource costs. Bilateral donors should follow suit.
Lesotho is a case in point. The country has the third highest HIV prevalence in the world after Swaziland and Botswana – and is the poorest of the three. It is struggling with a catastrophic health worker situation that threatens to make it impossible for the country to scale-up and sustain HIV care and treatment for the more than 270 000 Basotho presently living with HIV and AIDS.
In January 2006, Doctors Without Borders/Médecins Sans Frontières (MSF), an international medical humanitarian organisation, launched a programme in Lesotho in Scott Hospital Health Service Area (HSA), a rural health district with a catchment population of 220 000. The programme provides decentralised HIV care and treatment, including ART, integrated into existing primary health care services. In the first year, more than 3 500 people were enrolled in HIV care and over 1 000 had initiated ART at Scott Hospital and 14 rural health centres.
Scott Hospital HSA has a higher than average health worker coverage rate. Still, according to an assessment of workloads in Scott Hospital HSA carried out by MSF in August 2006, there are up to 45 consultations per nurse per day not including HIV-related consultations. With the introduction of dedicated HIV services, the workload in the past year has increased dramatically. The World Health Organisation recommends that nurses should conduct no more than 20 consultations per day.
Between January and July 2006, at least 18 nurses left the HSA for "greener pastures". Ten new nurses were hired after July 2006, but six additional nurses left, leaving more than a quarter of nursing posts vacant.
With more than 35 000 people estimated to be living with HIV and AIDS in Scott Hospital HSA alone, at least 5 000 of whom are in urgent clinical need of ART, the needs far outstrip the capacity of health facilities and health workers. MSF has employed several strategies to cope with these shortages – from providing mobile MSF medical teams to bring "in-service" support to nurses to task-shifting to new cadres of community health workers to introducing measures to improve staff retention.
Ultimately, however, immediate measures will need to be put in place at the national level to recruit and retain skilled nurses and other professional health care workers, including as a necessary first step, increasing their salaries. Without major investments in retention of skilled staff, ART programmes – including the MSF-supported programme – are vulnerable to collapse.
The GFATM, bilateral donors, and all other relevant actors, must clearly state, with money on the table, their support for funding salaries and other interventions to support human resources for health. Affected-country governments must then meet this commitment with emergency plans to address the human resource crisis.
As for Lesotho, an emergency human resource plan needs to be developed and donors need to step up to the plate. The US Millennium Challenge Account is committing an unprecedented US $140 million for health infrastructure. "Brick and mortar" projects are welcome, but without support for health care workers, this construction/renovation programme will be tantamount to supplying computer hardware without software to run programmes.
Funding salaries on a recurrent basis and supporting other initiatives to stem the loss of health workers and bring relief to overburdened staff and the thousands of patients they serve is a critical requirement in order to expand and sustain HIV/AIDS care and treatment.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, firstname.lastname@example.org. Further information on MSF and its programmes can be found at www.msf.org and on EQUINET work on AIDS and health systems www.equinetafrica.org.
In February this year the WHO Director General, Margaret Chan caused a storm when she was quoted in Thailand saying that the country should negotiate with pharmaceutical companies before issuing a compulsory license. She encouraged the nation’s public health ministry to improve its relationship with drug companies to strike the right balance in accessing drugs. Chan’s statement created the impression that there was something wrong with compulsory licensing that needed to be corrected through negotiating with pharmaceutical companies.
If the comments were meant to shock and awe, they achieved exactly that! Shocked treatment access advocates sought clarification from the DG herself on the alleged statements. Five days after the comments appeared in the Bangkok Post of February 2, civil society received information that a letter was dispatched to Thai’s Minister of Health, Mongkol Na Songkhla. There had been a misunderstanding, the Director General said. She regretted that her comments “were misrepresented in the media, and may have caused embarrassment to the government of Thailand. They should not be taken as criticism of the decision of the Royal Thai government to issue compulsory licences which is entirely the prerogative of the government, fully in line with the TRIPS agreement.”
For the avoidance of doubt, the Director General went on to say the following:
"WHO unequivocally supports the use by developing countries of the flexibilities within the TRIPS agreement that ensure access to affordable, high quality drugs. This includes the use of compulsory licensing, as described in paragraph 6 of the Doha Declaration on the TRIPS Agreement and Public Health. The decision whether to issue a compulsory license for a pharmaceutical product is a national one. There is no requirement for countries to negotiate with patent holders before issuing a compulsory licence."
This statement helped to clarify an impression that pharmaceutical companies have higher priority than people’s lives. For Africa this is particularly important, with Southern Africa the epicentre of the global HIV epidemic with 34 % of global AIDS deaths occurring in the region. While AIDS places a heavy burden on households and health systems generally, the cost of treatment for AIDS continues to be disproportionate to the incomes of affected families and of governments.
According to Oxfam reports, prices of some treatment regimens for AIDS are on the rise. This is saddening evidence coming six years after the historic signing of the Doha Declaration on TRIPS and Public Health in 2001. Fierce generic competition has helped prices for first-line AIDS drug regimen to fall by 99% from $10,000 to roughly $130 per patient per year since 2000. However prices for second-line drugs remain high due to increased patent barriers in key generics producing countries like India. Patients who develop resistance to first line regimens need these second line drugs, and the number is likely to grow over time, as will the unaffordable cost to health systems.
As outlined in the EQUINET / SEATINI leaflet on using TRIPS flexibilities (at www.equinetafrica.org) countries have full authority under TRIPS to use compulsory licensing or parallel importation of drugs if their laws provide for this and they need them for public health., Most (but not all) countries in the region have now passed the relevant laws for this. But the political and diplomatic pressure to dissuade governments from using these TRIPS flexibilities keeps mounting. A case in point is the legal action against the Indian government by a pharmaceutical company, Novartis. Novartis is challenging a section of India's Patents Act that aims to restrict certain kinds of patents. Novartis brought a civil lawsuit against the Indian government after the country rejected in January 2006 the company's attempt to patent a new version of its leukaemia drug, Gleevec, on the basis that the drug is a new formulation of an existing drug. If Novartis wins the case it could potentially set a precedent for other pharmaceutical companies seeking patent protection for formulations of drugs made before 1995, including antiretrovirals.
As institutions involved in health in Africa, we expect no ambiguity on this from WHO. Governments should be encouraged to use the flexibilities provided to them in the WTO TRIPS Agreement, including issuing compulsory licenses, to access generic drugs. With the Global Fund for AIDS, TB and Malaria and UNAIDS, still more needs to be done to bring down the cost of these drugs, particularly of the second line regimens, and to make them affordable on a long term basis.
For our part, we expect our governments and parliaments to ensure that our national laws incorporate TRIPs flexibilities, that our authorities are organised to implement them and that our populations are organised to protect their use. We expect our governments to reject clauses in bilateral trade agreements that attempt to remove authority to use these flexibilities. We have regional intergovernmental organisations such as COMESA and SADC to share information, resources and expertise and to harmonise legislation.
We can also stimulate the production and marketing of generic drugs, increasing returns to producers and access for people who need them. We can work through these same regional organisations to collectively issue compulsory licenses for common public health problems. In Latin America, for example, ten countries joined efforts to get agreements from generic manufacturers and originators on generic drug production. If ESA countries use regional frameworks to collectively issue compulsory licenses for the same drug, this builds a large enough market to encourage producers to invest in producing cheaper, generic versions of these drugs.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email email@example.com and please visit the SEATINI website at www.seatini.org. EQUINET work on health equity in economic and trade policy and further information on TRIPS flexibilities is available at the EQUINET website at www.equinetafrica.org.
Are institutions that tap poor people’s desire for credit, shrinking Third World states’ already beleaguered welfare policies? The role of microfinance in poverty reduction, reducing risk environments for HIV and promoting private health insurance has attracted high profile interest since Muhammad Yunus won the Nobel Peace Prize last December.
Yunus’s Grameen Bank battled backward Bangladeshi patriarchal and religious attitudes to extend credit to millions of people. Poor women were typically arranged in groups of five: two got the first tranche of credit, leaving the other three as ‘chasers’ to pressure repayment, so they could in turn get the next loans. But a decade ago (at a time of lower foundation subsidies, new competitors, adverse weather conditions and a backlash by borrowers who used collective power of nonpayment), Grameen imposed dramatic price increases on loan repayments and resorted to extreme pressure techniques, including removing tin roofs from delinquent women’s houses. This reduced Grameen Bank’s main philosophical position - ‘We consider credit as a human right’ - to merely an argument for access, not affordability. This distinguishes Yunus from all rights-based social movements demanding ‘rights’ to free lifeline access to healthcare, AIDS medicines, education, housing, land, water, electricity, etc.
According to Munir Quddus, chair of the Department of Economics and Finance, University of Southern Indiana, the model needs more investigation: ‘The very nature of setting up groups leaves out the very poor who would be perceived by fellow members to have no ability to generate income and therefore high risk … microcredit simply deepens the exploitation of the women since the rates of interest charged by the bank in real [after inflation] terms are quite high; consequently, credit often worsens the debt situation and gives the husbands even more leverage.’
Evidence on South Asian microcredit and major credit programs suggest that credit does not necessarily have a positive impact on social relations. Many loans targeted at women are appropriated by male family members, leaving women as buffers between their spouses and lending institutions, with often stressful and violent results. Even where women’s incomes have increased, research found women’s work and debt loads also increased. Women’s access to credit does not guarantee improved confidence, mobility, control over assets, or freedom from violence. Therefore, microcredit must be interrogated to determine if it is really about poor people gaining control, or if it leaves structural and often global causes of poverty unaddressed.
For example, in 1998, when an emerging market crisis led to rising interest rates across the Third World, South African microlenders and borrowers were driven into bankruptcy by a 7% increase imposed over two weeks as the local currency crashed. In Zimbabwe, a 1980s US$66 million flood of World Bank financing revitalised the rural microfinance sector (initiated under 1940s Rhodesian rule) and reached 94,000 households. But within a decade, the peasant default rate was 80% - with repayment affordability being a huge factor (a typical lender’s overhead and collection costs on a small loan were 15-22% (including incorporation of a 4% default rate)). Michael Drinkwater’s (1991) detailed study of central Zimbabwe showed peasant farmers faced serious difficulties in servicing loans of just a few hundred US dollars, since average net crop profit was just $0.15/hour of labour, according to a 1989 Agriculture Ministry survey. This was compounded by ‘an overzealous launching of a group credit scheme’ and the ‘doubtful viability of high cost fertiliser packages’, inappropriate for the erratic climate. ‘The increase in credit use means farmers have to market more to stay solvent ... At the household level it is commonly debts not profits that are on the rise.’
This raises the question: ‘Is credit the most useful input for African peasants’ economic and social wellbeing, especially women?’ According to Mohindra and Haddad (2005), women’s health capabilities (opportunities to achieve good health) and health functionings (e.g. being healthy), ‘can be expanded via key determinants of population health, such as access to resources and autonomy’, with microcredit as a primary tool. But is microcredit really a tool for expanding access to health inputs when the structural disempowerment and malfunctioning markets that bedevil credit systems are added to the overall retreat of the Third World welfare state?
The question is important as Grameen-style microcredit is increasingly linked to health services ranging from education to insurance, including: the Niger CARE ‘Microcredit and Health Education for HIV/AIDS-Affected Women and Children in the Valley of the Widows’; the Philippine NGO Innovations for Poverty Action and the Green Bank marketing of health insurance and preventative care through 2000 microentrepreneurs; or
the International Medical Corps microcredit project to support local health programs in Eritrea. The Microcredit Campaign Summit pointed to many new opportunities to substitute microcredit for state or donor assistance in reproductive health education. But such schemes need to be questioned on: whether they deliver on resources and autonomy, how they change local power relations; and their record on arrears, social conflict and defaults.
Few rigorous studies document the relationships between financial vulnerability and health burdens. A study of a Dominican microcredit program, which made small loans to individuals to start or expand small businesses, included three communities: one with health promotion alone; one with microcredit alone; and one with both. The community with parallel microcredit and health promotion programs had the largest changes for ten of eleven health indicators. However, the study also traced health gains to improved ability to purchase commercial water supplies, making a link between microcredit and the demand on poor people to pay for commercial and privatised water. As the UNDP Human Development Report (2006) noted, microcredit is explicitly used to promote the market in essential services and enable poor households to meet the financing requirements.
While not denying the prospect that some microcredit schemes are worthy and effective, the criticisms raised offer warning. Claims made about microcredit as an overarching strategy to end poverty, change power relations, attack structures of inequality or improve vulnerable population’s health education should be treated with caution. Certainly, microcredit cannot stand in for decent social policy when it acts as a safety net, co-existing with and not transforming entrenched structures that generate poverty . In the worst case, microcredit can become an ideology explicitly hostile to state support for healthcare.
‘I believe that “government”, as we know it today, should pull out of most things except for law enforcement and justice, national defense and foreign policy, and let the private sector, a “Grameenized private sector”, a social-consciousness-driven private sector, take over their other functions.’
To illustrate the dangers ahead, those were words uttered in the 1998 autobiography of Nobel Peace Prize winner Yunus.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email firstname.lastname@example.org. A more detailed analysis of the issues raised in this editorial can be found in Microcredit Evangelism, Health and Social Policy by Patrick Bond, Forthcoming in the International Journal of Health Services, June 2007.
On December 10 the Africa Public Health Rights Alliance launched an important “15% now!” campaign. We carry information on the campaign in this newsletter, and its call for African heads of state to allocate 15% on government spending to health, as promised at the African Union (AU) summit in Abuja, in 2001.
There is clear evidence of the pressing demand for significantly improved resources for health in east and southern Africa (ESA): We see it in high levels of poverty and deprivation, persistently high HIV, AIDS and other preventable diseases, high rates of child and early adult mortality, inadequately staffed and resourced public health services and massive inequalities in health outcomes between sub-Saharan Africa and other regions. The EQUINET newsletters in 2006 have presented different facets of this evidence. Health is determined by the conditions in which people live, work and interact, and depends on policies and spending beyond the health sector. The investments in the health sector are, however, critical, especially in the context of high levels of inequality and poverty. These investments can prevent avoidable illness and mortality, redistribute social resources to deprived households, protect against the impoverishing effects of ill health and demonstrate our values and commitment as a society to human security. As our May newsletter editorial suggests, health sector investments have greatest impact on low income communities when they are made in public sector primary health care and district health systems.
The World Health Organisation estimated in 2000 that an expenditure of US$60 per capita is the minimum level of health expenditure needed for a health system to function well. The Macroeconomic Commission on Health estimated in 2003 that a minimally adequate set of interventions to meet the basic health needs of poor communities is between US$34 and US$38 per person per year, not including some of the wider systems demands for a functional health system. However African health systems and communities face challenges that call for additional resources: The World Bank estimated in 2002 that Africa would need an additional US$4.2 billion to meet the costs of HIV prevention and AIDS Care, given the scale of the epidemic. Meeting the Millennium Development Goals (MDGs) adds to this cost. This makes an expenditure of US$60 per person per year a not unreasonable estimate, and one that would need to be made largely in the public sector if the benefits are to reach poor households.
Yet many public health sectors in ESA are trying to deliver health systems, pay health workers and respond to health challenges on less than $15 per person per year, and some on less than US$10 per year. Overall per capita expenditures on health in the region, public and private combined, average less than US$30 per person per year, while government spending on health is less than 10% total government spending for the majority of countries in the region.
Increasing to 15% of Government spending on health is an important and necessary sign of government commitment to health, even while it would not on its own for most countries in ESA provide adequate per capita resources for health. The call for “15% now!” justifiably calls for implementation of this commitment. If the 15% target is met through increased donor resources and not through increased application of domestic revenue, it is not a clear test of that commitment and is vulnerable to donor withdrawal. The “15% now” should thus be understood to exclude donor resources.
However, many countries in the region need more than the 15% government spending. Additional resources must be applied.
One of the sources for this must be debt cancellation. With over US$ 100 billion external debt in ESA in 2003 and even more paid out over three decades to service the debt, current debt relief measures are inadequate to overcome “debt domination”. Applied over many decades, with relatively small reductions in annual debt, they still leave African countries with significant debt burdens and deplete domestic resources for heath. As in last year’s call by civil society organisations and governments in the South-North consultation on alternatives to debt domination, the a call for “15% now!” must go together with a call for “Debt cancellation now!”.
Debt servicing is only one of the many ways resources are flowing out of our region. As demonstrated in the April EQUINET newsletter editorial, unfair and unequal terms of trade, outflows of private finance, shifts to speculative foreign investment, phantom aid, a massive outflows of health workers and global exploitation of non renewable African resources represent some of the vast and ongoing outflows of the continent’s existing and potential wealth. A recently released UN WIDER report included in this newsletter observes that inequalities in wealth have widened, with the richest 2% of adults in the world owning more than half of global household wealth, while the bottom half of the world adult population –a large share in Africa - own barely 1% of global wealth. Net outflows of African wealth represent a perverse flow of resources for health from those with greatest health needs in the poorest regions, to those with least health needs in the wealthiest regions.
This calls for a global response. An increase in predictable long term overseas development aid would provide one means of addressing this situation, and could be applied to increase the per capita spending on health to more meaningful levels, over and above the “15% now”. Efforts by some G8 countries to explore new sources of tax funding for global transfers are important steps towards this. So while African governments must be accountable for their 15% to health, so too wealthy countries must honour their commitment to “0.7% GDP to ODA now!”
But achieving global commitments to health in ESA calls for more than increased aid. Global commitments to universal access to antiretroviral treatment discussed in our June newsletter editorial, or the social development goals set at the 1995 World Summit for Social Development (WSSD), discussed in our November editorial, call for enabling, accessible, responsive and accountable states committed to mobilize the resources for health (15% now!), unencumbered by excessive debt servicing (Debt cancellation now!) and supported by ODA (0.7% GDP to ODA now!) Yet this can leave governments and people in ESA heavily reliant on external aid for their health, while wealthy groups in high income countries and corporates continue to benefit from trade, finance and resource outflows from the region. Levering increased investments in heath must be backed by challenge to these resource outflows and to the trade and macroeconomic policies that intensify inequities in control over the resources for health. “Reclaim African wealth for African health...now!”.
Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat at TARSC, email email@example.com