The debt relief movement is poised for a historic day this October 1st when G-7 finance ministers discuss 100% multilateral debt cancellation for impoverished countries. Debt cancellation would free up significant funds for development, including fighting AIDS and strengthening health systems. You can help make this happen.
If you are a health professional, please lend your name to an international health professional sign on letter that will reach all G-7 finance ministers and presidents/prime ministers before this important meeting. This letter is copied below. If you would like to add your name, please respond by September 20th to aidsact@phrusa.org with your full name, degree, affiliation, and state/country.
International Health Professional Sign-on Letter
September, 2004
Dear G-7 Presidents and Prime Ministers:
We write to you as health professionals from diverse countries in Africa, Asia, Latin America and the Caribbean, North America, Europe, and Australia who strongly support debt cancellation for poor countries. Debt cancellation is a prescription urgently needed to help heal seriously ailing health systems – some of which cannot even provide minimal care – in many of the countries in which we live and work.
Debt cancellation would free large sums of money, funds that should be used to build stronger and more equitable health systems, which are desperately needed if the fight against AIDS and other killer diseases is ever to be won. Right now we are losing that fight. AIDS alone kills about 3 million people per year, as another 5 million people becoming infected with HIV annually. At the end of June 2004, fewer than 10% of people in developing countries in urgent need of AIDS treatment were receiving it. In light of the health crises that many of our countries face, debt cancellation is necessary on human rights and humanitarian grounds. We therefore urge you to endorse 100% multilateral debt cancellation for impoverished countries when the issue is discussed at the meeting of G-7 finance ministers this October 1.
We know that poor countries need this debt relief urgently. African countries alone are collectively spending about $15 billion per year servicing their debts to wealthy creditors, including multilateral institutions. The fifteen focus countries of the U.S. President’s Emergency Plan for AIDS Relief spent $10.3 billion servicing their debts in 2001; this is more than the $9 billion these countries are scheduled to receive over the Emergency Plan’s entire five years. The World Bank, IMF, and regional development banks are typically the largest creditors of the most impoverished nations.
Relief from debt could be instrumental in enabling countries to meet AIDS treatment targets, as well as other health goals. Your governments all support the World Health Organization’s (WHO’s) 3 by 5 initiative, which aims to get 3 million people in developing and middle-income countries on AIDS treatment by the end of 2005. Yet treatment goals cannot be achieved without health workers. And as so many of us know through our own experiences, many countries, particularly in Africa, have nowhere near the necessary numbers of health personnel. For example, WHO and the World Bank have reported that Tanzania and Chad, both countries that would benefit greatly from debt cancellation, require their health workforces to triple and quadruple in size, respectively, to achieve the Millennium Development Goals.
The connection between suffering health systems and the debt payments that limit funds available to them is palpable. To a significant degree, the severe shortage of health workers in Africa is a symptom of acute underinvestment in health systems, many of which suffer from too few staff, too few supplies, and too few drugs. This underinvestment is a central cause of the migration of health professionals to wealthy nations, where health systems are stronger and pay is better. Creating the conditions that will enable health professionals to remain in their home countries and allow them to provide the best care possible for their patients will cost money. Health care workers will continue to leave if they are unable to meet the charge of our professions: serving our patients. Our colleagues will continue to emigrate so long as they do not have medicines for their patients, or functioning equipment, or proper supervision. And they will continue to leave so long as they cannot support their families or be confident of their own safety. They need fair salaries, equipment to protect themselves from occupational infections of HIV and other diseases, and psychosocial support to help cope with the constant death and stressors they face.
Full multilateral debt cancellation for impoverished nations could go a long way towards meeting people’s right to the highest attainable standard of health. Indeed, debt relief that countries have received under the Heavily Indebted Poor Countries (HIPC) initiative has already begun to do so. In Malawi, savings from debt relief have paid for extra staff and support in primary health centres, nurse training, and improving the supply of essential drugs in health facilities. In Mozambique, debt relief funds helped increase the number of children receiving immunizations for tetanus, whooping cough, and diphtheria. Debt relief savings have also helped fund primary health care in Uganda, including salaries of health care workers, while countries including Uganda and Cameroon have used debt relief savings to help finance HIV/AIDS programs.
Debt cancellation is an excellent investment not only in people’s health, but also in countries’ economic well-being. Increased spending by impoverished countries in health, education, and other fields that promote human development, which will result from debt cancellation, goes hand-in-hand with economic growth. As WHO’s Commission on Macroeconomics and Health has highlighted, investments in health will increase worker productivity, creating economic gains that would far exceed the initial cost to creditors of debt relief. Debt cancellation will help put countries that are economically marginalized and heavily dependent on foreign aid onto paths towards economic autonomy and integration in the world economy. By contrast, without debt cancellation and other investments to reverse the spread of and treat people with HIV/AIDS, decreased worker productivity will make countries increasingly dependent on foreign assistance and unable to participate in the global economy.
We therefore urge you to support 100% multilateral debt cancellation for impoverished countries, including HIPC countries and as well as non-HIPC countries that are in need of this relief. We hope that your finance ministers will announce your governments’ support for such an initiative at their October 1 meeting. And we encourage you to work with countries whose debts are cancelled to ensure that their savings from debt payments are used on poverty reduction and human development. Countries can establish mechanisms to ensure that savings from debt services payments are used to reduce poverty and to promote human development. Uganda has established a Poverty Action Fund into which savings from debt relief are channelled, and which includes a series of procedures to ensure that the debt relief savings are well spent. Other countries, including Tanzania and Malawi, have established similar mechanisms.
We also encourage you to work towards a permanent solution to the debt of impoverished countries – including for countries that do not receive 100% multilateral debt cancellation and for any new debt assumed by those countries whose debts are cancelled – by creating a new understanding of what level of debt countries are expected to repay. In particular, we urge you to announce that from this time forward, countries will be neither obliged nor expected to make debt payments that would compromise their ability to meet their people’s basic needs or otherwise fulfill their people’s human rights.
We are health professionals. Our job is to heal. So it pains us to see debt payments siphoning away funds that could go far towards enabling our colleagues and ourselves do our jobs and meet the needs of the patients we serve. We fervently hope that you will help enable us to be the healers that we were trained to be.
Sincerely,
[If you would like to add your name, please respond by September 20th to aidsact@phrusa.org with your full name, degree, affiliation, and state/country.]
1. Editorial
2. Latest Equinet Updates
Since 2003, EQUINET and HST have implemented a longer term programme of work that has carried out a wider review of the literature on the distribution and migration of health personnel in the region and a regional research programme aimed at building analytic capacity, evidence and policy engagement around the issue. EQUINET and HST collaborated with a consortium of institutions in southern Africa and internationally, known as the Human Resources for Health (HRH) Network, in order to link this southern African programme of work with wider international work on the equitable distribution of health personnel in southern Africa. In January 2004 a call for research proposals was made within a framework set out from the literature and policy review. The proposals were reviewed and a number of these selected for participation in a regional meeting. Between 15 and 17 April 2004, the Health Systems Trust and EQUINET organised the regional meeting in Johannesburg, South Africa, bringing together researchers and stakeholders from southern and western African, Canada, the UK, USA and Australia.
Noting:
The 1997 Kasane meeting on Equity in Health that confirmed the commitment to equity in health at all levels in southern Africa; the 1999 Southern African Development Community (SADC) Protocol on Health, the 2003 Maseru Declaration on HIV and AIDS and the resolutions of the SADC Heads of States Summit on food security held in Tanzania, 2004... To read more, please visit the Equinet website.
3. Equity in Health
This article, published in the British Medical Journal (BMJ), focuses on health as central to the achievement of all the millennium development goals (MDGs). Key challenges for health improvement include reversing the global HIV/AIDS epidemic and reducing child and maternal mortality. The authors acknowledge the need for more aid but argue that this is only part of the picture. To effectively absorb increases in aid, poor countries need strong, equitable health systems and institutions. They also need the capacity to deliver services, which includes having enough skilled staff.
The number of people infected with tuberculosis in sub-Saharan Africa has risen dramatically in the past 15 years, largely due to HIV infection. Bloodstream infection with Mycobacterium tuberculosis (mycobacteraemia) is a common cause of fever in sub-Saharan Africa, but diagnosis requires the help of specialists and a lengthy incubation period. Cheap and practical tests for eye disease such as the examination of the back of the eyeball (ophthalmoscopy) for choroidal granulomas could be an efficient alternative in the diagnosis of mycobacteraemia.
The combination of safe drinking water and hygienic sanitation facilities is a precondition for health and for success in the fight against poverty, hunger, child deaths and gender inequality. It is also central to the human rights and personal dignity of every woman, man and child on earth. Yet 2.6 billion people – half the developing world – lack even a simple ‘improved’ latrine. One person in six – more than 1 billion of our fellow human beings – has little choice but to use potentially harmful sources of water. The consequences of our collective failure to tackle this problem are dimmed prospects for the billions of people locked in a cycle of poverty and disease.
In the main, Poverty Reduction Strategy Papers (PRSPs) do not systematically identify those health issues which are the biggest contributors to poverty or the greatest brake on economic growth. Nor do they look systematically at the health situation of the poor – beyond noting that they tend to have the worst health outcomes and are unable to afford health care fees. A further important point is that PRSPs do not deliver on their potential to stimulate cross-sectoral action for health. This is according to a second synthesis report from the World Health Organisation, 'PRSP's - Their significance for health'.
An editorial in the August 7 issue of The Lancet painted a bleak picture of the work of WHO in the African Region, giving the impression that WHO is not recording any successes there. In fact, despite the challenges of poverty and ongoing instability, the opposite is true. For example, in spite of recent political difficulties, the number of polio-endemic countries in the African Region has fallen from 20 in 1999 to just two today. Huge efforts are underway to eliminate the disease completely.
4. Values, Policies and Rights
"The fact that a very large part of the world’s population has inadequate access or none to essential and often life-saving medicines is of grave concern. It results in a vast loss of life and much suffering, more particularly among the poor and underprivileged. It is in blatant contradiction to the fundamental principles of human rights. And, even if one were to set humanitarian considerations side, it results in serious damage to the economy and to the functioning of society."
In this paper, the UK Department for International Development (DFID) sets out its position on sexual and reproductive health and rights, reaffirming its commitment to realising the goals of the International Conference on Population and Development (ICPD). New challenges are highlighted, including the HIV/AIDS pandemic; threats to international consensus; increasing demand for reproductive health services; and weak or failing health systems, alongside a shortage of skilled health workers.
5. Health equity in economic and trade policies
In recent years there have been enormous changes in our technology, our economy, and our society. But has there been progress? asks economist Joseph Stiglitz. In the countries that have been less successful, globalization is often viewed with suspicion. "As I have argued elsewhere, there is a great deal of validity to the complaints of those who are discontent. In much of the world, there has been in recent years a slowing of growth, an increase in poverty, a degradation of the environment, and a deterioration of national cultures and of a sense of cultural identity."
Disease has travelled with goods and people since the earliest times. Armed globalization spread disease, to the extent of eliminating entire populations. The geography of disease shaped patterns of colonization and industrialization throughout the now poor world. Many see related threats to public health from current globalization. Multilateral and bilateral trade agreements do not always adequately represent the interests of poor countries, the General Agreement on Trade in Services may restrict the freedom of signatories to shape their own health delivery systems, and it remains unclear whether current arrangements for intellectual property rights are in the interests of citizens of poor countries with HIV/AIDS.
The World Bank and IMF have produced a paper entitled "Enhanced HIPC Initiative - Possible Options Regarding the Sunset Clause", dealing with the sunset clause of the Highly Indebted Poor Countries Initiative (HIPC). The paper provides a brief background to the sunset clause and discusses the implications of its expiry at the end of the year before going on to discuss four possible policy options and concluding remarks. Eurodad, the European Network on Debt and Development, comments that any extension would: "...embarrassingly for the WB and IMF, represent the fourth extension to the initiative. We argue that this demonstrates the severe technical shortcomings (and therefore credibility) of the initiative."
Wemos and Medact have prepared this report to fuel the discussion on how PRSPs can be used to improve the health of the poor. The report builds on the materials from seven country studies, prepared by NGOs to gain insight into the possible added value of PRSPs for health in their countries. Based on these and other sources, the report highlights a number of issues that in our view are crucial for achieving equitable health systems and which should receive much more attention in PRS processes than they do so far. These include the coordination of development aid and international health initiatives, the debt burden and other macroeconomic constraints to increased health spending, and policy initiatives to make health care markets more socially-inclusive in low-income countries.
The average level of real income in the richest countries is 50 times that of the poorest. The richest tenth of the South African population enjoy levels of consumption per person almost 70 times those of the poorest tenth. Citizens of the world also experience profound differences in influence, access to legal systems, power and social status, whether at the level of individuals, between men and women, or between groups. Acute inequality in incomes, in health status, in educational outcomes and in other dimensions of welfare is a stark fact of life. The 2006 World Development Report will explore the relationship between equity and development strategy.
6. Poverty and health
In 2001–3 in many countries in Southern Africa national grain stocks had been run down and grain imports were slow to arrive, so that localised harvest shortfalls quickly resulted in three- and four-fold increases in food prices which, for the large number of vulnerable people in the region, spelled crisis. In the end, the donor and government response but equally importantly the response of the commercial sector and people’s own ‘coping’ strategies meant that large-scale famine-related deaths were avoided in 2002 and 2003 but unacceptable levels of chronic food insecurity remain.
The recent food crisis has drawn attention to the fact that Malawi's poverty is deep-rooted and structural. Provision of temporary humanitarian relief and sustained safety net provision may alleviate the symptoms of chronic poverty but such interventions are not adequate as ends in themselves: they will not prevent similar crises occurring in the future, or develop the kind of resilience that households and communities need to be able to cope with crises.
7. Human Resources
Malawi is facing a health crisis as trained nurses leave to seek better wages abroad. More than half come to Britain to work for the NHS and private hospitals. Last year over 12,000 nurses from outside the European Union registered to work in the UK. In contrast Malawi, one of the world's poorest countries, trains around 60 nurses each year.
With the United Kingdom needing 10 000 more doctors, and with more than 7000 nurses from the Philippines alone currently registered in the United Kingdom, compared with just 52 in 1999, a new report says that the countries providing the workers, as well as those that hire them, need to look for solutions. The report says that many African doctors also migrate within the continent, mostly to southern African states where salaries are often higher: for instance, $1242 a month in South Africa, compared with $50 in Sierra Leone.
Medical practitioners and nurses represent a small proportion of the highly skilled workers who migrate, but the loss for developing countries of human resources in the health sector may mean that the capacity of the health system to deliver health care equitably is significantly compromised. It is unlikely that migration will stop given the advances in global communications and the development of global labour markets in some fields, which now include nursing. The aim of this paper is to examine some key issues related to the international migration of health workers and to discuss strategic approaches to managing migration.
Anticipating significant scale-up of its current HIV/AIDS services, the Zambian Central Board of Health commissioned this study of the human resource implications. The study collected data at 16 government, NGO, and private for-profit sites across Zambia that currently provide VCT, P-MTCT, and ART services. It analyses the time taken to carry out the prescribed tasks involved in each of the services, describes the present workforce involved in providing these services and the extent to which services are currently following national service delivery standards, and projects the human resource requirements and costs associated with scaling up services to planned levels.
8. Public-Private Mix
With the dust not yet settled on the health department's bid to regulate medicine prices, another messy conflict over state regulation of private health care looms large. A decade-long attempt to provide a unified health system that includes both public and private sector providers took concrete form on Friday, when President Thabo Mbeki signed the long awaited National Health Bill into law. The move is set to spark loud protest from doctors and private hospital groups, anxious about clauses in the legislation designed to regulate their services.
The need for public-private partnerships arose against the backdrop of inadequacies on the part of the public sector to provide public good on their own, in an efficient and effective manner, owing to lack of resources and management issues. Though such partnerships create a powerful mechanism for addressing difficult problems by leveraging on the strengths of different partners, they also package complex ethical and process-related challenges. Participation of international agencies warrants that they be set within a comprehensive policy and operational framework within the organizational mandate and involvement of countries requires legislative authorization, within the framework of which, procedural and process related guidelines need to be developed. This paper outlines key ethical and procedural issues inherent to different types of public-private arrangements and issues a Global Call to Action.
9. Resource allocation and health financing
In the past two years, the political commitment to respond to the HIV/AIDS pandemic has increased substantially. In this policy environment, the importance of information on resources allocated to HIV/AIDS prevention and care has increased. In order to avoid resource misallocation, policy makers need information on the level and flow of current resource allocations to HIV/AIDS. They need to know where money for HIV/AIDS prevention and care is coming from, the services and commodities that are purchased with these funds, and the population coverage of the implemented interventions. At the same time, to identify needs and plan strategically, policy-makers require information on the scale of resources required to prevent the further spread of HIV and to provide adequate care for those people living with HIV/AIDS.
10. Equity and HIV/AIDS
This report from the South African Budget Information Service (IDASA) analyses budget allocations and funding flows from the national fiscus for HIV/AIDS interventions. It investigates the best way to deliver funds to the provinces of South Africa to tackle HIV/AIDS. Analysis of official budget documents and interviews with national and provincial social service and treasury officials reveals that provinces are generally improving their spending on the HIV/AIDS conditional grants and beginning to allocate significant funds from provincial budgets to tackling HIV/AIDS.
People living with HIV/AIDS in Tanzania will soon have access to free antiretroviral drugs under the government's four-year treatment programme. More than US $1.8 million was recently released by the Treasury Department for the Ministry of Health to purchase anti-AIDS drugs, a local newspaper, The Guardian, reported.
This paper is intended both for managers and technical staff working either in food security and livelihoods or in HIV/AIDS and reproductive health who require an introduction to the linkages between the two areas, and as a guide to the many issues that need to be considered when carrying out assessments (or reviewing others’ assessments) and when planning interventions. The focus is specifically on economic impacts of AIDS, and does not address important emotional, psychological and social impacts.
HIV/AIDS is threatening subsistence agriculture in Mozambique, with "ominous implications" for the country's food supply, the Food and Agriculture Organisation (FAO) has warned. By 2020 the country will have lost over 20 percent of its agricultural labour force to HIV/AIDS, according to FAO. Mozambique and Namibia feature among the nine hardest-hit African countries, all in southern and eastern Africa, where FAO predicts a loss of agricultural labour to the disease.
The US-based NGO, AIDS Healthcare Foundation (AHF), has lodged a complaint with South Africa's Competition Tribunal against leading anti-AIDS drug producer, GlaxoSmithKline (GSK), saying Glaxo's high drug prices are preventing the treatment of more HIV-positive South Africans. A local newspaper, Business Day, quoted AHF president Michael Weinstein as saying: "We have had to turn people away from our clinic because we simply don't have the funds to treat all the people who need treatment. If the price of GSK's AIDS drugs had been lower, we might have been able to save their lives."
Zambian President Levy Mwanawasa has urged people living with HIV/AIDS to make use of anti-AIDS drugs, which are freely available at healthcare sites throughout the country. Mwanawasa was quoted by a local newspaper, The Times of Zambia, as saying: "The answer does not lie in sitting back with your disease but in presenting your case to authorities ... so that you can get treatment." He noted that antiretroviral treatment would improve their health.
Doctors have resolved to lobby the Global Fund to give Zimbabwe funds for use in HIV/Aids initiatives. At the Zimbabwe Medical Association congress, which took place in Victoria Falls from August 19 to 22 under the theme "New Horizons in the Health Sector", the doctors said it was grossly irresponsible and a violation of human rights for Zimbabwe to be denied money from the fund. Zima secretary-general Dr Paul Chimedza said doctors suspected that the reason the country was denied the money was political.
11. Governance and participation in health
This paper proposes a broad outline for designing health promotion programmes in developing countries, based on the Ottawa Charter for health promotion and principles of self-care and community participation. There is now a window of opportunity for promoting self-care and community participation for health promotion in developing countries. It recommends that supportive policies are framed, with self-care clearinghouses set up at provincial level to co-ordinate the programme activities in consultation with district and national teams. Self-care should be promoted in schools and workplaces. For developing individual skills, self-care information, generated through a participatory process, should be disseminated using a wide range of print and audio-visual tools and information technology based tools.
This paper aims to provide insight into the practical challenges faced by parliaments and parliamentarians in addressing the issues of equity in health. It goes on to describe the attempts that have been made to address those challenges in southern Africa. A number of opportunities for parliaments to promote health equity are identified. Firstly, parliaments are in charge of their rules, which they can revise to become more efficient and effective when they commit themselves to reforms. Secondly, in the region there is a vibrant civil society that raises questions and compels parliaments to address issues.
12. Monitoring equity and research policy
"In today's cost-conscious health care environment, translating evidence-based quality innovations into clinical practice is a challenge. Limited resources mean providers and health systems must follow proven methods for diffusing and adopting effective interventions.” For this study, the authors conducted case studies of four varied clinical programs to learn key factors influencing the diffusion and adoption of evidence-based innovations in health care.
13. Useful Resources
Building Blocks: Africa-wide briefing notes is a set of six locally adaptable resources to help communities and local organisations in Africa support children orphaned and made vulnerable by HIV and AIDS. These resources are based on the experience of the Aids Alliance, its partners and other organisations and have been produced in English, French and Portuguese.
In response to an overwhelming appeal for access to health information from researchers and scientists in the developing world, the Health InterNetwork Access to Research Initiative (HINARI) was launched in January 2002. HINARI is a partnership between the World Health Organization (WHO) and major international publishing companies and offers access to academic institutions, which currently provides free or low-cost access to over 2400 online biomedical and social science journals for eligible institutions in 103 countries.
Health care workers are an invaluable resource for improving maternal and child nutrition in developing countries. Recognizing the need to reinforce the capacity of health care workers in Sub-Saharan Africa, the Support for Analysis and Research in Africa (SARA) and BASICS II projects developed a comprehensive training manual on implementation of Essential Nutrition Actions.
14. Jobs and Announcements
AIFO/Italy and People's Health Movement Africa invite articles in English, French, Portuguese and Italian from activists, non-governmental organisations and grass-roots organisations based in Africa related to experiences of innovative approaches linked to promotion of any aspect of better health for different community groups. Articles selected by an international jury will be part of a book to be released and distributed at the Second People's Health Assembly (PHA-II) in Ecuador in 2005 and will also be made available on the AIFO website. Three best articles will receive a cash prize of 500 Euros each. Last date for sending entries is 15 October 2004. It is possible that some selected partners from this initiative will be sponsored by AIFO to participate in the PHA-II. A decision regarding this will be taken before the end of 2004. In addition, authors of the three prize winning entries may also be invited to an award ceremony in Italy. For more details write to: sunil.deepak@aifo.it
The GHW is putting out a call for the submission of country or region-specific case studies. These case studies will form part of the electronic accompaniment to the alternative World Health Report to be launched in July 2005 at the Peoples health Assembly in Ecuador.
Through the Health Leadership Service, the World Health Organization (WHO) has begun recruiting young health professionals to a two-year work and training program, specifically aimed at strengthening the knowledge and skills essential for leadership roles in public health at all levels -national, regional and global.
The Graduate School, Faculty of Health Sciences, University of the Witwatersrand is dedicated to building health research capacity in South Africa and the SADC region. The School is inviting applications for fellowships (sponsored by the Belgian Embassy) to enable trainees to undertake full time master's level training in the Faculty of Health Sciences.
This publication is the first in a three part series on HIV/AIDS and agriculture in sub-Saharan Africa with the overall objective of providing a resource base on issues of rural development in a broad sense in the times of HIV/AIDS. This first book discusses the impact of the epidemic as it has emerged over the last decades at different levels of the agricultural sector, namely the farming system level, the livelihood level, and the household level. In a further step, impact on the agricultural estate sector as well as pastoralism is discussed.
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