The conception and birth of the Global Health Watch
Five years ago, about 1500 people from 80 countries met in Bangladesh at the first Peoples Health Assembly. The Assembly was organised as a counter-balance to the official World Health Assembly convened every year by World Health Organisation, and represented a protest against the failure to achieve health for all by the year 2000.
The Assembly gave renewed expression to social objectives such as fairness and the universal right to health care, as well as to the public health principle that in addition to providing health care, health systems and health professionals must act to abolish poverty and work towards people having access to education, nutrition, water, sanitation and peace.
It also gave birth to the Peoples Health Movement – a network of individuals and organisations from all regions of the world, formed with the understanding that the principles of the Charter would only be achieved through social mobilisation and political engagement. The Global Health Watch, an alternative world health report from the perspective of civil society, was designed as an instrument to support advocacy and mobilisation. Amongst its aims is to provide a platform that will embrace the science and politics of development, and thereby, simultaneously involve academics, health practitioners, parliamentarians, journalists and civil society in improving health and equity.
More than 120 people – researchers, health workers, non-government policy analysts and campaigners - and 70 non-government organisations contributed to the report. The connection of the Watch to the Peoples Health Movement and a wide range of NGOs will hopefully ensure that it doesn’t end up as another report gathering dust – disengaged from the vehicles that can help translate analysis and recommendations into actual action. Already a number of NGOs have volunteered to host launches of the Watch in other countries, including Malaysia, South Africa, Ireland, Egypt, Germany, Holland, and the US.
Watching
The Watch is not designed to report on the state of health and poverty – it is not about the size of the HIV pandemic, or the number of children who die every second; or the declining life expectancy in Africa. The aim is to provide a report on what is being done about improving health by reporting on the actions, policies and programmes of organisations charged with improving health. This idea of “watching” the performance of key institutions can also be viewed as a contribution to democratic deficits that exist at many levels of decision-making and the erosion of public accountability that has accompanied globalisation and the concentration of wealth and power.
Global political and economic institutions
According to the Universal Declaration on Human Rights, people do not just have a right to an adequate standard of living and medical care – they also have a right to live in a social and international order in which the rights to medical care can be realised. However, this right is continually violated. According to the World Commission on the Social Dimension of Globalisation, “none of the existing global institutions provide adequate democratic oversight of global markets, or redress basic inequalities between countries”.
The Watch questions the success story painted by proponents of the current form of globalization, pointing to increases in poverty in Africa, eastern Europe, central Asia and Latin America. Producers in developing countries have often been undermined by increased global competition from powerful nations after trade liberalisation. In Mexico, for example, the liberalisation of the corn sector under the North American Free Trade Agreement, led to a flood of imports from the United States, where agribusiness is massively subsidised. Mexican corn production stagnated whilst prices declined. Small farmers became much poorer and some 700,000 agricultural jobs disappeared over the same period. Rural poverty rates rose to over 70%, the minimum wage lost over 75% of its purchasing power, and infant mortality rates amongst the poor increased.
To change this will require a shift away from the dominant human rights discourse which focuses on the obligations of national governments towards their own citizens, towards more of a focus on a) the obligations of governments to the citizens of other countries; and b) the obligations of non-government actors, as well as the rules by which the world economy is controlled and governed. Furthermore, whilst some countries have social contracts, progressive taxation systems and laws and regulations to manage the human consequences of market failures at the national level, there is no ‘global social contract’ to manage the failures of globalization.
World Health Organisation (WHO)
A key chapter in the report is dedicated to WHO. The report argues that WHO is insufficiently resourced, inadequately empowered, undermined by national political agendas and handicapped by internal management problems. WHO does many things well and repeatedly demonstrates the need for a multilateral agency charged with protecting and promoting health, but the Watch calls for better funding and improvements in WHO’s operating environment. The report also notes that the proliferation of public private initiatives, vertical programmes and the insidious influence of the World Bank has resulted in WHO being further undermined as the leading global health agency.
But we need, for example, a WHO that can challenge and aspire to block trade and economic agreements that threaten to harm health and human rights. As a starting point, the Watch calls upon WHO to convene a delegation of public health and trade experts to attend the trade talks in Hong Kong this year, mandated with the role of providing public health advice to Ministries of trade and finance. But this simple request is unlikely to be granted without public lobbying. At the most recent Executive Board meeting of WHO, a mild resolution put forward by developing countries requesting WHO to conduct a more active analysis on the impact of trade on health was blocked by the US and other countries – illustrating the impotence of WHO in tackling the more fundamental determinants of health.
Other recommendations aimed at WHO include:
Steering the global health ship
- Substantially increase funding for WHO with more proportionately devoted to its core budget with fewer strings attached;
- Open a debate on WHO’s key roles to avoid mission-creep and to develop consensus within and beyond the organization;
- Strengthen WHO’s role at country level and give it a mandate to help governments co-ordinate global, bilateral and international NGO initiatives to improve health.
An organization of the people not just of governments
- Expand current efforts to reach out to civil society, especially in the developing world;
- Ensure that public-interest civil society organizations are differentiated from those acting as a front for commercial interests;
- Improve the nature of the WHO leadership elections – possible solutions include a wider franchise, perhaps of international public health experts and civil society organizations. Candidates should be required to publish a manifesto and debate their vision for the organization publicly.
Improve the management of the organization
- Improve the mix of the professional staff, ensuring that there are more social scientists, economists, public policy specialists, lawyers and pharmacists. More representation from developing countries should be coupled with stronger regional offices run by experienced professionals.
The corporate sector
Of the 100 largest economic entities in the world, 51 are businesses; and the combined sales of the top 20 businesses are 18 times the combined income of the poorest 25% of the world’s population. Transnational corporations wield immense power through their wealth, control of resources and influence on governments and key decision-making bodies, with profound consequences for health and development.
The price of medicines and the radical changes to the way we construct patents; the resistance to making the required changes to address climate change; widespread labour exploitation and occupational health hazards; the dumping of cheap, subsidised food in Africa; the corrupt trade in weapons; the unchecked pollution of many extractive industries; and the unhealthy changes in food eating practices are just some examples described in the report, of the causal relationships that exist between profit-seeking corporate activity and the state of global health.
While commercial activity and free enterprise in themselves should not come under attack, the deterioration of democratic control and oversight over corporate actions and power must be highlighted. The imbalance between corporate freedom and social obligations is unhealthy, and health professionals need to assert their public health authority to limit the negative consequences of corporate actions, and ensure proper regulatory frameworks.
The attention paid to the corporate sector also leads us to shift thinking away from an exclusive focus on poverty towards an equally necessary focus on wealth, and in particular one what many would call obscene wealth. One of the demands we make is for the establishment of an international tax authority to help recover the conservatively estimated US$255 billion that is lost annually through tax avoidance.
This is an amount of money, in spite of the low tax rates, that would fund comprehensive and functional health care systems in every poor country. Public-private partnerships and corporate social responsibility programmes are great, but the Watch calls for the greater use of legitimate, fair and non-punitive instruments of public policy to ensure the universal provision of health care and social security, and the redistribution that is required to reverse the politically unsustainable deepening of global disparities.
Health systems
The chapter on health systems sets a very different agenda from the one currently popular with donors, where the emphasis is on fragmented, vertical health programmes usually focussed on one or two diseases, or on particular selected interventions. The Watch describes how Ministries of Health in poor countries operate in a policy circus, pulled in a hundred different directions by different programmes, donors and agencies, undermining coherent and integrated health systems development. In many instances, these agencies also contribute to an internal ‘brain drain’ – sucking many of the most skilled professionals out of public health care systems.
In the poorer countries, this has come on top of economic crises, structural adjustment programmes and neoliberal reforms that have decimated public health care systems and extended the commercialisation of health care to the detriment of equity, accessibility and efficiency.
The Watch presents new evidence which suggests that higher levels of private finance and provision lead to worse health outcomes, and explains how private financing and provision leads to a commercialisation of health care systems which widens health care inequities, lowers access to care for the poor, causes inefficiencies and deteriorates levels of trust and ethics.
Unless a common vision of health care systems development is established, we will not achieve the health-related Millennium Development Goals. The Watch therefore calls for the adoption of a 10-point agenda to repair and develop health care systems (more detail on the recommendations is available from both the Watch itself and the accompanying advocacy document, Global Health Action):
1. Provide adequate funding for health care systems;
2. Take better care of public sector workers;
3. Ensure that public financing and provision underpin health care systems;
4. Abolish user fees that push people into poverty;
5. Adopt new health systems indicators and targets that incentivize countries to improve the health system rather than simply tackle specific diseases;
6. Reverse the commercialization of health care systems by using regulatory and legislative instruments; and search for ways in which the private sector’s resources can be harnessed for the public good;
7. Strengthen health management and adopt the District Health System as the model for organising health care systems;
8. Improve donor assistance within the health sector;
9. Promote community empowerment to improve the accountability of the health system;
10. Promote trust and ethical behaviour to combat the corrosive effects of commercialization.
At the moment international health agencies consistently stress the importance of strengthening health care systems – but with little debate or discussion as to what this actually means. This is one area where WHO can really play a positive role and demonstrate health sector leadership.
Global Health Watch 2
Planning for the second edition of the Watch has begun. But between now and then, the challenge will be to actively mobilise the broader health community around the Watch and the advocacy agenda that accompanies it.
At the launch of the report in London, NHS organisations and professional associations were asked to think of institutional responses to the global health crises by:
- Developing long-term ‘partnerships’ with counterparts in poor countries - involving support, the transfer of material resources, skills and technology – and also providing a mechanism by which health workers in the NHS can learn and understand the impact of UK actions and policies on global health);
- Daring to put aside a proportion of money to promote global health until such time that we have a mechanism to recompense poor countries for training so many of our health workers;
- Implementing fair trade and ethical purchasing policies within our own organizations; and
- Campaigning for change. Medact, which was established specifically as a membership organization for health workers to promote global health, provide one concrete vehicle by which individual health workers can work together to lever change.
In southern Africa, the health and development community should consider ways in which the Watch can be used as a tool to strengthen and develop a progressive global public health movement and greater public accountability.
* David McCoy and Mike Rowson are managing editors of GHW
* Please send comments to admin@equinetafrica.org
1. Editorial
The social and economic impact of the adjustment programmes of the International Monetary Fund (IMF) and the World Bank in developing countries has been a source of heated debate over the last two decades. Research on the effects of these policies has led to contradictory conclusions.
A number of World Bank evaluations indicate that 'adjuster countries' generally succeed in improving health, education, and social welfare programmes compared to 'non adjusters' (1-3). Based on such studies, the World Bank concludes that adjustment programmes do not necessarily adversely affect vulnerable populations. Furthermore, the World Bank believes that reforms that include these reforms are necessary for poverty eradication in developing countries.
On the other hand, publications from UNICEF and from representatives of academic institutions and non-governmental organizations (NGOs) indicate that adjustment policies may be particularly harmful for the most vulnerable populations. In "Adjustment with a human face", UNICEF reports studies from several developing countries which indicate that adjustment policies have negatively affected the health status of women and children (4).
Evidence suggests that the adjustment programmes may also create conditions favouring societal vulnerability to HIV/AIDS (5). Unfortunately, no study, to date, has systematically evaluated the relationship between IMF/World Bank economic reforms and the vulnerability of women and children to HIV/AIDS.
This paper reviews what is known regarding the social and economic consequences of adjustment policies on maternal and child welfare and explores the potential impact such consequences may have on the vulnerability of women and children to HIV/AIDS. We approach the impact of macroeconomic adjustment policies from a conceptual perspective. Our theoretical framework illustrates how adjustment policies may influence the predisposing factors for impoverishment of women and exposure of children to HIV/AIDS in sub-Saharan Africa.
The underlying assumption is not that adjustment is the only cause of vulnerability of women and children to HIV/AIDS. Antecedent predisposing factors, such as poverty and inequality, are responsible for the vulnerability of women and children to HIV/AIDS in the first place. However, adjustment policies may further contribute to a socioeconomic environment that facilitates the exposure of women and children to HIV/AIDS, especially when their implementation is not accompanied by specific measures protecting the most vulnerable populations.
AIDS in sub-Saharan Africa directly and indirectly devastates the lives of millions of women and children. According to the joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization, 19.2 million women and 3.2 million children aged less than 15 years are living with HIV/AIDS in the world. Almost two-thirds of them reside in sub-Saharan Africa. In 2003, over one million women and approximately 610,000 children died from AIDS.
Socioeconomic conditions of women and children are determined by a series of hierarchical factors that interact with one another at different levels of their ecosystem. These factors correspond to the household level (i.e. income of the family), the meso level (i.e. food prices, real wages, employment opportunities), and the macro level (i.e. economic policies, health policies, social welfare systems). The latter level is particularly important: macroeconomic changes modify the meso-economic conditions that, in turn, are transmitted down to the household level. Macroeconomic measures, such as adjustment policies, may have an impact not only on macroeconomic indicators, such as gross domestic product (GDP) growth and the external debt rate, but also on social indicators, such as access of women and children to shelter, food, healthcare, and education. Since poor access to basic human needs may facilitate the exposure of children to HIV/AIDS, economic policies at the macro level may ultimately be related to the socioeconomic conditions that reduce or facilitate the spread of HIV/ AIDS among infants and youths.
Economic reforms that decrease access to basic needs for poor households will eventually result in increased exposure of women and children to HIV/AIDS. Conversely, economic growth that leads to increased access to basic goods and services for the most vulnerable families may significantly reduce their exposure to the infection.
Since 1980, most sub-Saharan African countries entered into one or more adjustment programme(s) of the IMF/ World Bank. Many of these programmes have not been implemented as prescribed by the World Bank and IMF, but as implemented, these policies have not produced the expected results in terms of economic growth and reduction of unsustainable debt. A World Bank study of 26 African countries that implemented adjustment policies concluded that six countries had a large improvement in macroeconomic indicators, nine had a small improvement, and 11 had a deterioration (3). Moreover, Africa's external debt increased from US$ 120 billion in 1980 to US$ 340 billion in 1995 (14).
Adjustment policies mainly consist of currency devaluation and financial liberalization; privatization of government corporations; trade liberalization (including import liberalization and export promotion); elimination or reduction of subsidies for agriculture and food staples; and reductions in government spending (including expenditure for health, education, and social services).
Analyses of the effects of currency devaluation on prices for basic items, such as food, housing, and transportation, lead to controversial conclusions. Prices for basic commodities rise after the adoption of the adjustment policies because currency devaluation increases the cost of imports. In Zambia, devaluation increased the cost of bread from 12 kwacha a loaf in 1990 to 350 kwacha in 1993 (21). In Senegal, after currency devaluation, inflation rates dramatically increased especially for daily food and health products (22). In Kenya, the real price for maize rose by 29% between 1982 and 1983 (23). In Tanzania, commodity prices skyrocketed as a result of devaluation (24).
Despite these results, there is also evidence that currency devaluation may be an appropriate solution to prevent a further collapse of a failing economy (13). A study conducted in cocoa-growing areas of Ghana concluded that even the poorest smallholders benefited from the improved producer prices resulting from devaluation (25).
If currency devaluation produces mixed effects, removal of food subsidies has a more direct impact on access to food and basic commodities, especially among low income groups. In Zambia, after the removal of subsidies in 1985, the price of maize meal rose by 50% (26). In Zimbabwe, after eliminating food subsidies, the cost of living for lower-income urban families rose by 45% between mid-1991 and mid-1992. The increased cost of food items results in a sharp reduction of low-income household expenditure on other basic commodities.
Sharp increases in the cost of living and impoverishment of women not only increase the vulnerability of infants to HIV/AIDS, but also have a negative impact on vulnerable young people. Children of poor mothers are more likely to be exposed to predisposing factors for HIV (10). Socioeconomic constraints force these children to leave school and search work to support their families. Children may also be abandoned. Youths and children living in impoverished families are more likely to live and work on the street, where they may be forced into prostitution to exchange sex for money, goods, food, or shelter (31).
Privatization results in significant job losses in the public sector without necessarily increasing employment in the private sector (34-36). To improve efficiency and keep production costs low, public enterprises reduce costs of labour by freezing wages and reducing employment.
This results in a decline of real wages or an increase in unemployment, especially among low-income workers. During the 1980s, average real wages declined in 26 of 28 African countries (34). In Ghana, between 1984 and 1991, after privatization of the 42 largest state enterprises, more than 150,000 workers lost their jobs (31).
These cutbacks in public-sector employment disproportionately affect women (4,37,38) who traditionally hold positions, such as clerical workers, cleaners, nurses, or teachers. In Ghana, the least skilled women working in the public sector lost job protection, security, and benefits as a consequence of policies aimed at increasing efficiency, while others lost employment altogether (39). Privatization not only affects women in urban areas, but also impacts those in rural areas since informal land privatization is linked to a reduction in access of women to subsistence food production (40).
Unemployment, low wages, and job insecurity caused by privatization not only increase women's adoption of survival strategies, including prostitution, but also modify existing gender-related relationships. Employed women tend to be more empowered by having more opportunities for education, more experience in public life, more self-confidence and self-esteem, all basic prerequisites for negotiating safe sex with male partners (41). Conversely, unemployment, job insecurity, and reduced purchasing power increase the exposure of women to sexual harassment and sexual abuse, especially among those working in low-earning jobs (42).
Reduced employment opportunities resulting from privatization may also increase the proportion of African children forced to live on the street or work to support their families (43). In Zambia, due to privatization and retrenchment of government employees, 72,000 people lost their jobs and child labour increased nine folds among females aged 12-14-years (44).
In regions where a significant proportion of population live in miserable conditions, indiscriminate cost-recovery measures disproportionately affect those who cannot afford to pay user-charges. The World Bank and other organizations which support the implementation of user-fees for health services insist that even poor households are willing to pay for higher quality, more reliable health services. In a household survey conducted in Rwanda, most respondents, regardless of income, indicated a preference for higher fees to assure the availability of medications (59).
However, populations living on less than a dollar per day can rarely afford to pay user-fees and their inability to pay may negate their 'willingness' to pay (60). The literature repeatedly shows that introducing user-charges at STI clinics result in a dramatic drop in women's use of services (61-64). Access to free STI treatment and condoms increase their use (65-66), and the introduction of user-charges creates an obstacle to HIV-preventive behavioural practices among women. Women and youth without access to AIDS education, HIV screening, STI treatment, and reproductive health services have little control over their AIDS-related risk factors. Untreated STIs increase the risks of HIV transmission (67) as shown in Uganda where over 90% of new HIV infections were attributable to other STIs (68). The introduction of user fees for health clinics is likely to increase the number of untreated STIs consequently producing high HIV susceptibility in women (66). These HIV-infected women infect their children through vertical transmission of the virus.
Following the prescriptions for structural adjustment and stabilization policies, many sub-Saharan African countries reduced public expenditure on education and introduced school fees limiting access to education, especially among those children who cannot afford to pay such charges (4,36). The introduction of school fees causes a dramatic fall in primary school enrollment rates and increases the number of children who drop out of school. Sub-Saharan Africa has the lowest primary school enrollment ratio in the world. This ratio fell from 77.1% in 1980 to an estimated 66.7% in 1990 (69).
Certain components of adjustment reforms, such as currency devaluation and trade liberalization, may produce mixed effects on the vulnerability of women and children to HIV/AIDS. Other reforms, such as financial liberalization, removal of food subsidies, and introduction of user fees for healthcare and education have a negative impact on the spread of the epidemic among poor women and children. In most cases, adjustment policies create synergies making it extremely difficult to identify their net social effects. Clearly, there is, currently, no single study capable of demonstrating a causal link between adjustment policies and the exposure of women and children to HIV/AIDS. However, this analysis provides some evidence that adjustment policies may inadvertently facilitate societal conditions that increase the vulnerability of women and children to HIV/AIDS in sub-Saharan Africa.
It must also be acknowledged that the World Bank is, at present, the largest single investor in health in sub- Saharan Africa. Such investment may reduce the HIV epidemic through some mechanisms. However, the unintended consequences of adjustment policies may have greater negative effects on the same health outcome.
Given the potential for adjustment policies to exacerbate the AIDS pandemic among women and children, there is an urgent need to either demonstrate that such measures are not harmful to maternal and child welfare or to modify policies. The present buffering mechanisms designed to protect the most vulnerable segments of the population during macroeconomic stabilization and structural adjustment are not sufficient. The IMF and the World Bank need to provide adequate scientific evidence demonstrating the effectiveness of their policies. Failure to do so may undermine their international credibility and further exacerbate the already tragic social conditions of marginalized women and children at risk of HIV/AIDS in the developing world.
* This article is composed of extracts from the original review paper, done with permission of the author. For the full paper and list of references visit http://www.phishare.org/documents/icddrb/3205/
* Roberto De Vogli is with the Department of Epidemiology and Public Health, University College of London. Gretchen L. Birbeck is with the African Studies Center and Departments of Neurology and Epidemiology, Michigan State University.
* Please send comments to admin@equinetafrica.org
2. Latest Equinet Updates
This briefing describes the programme of student research grants in EQUINET and invites applicants for the third round of grants. The Regional Network for Equity in Health in Southern Africa (EQUINET) promotes policies for equity in health across a range of priority theme areas (See www.equinetafrica.org) EQUINET has over the years, organized its work in various theme areas, including: economic and trade policy and health; human rights, governance and participation, equity in health sector responses to HIV/AIDS, human resources for health; monitoring and surveillance and others. Within these areas of work EQUINET aims to identify, recruit and build capacity and analysis.
3. Equity in Health
"Here in my country, ten people die of AIDS every hour. About one million people are infected with HIV out of a population of some 12 million. Our government is working hard to try to slow down this epidemic: We have an extensive voluntary counseling and testing program and hope to treat as many as 80,000 people with antiretroviral drugs by the end of the year. Unfortunately, there is only so much we can do. One of our biggest obstacles, which many nations on our continent share, is a shortage of health care workers. Simply put, Africa cannot fight poverty and disease without more doctors and nurses."
At the World Health Assembly in May 2003, the People's Health Movement, together with GEGA and Medact discussed the need for civil society to produce its own alternative World Health Report. It was felt that the WHO reports were inadequate; that there was no report that monitored the performance of global health institutions; and, that the dominant neo-liberal discourse in public health policy also needed to be challenged by a more people-centred approach that highlights social justice. The idea of an alternative World Health Report since developed into an initiative called the 'Global Health Watch' the first of which was launched on July 20, 2005.
More than 10 million people will need humanitarian assistance in six countries across southern Africa over the coming year following yet another year of poor agricultural production caused by erratic weather together with late, and in some cases unaffordable inputs, such as fertilizer and seeds, two UN agencies and the Southern Africa Development Community (SADC) have warned.
Delegates attending the second people’s health assembly called for the total abolition of patents on essential medicines. “Patents are shortening the lives of people and is a curse for poor people,” said Dr. Eduardo Espinoza, the former dean of University of El Salvador. “There are two serious concerns about essential medicines. Firstly, it is about their availability. Secondly its affordability,” said Mr. Amitava Guha, a trade union leader from India. “The manifestations of the unfair patent regime are taking a heavy toll on poor people, especially those who are infected and affected with HIV / AIDS,” said Mr. Guha, who currently heads the Federation of Medical Representatives Association of India.
4. Values, Policies and Rights
There are between 500 and 700 AIDS-related deaths in Kenya every day. Beyond this tragedy, the HIV/AIDS epidemic creates problems in many aspects of social and economic life. One such problem is decreased security of land tenure. There are dramatic accounts of AIDS widows and orphans being chased from their land and many more that tell of an increased sense of tenure insecurity due to HIV/AIDS. Is this the whole story of the relationship between HIV/AIDS and land rights? Research sponsored by the Department for International Development (UK) and the Food and Agriculture Organisation of the United Nations examines the relationship between HIV/AIDS and land rights in three Kenyan districts.
The People's Health Movement, an international organisation of health activists, launched a new global campaign on the right to health at its second assembly in Cuenca, Ecuador, held from 18 to 23 July. Assembly delegates from many countries attested to the campaign's importance. Increasing erosion in access to universal health care, growth of unregulated private providers, and declines in public funding are leaving millions of people without insured services.
5. Health equity in economic and trade policies
This year people in bars and at football matches were asking about the Group of 8 (G8) nations summit in Gleneagles, Scotland. Such unprecedented popular interest was prompted by Bob Geldof's Live 8 concerts and the Make Poverty History campaign. These initiatives were organised to raise awareness about African poverty and to pressure politicians into tackling the preventable global burden of disease afflicting billions of people living in low-income settings. When asked if his lobbying had paid off, Geldof said, “A great justice has been done”. He should have said “No”. (requires registration)
Alternative reports on global health, presented at the second People's Health Assembly in Ecuador this week, question the free-market, neoliberal economic model and view it as the cause of many of the health problems facing humanity today. These include the indiscriminate use of toxic products in agriculture, pollution caused by the oil industry, the consumption of transgenic crops, the destruction of the urban environment by pollution, and the commercialisation of health services. The reports by the Global Health Watch and the Observatorio Latinoamericano de Salud see a healthy life as a fundamental human right, the enjoyment of which depends on economic, political and social factors.
"Today the G8 has made an unprecedented commitment to health which has the potential to forever change the lives of millions of people in Africa. Disease kills 3.5 million African children under five every year. HIV/AIDS affects more than 25 million African people. Tuberculosis kills 1500 each day. A woman living in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy or childbirth. I welcome the G8's pledge to turn these trends around. The aim of providing near-universal access to AIDS treatment for people living with HIV/AIDS by 2010, combined with prevention and care, has the potential to turn the tide on this epidemic. We already know that treatment can turn a fatal disease into a chronic condition and we have demonstrated that this works in resource-poor countries."
6. Poverty and health
Despite claims that Uganda’s recent success in poverty reduction has been significantly related to “getting the politics right,” there are concerns that the poorest may not have benefited from this form of poverty reduction or the types of politics that have helped shape it. Employing the analytical framework of political space reveals that although some of the poorest groups are represented within the political system, political discourse reveals a strong bias toward the “economically active,” leaving the poorest excluded from poverty programs. Significantly, there is an increasing divergence between the regime’s political project of “modernization” and the international poverty agenda, with important implications for the poorest.
7. Human Resources
"Health care agencies report that the major limiting factor for implementing effective health policies and reforms worldwide is a lack of qualified human resources. Although many agencies have adopted policy development and clinical practice guidelines, the human resources necessary to carry out these policies towards actual reform are not yet in place. The goal of this article is to evaluate the current status of human resources quality, availability and distribution in Northern Tanzania in order to provide emergency obstetric care services to specific districts in this area. The article also discusses the usefulness of distribution indicators for describing equity in the decision-making process."
This policy brief from the World Health Report argues that it will not be possible to effectively scale up Maternal, Newborn and Child Health (MNCH) care without confronting the global health workforce crisis. It argues that the low number of health professionals is one of the main factors in the exclusion from care and high mortality rates for mothers and newborns. It highlights how lack of managerial autonomy, gender discrimination and violence in the workplace, dwindling salaries, poor working conditions and some donor interventions have all contributed to a lack of productivity, as well as the rural to urban, public to private and poor to rich country brain drain and migration.
8. Public-Private Mix
This paper, from the DFID Health Resource Centre (HRC) aims to provide a common understanding of what Global Health Partnerships (GHPs) are, how they might be classified and how they operate. The document reviews definitions of GHPs, outlines a classification system used in the Resource Centre’s broader GHP project, describes the key findings, and provides a detailed list of GHPs with their missions, aims and/or objectives. It also details a global GHP mapping exercise, which examined prevalence or cases of specific diseases of interest to target GHPs, poverty, and political and health systems characteristics.
"This paper reviews the current status of the global pharmaceutical industry and its research and development focus in the context of the health care needs of the developing world. It will consider the attempts to improve access to critical drugs and vaccines, and increase the research effort directed at key public health priorities in the developing world. In particular, it will consider prospects for public-private collaboration. The challenges and opportunities in such public-private partnerships will be discussed briefly along with a look at factors that may be key to success. Much of the focus is on HIV/AIDS where the debate on the optimal balance between intellectual property rights (IPR) and human rights to life and health has been very public and emotive."
Debates about the roles of public and private healthcare sectors reflect the experiences of advanced market economies. But in many developing countries, the boundaries between public and private sectors are blurred. Strategies towards private providers must address the context of local relationships between the state, market and civil society. A paper from the UK Department for International Development's Health Systems Resource Centre aims to help the development of a common understanding of the reality of countries where most poor people live and of practical strategies for meeting their needs.
9. Resource allocation and health financing
The availability of limited funds from international agencies for the purchase of antiretroviral (ARV) treatment in developing countries presents challenges, especially in prioritizing who should receive therapy. Public input and the protection of human rights are crucial in making treatment programs equitable and accountable. By examining historical precedents of resource allocation, we aim to provoke and inform debate about current ARV programs.
This document, by the Zambian Ministry of Health and PHRplus, summarises how the National Health Accounts (NHA) system was used to assess both general health and HIV and AIDS-specific spending in Zambia in 2002. The document also reviews health care use and borrowing patterns for people living with HIV and AIDS (PLWHA). Findings show that the private sector, including households, finance 15.3 per cent of HIV and AIDS spending, whereas the public sector finances 7.2 per cent. Findings also reveal that PLWHA spend 12 times more on health care than those who are not infected. Traditional healers were also found to play a major role as providers of health care for people living with HIV and AIDS.
10. Equity and HIV/AIDS
Only governments sensitive to the demands of their citizens appropriately respond to needs of their nation. HIV prevalence is significantly associated with poor governance. International public health programs need to address societal structures in order to create strong foundations upon which effective healthcare interventions can be implemented.
HIV/AIDS care encompasses a range of different programmes, including voluntary counselling and testing (VCT), prevention of mother to child transmission (PMTCT), health education, nutrition and psycho-social support, treatment of opportunistic infections and staging. Yet, since government’s decision to introduce anti-retroviral therapy in public health facilities, research and debate has focused almost exclusively on the delivery of ARVs. Most of these essential HIV/AIDS services are rendered or supported by nurses at primary care facilities (clinics or community health centres). Yet primary care nursing is in danger of being seriously undermined in South Africa (and elsewhere in Africa) by an accelerating brain drain of nurses, decreasing productivity, lack of skills, and overwhelming anecdotal evidence of burnout and low morale amongst nursing staff.
The HIV/AIDS epidemic has a dramatic impact on agricultural production, rural livelihoods and food security in many countries. Labour-saving crops and improved agricultural techniques will be a valuable support measure for communities to increase agricultural output and food production.
In the agricultural sector of parts of eastern and southern Africa, HIV/AIDS has contributed to a loss of assets and land, and, in some cases, labour shortages. As a result, crop production has declined for many farm households and rural inequality appears to have increased. Agricultural growth built on policies sensitive to the impacts of HIV/AIDS is essential.
11. Governance and participation in health
Identifying new approaches to tuberculosis treatment that are effective and put less demand to meagre health resources is important. One such approach is community based direct observed treatment (DOT). The purpose of the study was to determine the cost and cost effectiveness of health facility and community based directly observed treatment of tuberculosis in an urban setting in Tanzania. The conclusion is that community based DOT presents an economically attractive option to complement health facility based DOT. This is particularly important in settings where TB clinics are working beyond capacity under limited resources.
12. Monitoring equity and research policy
To achieve universal access to HIV prevention and treatment, the scientific and public health community must respond quickly to developments on the ground to narrow the gap between discovery and intervention. Dr Charlie Gilks, head of treatment, prevention and scale up at the World Health Organization's (WHO) HIV/AIDS Department, stressed the need to "learn by doing" at the 3rd International AIDS Society Conference on HIV Pathogenesis and Treatment, a biennial scientific meeting, in Rio de Jeneiro, Brazil. Gilks emphasized the importance of research on HIV prevention in addition to more effective ways to deliver treatment. "While we work to keep people alive and healthy with the tools we have now, we also need to ensure that future generations will have access to better prevention technologies," said Gilks, referring to the importance of vaccine and microbicide research.
13. Useful Resources
The following notes are now available to download for free from the Praxis area of INTRAC's website:
* 'Building Capacity to Mainstream HIV/AIDS Internally: Reflecting on CABUNGO's Experience with NGOs in Malawi', by Rick James and CABUNGO, July 2005
* 'Robbed of Dorothy! The Painful Realities of HIV/AIDS in an Organisation', by Betsy Mboizi and Rick James, June 2005
* 'Capacity Building in an AIDS-Affected Health Care Institution: Mulanje Mission Hospital, Malawi', by Hans Rode, April 2005
* 'The Crushing Impact of HIV/AIDS on Leadership in Malawi', by Rick James, April 2005
www.intrac.org
Scidev.net have just launched a range of new in-depth materials on the latest scientific and technological advances to combat HIV/AIDS in developing countries. Articles include perspectives from the South, with an overview of HIV research in Brazil and microbicides research in South Africa forming two of the new opinion pieces.
Chronic, non-communicable diseases (NCDs), mental disorders, and injuries and violence are major public health problems in developing countries. Together, they account for over 40 per cent of the disease burden in high mortality developing countries, and over 75 per cent in lower mortality developing countries. So why are they so often overlooked by policymakers? The HRC/Eldis Health Resource Guide has launched a topic guide to NCDs, injuries and mental health. Produced in collaboration with subject experts, it provides a synthesis of the latest thinking and research on these issues, with summaries of key readings and links to further resources.
Source is an international information support centre designed to strengthen the management, use and impact of information on health and disability.
14. Jobs and Announcements
CHP is a publication of the People's Health Movement, South Africa (South Africa). It is produced with the aim of offering an alternative, "peoples health" perspective and stimulating debate on critical issues related to health and health care in South Africa and elsewhere. CHP is produced once a month and distributed electronically with a distribution list of around 500 people. It is also distributed to a number of email lists. The distribution list consist of professionals interested in health care issues, staff in NGO's, trade union membership, media, government officials, activists.
Published for the Network for Equity in Health in Southern Africa by
Fahamu - Networks for Social Justice
http://www.fahamu.org/
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