Developing countries took several initiatives at the World Health Organisation's (WHO's) 59th World Health Assembly (WHA) in May 2006 to raise the need for WHO more strongly assert its global role in protecting health in the global economy.
A resolution was passed to increase coordination between WHO and the World Trade Organisation (WTO) on Trade and Health. It mandated the WHO to assist countries that are negotiating trade agreements that have an impact on their health sectors. Ministers at the East, Central and Southern African Health Community 42nd Regional Health Minister’s Conference in February 2006 called for such training for government and civil society to facilitate better understanding of the TRIPs agreement. Towards this EQUINET has developed a training toolkit on trade and health and carried out pilot workshops in Malawi, Zimbabwe and Tanzania. These confirm the call for greater support to country teams in negotiating new issues on trade and health. Countries are currently dealing with the General Agreement on Trade in Services (GATS) and the implementation of flexibilities under the WTO's Trade Related Intellectual Property Rights (TRIPs) agreement. TRIPs flexibilities relate to access to patented medicines or legally produced generics. The GATS deals with the liberalisation of health and health related services and has implications for cost recovery, cross subsidisation, health insurance, the regulation of commercial or competitive health services and indirectly related sectors like distribution.
Critics of the GATS have, for example, pointed out that it can and has limited the ability of governments to regulate health services towards the necessary cross subsidies and equity measures needed to promote universal access. EQUINET has resolved in its past forums that in a situation of high inequality in access to services, governments should enjoy full flexibility to regulate their health sectors in the public interest, unconstrained by WTO disciplines. The WTO Secretariat countered such criticisms in a publication “GATS - Fact and Fiction”, responding that countries were free to make commitments only in sectors they choose and could therefore limit liberalisation. This poses a problem for countries like Zambia who have already committed their health services in GATS, and may now want to regulate areas of health service provision. A ruling in April 2004 of the WTO's dispute settlement body in a case between the US and Mexico raises even greater concerns for countries like Zambia, as the dispute settlement body decided that the right of a country to promote development was not as important as its commitments to trade in services under the GATS.
In the TRIPs negotiations, flexibilities for developing countries for local production or import of pharmaceuticals under compulsory licenses have also led to relatively stiff resistance to proposals for improved flexibilities. Countries have also had to deal with bilateral trade agreements that erode these flexibilities. Some Latin American ministers at the WHA made a separate statement saying that TRIPs obligations should not be increased under bilateral/regional agreements. At the same time, the ECSA Regional Health Ministers noted that countries in the region still need to fully utilize these flexibilities and embed them in their national laws.
WHO clearly has significant challenges to address to promote health under WTO agreements. The mandate of the Trade and Health resolution is broad and will need to be closely monitored to ensure that the co-ordination promotes public health priorities and challenges the WTO's stronghold in health, particularly for developing countries.
One area of ground work for this has been in the WHO Commission for Intellectual Property Rights and Innovation in Public Health. The commission report was tabled at the WHA and made a number of recommendations on the IPR system for health, including that needs-driven health research should follow public health and development priorities; and promote innovation to develop solutions to health problems.
Parallel to this report an Intergovernmental Working Group was established by a resolution of the WHA, proposed by Kenya and Brazil. The proposal responded to the limitations of the current risk-reward innovation system of IPRs. This profit driven model fails to provide incentives for research into diseases affecting developing countries. Because the expectation of profit is limited in these “neglected diseases,” drugs are not researched and developed. The Working Group was mandated to produce a strategy and action plan on ways of promoting research for the prevention and management of these diseases and to examine the impact of this research on public health. This too will be an area where inputs from Africa will be important, given the extreme inequities that exist between public health burden and access to the technologies, diagnostics and drugs to prevent and manage disease.
African countries again raised the issue of the “brain drain” at the WHA, and the effect it has on their ability to cope with health demands. They requested compensation and ethical recruitment practices in sometimes tense debates. The African proposals were contested by the some developed countries, including those recruiting and receiving health personnel from Africa. The debates were not resolved, and the WHA resolution adopted committed rich countries to increase funding for health worker education in developing countries, inadequately addressing the wider demand for mechanisms that fairly and sustainably address perverse subsidies and enable African health sectors to value and retain their own health workers. At the same time, countries in the region need to be aware of the implications of the commitments they make under the GATS agreement on the movement of persons. Countries that make commitments that include liberalising the movement of people in the health sector may weaken their claims to compensation for that movement. Given the significant impact the shortfall in health workers is having in access to health care in east and southern Africa, we need bolder, more challenging global arrangements to manage issues of migration and resource transfers than have been the case to date.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org and to SEATINI (www.seatini.org). EQUINET work on health equity in economic and trade policy is available at the EQUINET website at www.equinetafrica.org.
1. Editorial
Compared to 20 years ago in Kenya, people live for ten years less on average, more children die in infancy and a greater proportion of those who survive face stunting. Why? Soren Ambrose makes a case for holding the International Monetary Fund (IMF) responsible, arguing that the institution's obsession with low inflation rates - one of the foundations of trade liberalization - starves economies and hurts the poor.
On March 6, Kenya's Assistant Minister for Health, Enock Kibunguchy, told the press that Kenya urgently needs to hire 10,000 additional professionals in the public health sector, blurting out: “We have to put our foot down and employ. We can tell the International Monetary Fund and the World Bank to go to hell.”
These are strong words for a high-ranking government official to put on record regarding the most powerful international financial institutions (IFIs), and in particular the IMF, a body whose power extends to being able to call for the withdrawal of virtually all external assistance to a country.
Minister of Health Charity Ngilu had in fact been rumored to have made similar accusations in meetings with IMF officials and civil society representatives; since Kibunguchy's declaration she has confirmed she shares his view. Similar allegations have also been made by several civil society organizations focused on the IMF and on health rights. Indeed, in the last two years a number of organizations have identified IMF restrictions as a serious disincentive to hiring desperately-needed health professionals not only in Kenya, but in many other African and Global South countries as well.
Specific IMF policies, in particular the low ceilings it sets for inflation rates and wage expenditures in borrowing countries, are demonstrably illogical and detrimental. Together with the dubious defense the IMF mounts for maintaining such restrictions, cases like Kenya's provide a strong argument that those controlling the IMF should re-examine the restrictions it places on borrowing governments. The logic of demanding continual decreases in public wage bills is likewise suspect, as are the IMF's routine inflation targets. With increased funding from new sources, improved standards of living are within reach of even the most impoverished countries, if only the IMF would allow it.
The Health Care Crisis
Kenya's health care crisis has been 20 years in the making. Its dimensions are spelled out in the 2004 Poverty Reduction Strategy Paper (PRSP) - a government document written in consultation with the IMF and World Bank and approved by both bodies' boards. Life expectancy declined from 57 in 1986 to 47 in 2000; infant mortality increased from 62 per thousand in 1993 to 78 per thousand in 2003; and under-five mortality rose from 96 per thousand births to 114 per thousand in the same period. The percentage of children with stunted growth increased from 29% in 1993 to 31% in 2003, and the percentage of Kenya's children who are fully-vaccinated dropped from 79% in 1993 to 52% in 2003.
Why this deterioration? As in most African countries, Kenya's health care system was hit hard by the “structural adjustment” policies imposed by the IMF and World Bank as conditions on loans and as prerequisites for getting IFI approval of the country's economic policies. Those policies were introduced in the 1980s, and have left a lasting mark on Kenya's health. As usual with such programs, the emphasis was on cutting budget expenditures. As a result, local health clinics and dispensaries had fewer supplies and medicines, and user fees became more common. The public hospitals saw their standard of care deteriorate, increasing pressure on the largest public facility, Kenyatta National Hospital in Nairobi. As a consequence, that hospital, once the leading health facility in East Africa, began, like so many other African hospitals, to ask patients' families to provide outside food, medicine, and medical supplies. Most beds at Kenyatta and the regional and local hospitals accommodated two patients. Professional staff have taken jobs - some part-time, some full-time, at private healthcare facilities, or migrated to Europe or North America in search of better pay.
An October 2005 communication from an NGO coalition to the November 2005 “High Level Forum on Health MDGs (Millennium Development Goals)” notes that “between 1991 and 2003, the [Kenyan] government reduced its work force by 30%” - cuts that hit the health sector particularly hard.[3] For the period between 2000 and 2002 alone, the government was scheduled to lay off 5,300 health staff.
Those requirements were externally imposed. A World Bank Group document from November 2003, written to justify waiving a loan condition calling for a workforce reduction, notes: “This condition required retrenching 32,000 personnel from civil service over a period of two years. In practice, 23,448 civil servants were retrenched in 2000/01 before the program was interrupted by lawsuits. A specific commitment in the updated [agreement] is to reduce the size of the civil service by 5,000 per year through natural attrition.” The very same document supports Assistant Minister Kibunguchy's assessment of the sector's current needs - “the health sector currently experiences a staff shortage of about 10,000 health workers.” The document, however, draws no connection between the shortage and the insistence on cutting more workers.
The impact of the layoffs and budget slashing in the health sector over the last 15 years was cited recently by Member of Parliament Alfred Nderitu as the primary motivation for his motion of censure against the IMF and World Bank in the Kenyan Parliament. His initiative would insist that any future loans from the institutions get Parliamentary approval.
Clinics Without Nurses
Many African countries have shortages of medical staff because of lack of training capacity; in Kenya this is not the case. Thousands are unemployed or underemployed, eager to take up full time positions.
Both the Kenyan government and the IFIs regularly announce that health spending will increase substantially. With all these promises of increased resources for health care, with the World Bank's acknowledgement of a staff shortage, and with all those unemployed nurses, one might expect that the government would waste no time in hiring the thousands of nurses Kenya so desperately needs. And indeed, frequent promises are made by government officials to that effect. But the promises are almost never kept.
According to the Chief Economist in the Ministry of Health, S.N. Muchiri, the reason is that while the IFIs support increased expenditures on health, they forbid spending that money to pay staff wages. This is accomplished through insisting on a ceiling on wage expenditures; in Kenya, the targets are 8.5% of GDP in 2006 and 7.2% by 2008. The IMF doesn't specify that hiring in the health sector specifically must be limited, but when the entire wage bill must be suppressed, the chances of hiring the personnel needed are slim indeed.
So when IFI staffers call for more funding for clinics, as they do in their critique of the government's draft PRSP, they mean buildings, equipment, and medicine. Unfortunately, personnel are required to run the clinics. It is the choice by those institutions to prioritize targets for reduced spending on public salaries and on inflation, says Muchiri, that prevents Kenya from hiring health workers.
Muchiri provides valuable “inside” confirmation of charges made with increasing intensity by civil society organizations over the last two years. Advocates point out that while recent funding initiatives like the Global Fund for AIDS, Tuberculosis & Malaria and PEPFAR have made stemming the most critical health crises in Africa more possible, the IMF's power over borrowers' economic policy and its narrow focus on keeping inflation and payrolls as low as possible is actively discouraging governments from putting the available funds to use.
Numbers, Not People
On one level, it seems like commonsense for an organization like the IMF to seek out ways in which governments can reduce the amount spent on salaries, especially in countries like Kenya, which have had troubles with “ghost employees” on public payrolls in the past. But the self-defeating nature of this quest quickly becomes apparent. If the government were simply expected to identify and eliminate ghost employees, that would obviously lighten the government's burden and enable it to target its resources more wisely.
But the IMF's conditions deal with bottom-line expenditures, not with going to the root of the problem. Kenya's PRSP spells out the implications: “…achieving the 8.5 percent target by 2005/06 will require that any awards to be provided to the civil servants or any additional awards will be matched by a proportionate downsizing of the civil service.” Any hiring of nurses, for example, would require that some other public employees be eliminated - regardless of how much the nurses may be needed, or how vital the other positions may be. Indiscriminate targeting like this only demonstrates the prioritizing of abstract economic statistical standards over real-life outcomes, including those most likely to have a positive material impact on poverty and on contributing to the overall health of both Kenya's population and the economy.
So if the health budget is to rise - as both the IFIs and the government repeat often - then the PRSP must remind us that: “The fiscal strategy assumes that these health expenditures will be focused on non-wage non-transfer expenditures and will thus enable the rapid increase in basic health services.” Indeed, Muchiri reports that funds are often available for facilities or supplies, but not for staff. The result is that more people may seek out health services, but the ministry will actually be less able to provide them because of lack of personnel to administer the drugs or operate the machinery.
Inflation, Inflation, Inflation
But why does the IMF, with its power to exclude a country from the global economy by declaring it “off-track,” insist on reducing government payrolls? Adding employees to the government payroll, especially if accomplished with aid money, is considered by orthodox economists like those at the IMF to increase inflationary pressures in a developing country. And an increase in inflation is anathema to the IMF.
The IMF quite openly prioritizes inflation targeting over almost any other factor in the countries where it works. Pressed on the question, as they have been in the debate over health spending, its officials will invariably respond that inflation is a “tax” that hits the poor the hardest.
But is that true? Anis Chowdhury points out that:
“The poor have very limited financial assets; they are largely net financial debtors. Thus inflation can benefit the poor by reducing the real value of their financial debt. Meanwhile, the IMF's cure for inflation - raising interest rates - can actually harm the poor because this increases the servicing costs of their current debts. The poor fare worse when unemployment rises and persists, especially when there is no adequate safety net or social security system. At the same time, the real value of their household debt rises with falling inflation rates. Hence the poor have more reason to be averse to unemployment and less averse to inflation than the elite in society."
After this seemingly obvious point is made, it seems only too easy to point out that those who stand to lose the most from inflation are those who hold large amounts of money - financiers, investors, bankers. Yes, there are risks to the poor in high and/or persistent inflation, but increases in inflation below a certain point are far more likely to cause pain to those whose incomes depend on relatively minor fluctuations in currency values. For the impoverished, as Chowdhury explains, such increases in inflation are likely to be more beneficial than harmful.
As is so often the case, it is easiest to discern the interests of policy-makers not from their rhetoric, but from whose interests are most vigorously protected by their policies - by who “wins” as a result. The IMF's longtime prioritization of inflation over all else lends weight to those who accuse it of using its powers to protect the interests of the wealthy over those of the impoverished, regardless of their rhetoric that maintains the reverse.
IMF official Andy Berg recently admitted as much: “Higher inflation tax[es] people who hold cash or whose nominal incomes are fixed.” But Berg's next sentence restores IMF ideology, and at the same time exposes its flimsiness: “And this tax discourages private investment and tends to fall on those least able to adapt - in other words the poor.” Berg relocates the pain from the rich to the poor, but offers no logic for that move.
Drawing a Reasonable Line on Inflation
To challenge the IMF, the question must be where to draw the line - at what point, to use Berg's phrase, is “inflation out of control,” or at risk of spinning out of control? Berg says “in poor countries the danger point is somewhere between 5 and 10 percent.” The good news is that this figure is actually less conservative than the standard used in most IMF programs. In most countries with IMF loans, the conditions call for inflation to decline and stay below five percent.
Few economists outside the IMF opt for a level as low even as 10% in defining a healthy rate of inflation for a growing economy in a developing country. Terry McKinley, an economist with the United Nations Development Program (UNDP), declares: “As long as current revenue covers current expenditures, governments can usefully borrow to finance [social] investment. […] Fiscal deficits should remain sustainable as ensuing growth boosts revenue collection. The resultant growth of productive capacities will keep inflation moderate - namely, within a 15 percent rate per year.”
There is no room for neutrality in this debate. Adhering to IMF standards in order to avoid trouble will, according to McKinley, likely sabotage any hope of genuine development:
“Moderate inflation can, in fact, be compatible with growth. But low inflation can be as harmful as high inflation. When low-inflation policies keep the economy mired in stagnation or drive it into recession, the poor lose out, often for years thereafter, as their meager stocks of wealth are wiped out or their human capabilities seriously impaired. […] Without jobs and income, people cannot benefit from price stability.”
Tactfully avoiding mentioning the IMF by name, McKinley argues: “The new 'politically correct' justification for minimizing inflation is that it hurts the poor. However, this misreads the facts: very high, destabilizing inflation (above 40 per cent) definitely hurts the poor; and very low inflation (below 5 per cent) can also harm their interests when it impedes growth and employment.”
Rick Rowden points out that Latin American countries and “East Asian tigers” like South Korea grew rapidly despite inflation rates of around 20%. But that was before the IMF moved into the development world in the 1980s, and re-wrote the rules - without any definitive evidence to support their claim that doing so was advantageous to the poor.
The IMF appears to be caught in a classic case of “fighting the last battle.” When the IMF started lending to developing countries in the early 1980s, they were afflicted with astronomical, runaway inflation. It still apparently believes that hyperinflation is the most dangerous threat. But hyperinflation has been eliminated almost everywhere (apart from crisis or pariah countries like Zimbabwe); indeed most developing countries now have inflation rates well below 10%, and many below 5%. This is largely as a result of the IMF's hyper-vigilance over the last 25 years. The problem today is not hyperinflation, but IMF-induced stagnation.
More and more economists - outside the IMF - are taking a more complex view of growth and inflation. Rather than insisting that a country have a demonstrated “absorptive capacity” before increasing the flow of revenues, they look at the likely impact of increased flows. In the case of increased spending on health care, not only is employment created (if wage ceilings are set aside), but the population's overall economic capacity improves, and private-sector activity, rather than being discouraged by public funds, is spurred by the increasing availability of resources.
Muchiri, in Kenya's Health Ministry, concurs with McKinley's positions on inflation targeting, and with the view that public spending, especially on healthcare, will encourage growth. He acknowledges that his government has committed to a low inflation target - its “Letter of Intent” to the IMF states: “The monetary program for 2004/05 is designed to reduce underlying inflation to 3.5 percent.” And thus far Kenya seems to be meeting that goal.
But, says Muchiri: “3.5 percent is too low for an economy that is supposed to grow by 5 percent. A certain level of inflation is healthy - you can't grow otherwise.” This recognition moves Muchiri to criticize officials of a nearby country who have told him they must limit expenditures on health care - even refusing funds from the GFTAM - in order to prevent any risk of inflation rising. That line of thinking is clearly reflected in the recent statements by Kibunguchy and Ngilu.
But Finance Ministers who have committed to the IMF's inflation targets, and in many cases made those targets the centerpiece of their macroeconomic policy, are deeply reluctant to do anything that might raise that rate. Not only would doing so risk IMF disapproval and blacklisting, but it would also be seen as reversing a position they have publicly, and politically, committed to. Until this logjam is broken, a higher quality of life - even life itself - will continue to elude many thousands.
Muchiri counts as a significant victory the recent concession made by the IMF, after substantial negotiations, that Kenya could hire more health professionals if it could find donors willing to provide extra funds who themselves were comfortable with the impacts - economic and otherwise - that hiring additional health staff might have. It is this concession that recently allowed Kenya to announce that it will use funds from the Clinton Foundation, PEPFAR, and the GFATM to hire upwards of two thousand new nurses and other health professionals. Unlike with previous pledges, advertisements for the positions are now appearing in newspapers.
But the very existence of these policies, and the fact that he must invest so much in winning exceptions to them, cause Muchiri to reflect on his experiences of watching mothers and children die in hospitals for lack of surgeons or a lack of capacity to offer preventive care, and speculate that the IMF and World Bank could reasonably be charged with genocide. “The only difference from what happened in Rwanda is they don't use pangas [machetes]. They use policies.”
Reproduced with permission from the author from Pambazuka news 1 June 2006. http://www.pambazuka.org/en/category/features/34800
2. Latest Equinet Updates
The work presented in this policy brief was prompted by a request from the Zambian parliamentary committee on Health, Community Welfare and Social Development. The parliamentarians had wanted to know why despite all the funding to the health sector, there were no ‘visible’ gains to speak of from the on-going health reforms.
Human resources for health have become a topical issue at local, regional and global levels. In Namibia health worker mobility remains a concern for those in human resources planning. Achieving equity in this area needs a concerted effort from all sectors involved. However little is understood about the role that conditions of service play in influencing health professional mobility in Namibia. The study set out to explore and describe the influence of conditions of service on the movement and retention of the health professionals in Namibia. It is a qualitative study targeting mainly professional nurses, doctors, social workers and health inspectors at both operational and managerial levels, in public and private sectors.
his study explored the possibility of joint health worker and community activism at a primary care level in South Africa, and the human resource requirements needed for the effective treatment and care of HIV/AIDS within the public health service. The study used participatory approaches and involved five SAMWU shop stewards in the design, data collection and analysis of the research. The study was implemented between October and November 2005 in five primary health care (PHC) clinics in the Western Cape, Free State and KwaZulu Natal. Twenty-four health workers (fifteen of which were interviewed in depth) and eighteen health committee members were interviewed across the five different sites using a semi-structured interview guide.
3. Equity in Health
This year’s World Health Assembly began and closed rather dramatically. This article describes the highlights of the meeting and the decisions made on various health issues which include the selection of the next WHO Director General, a global strategy on IPRs and health research, the medical brain drain and the prevention of STIs.
This review article, published by the World Health Organization, assesses the impact of four key health care reforms – decentralisation, financing, privatisation and priority setting – on gender equity in health. It reports that, in many low income countries, rapid decentralisation has led to difficulties in providing affordable, accessible and equitable health services, and may also inadvertently support a more conservative reproductive health agenda. Other findings include that: taxes and social insurance schemes provide the most equitable basis for health care financing; privatisation may worsen gender equity; and some priority setting methods incorporate gender biases, and so underestimate the burden of disease on women.
This is a report from the Water Supply and Sanitation Collaborative Council and the Water Engineering and Development Centre. According to the report it is crucial to put women at the centre of water supply, sanitation and hygiene activities. Taking women's needs and preferences into account has resulted in a decrease in drop-out rates from school of young women, reductions in child mortality and maternal morbidity, and improved health for women and girls.
4. Values, Policies and Rights
he United Nations Population Fund (UNFPA) and other organisations working to achieve the goal of universal access to reproductive health have to negotiate highly sensitive and embedded beliefs and practices. In certain contexts challenging female genital cutting, child marriage and instituting gender equity, access to contraception, sexual and reproductive health and information are highly contentious issues. Rather than perceiving cultural perspectives to constrain positive social change, UNFPA’s Culture Matters approach illustrates how development actors might work sensitively with the dynamics of culture to enhance the achievement of development objectives and human rights within a variety of social, cultural and spiritual settings.
This key issues guide reviews current policy issues relating to sexual and reproductive health and rights (SRHR), examining questions of definition and exploring key debates. The guide also highlights current and future challenges for attaining greater levels of sexual and reproductive well-being, and considers the role of innovative technologies and approaches in achieving sexual and reproductive health and rights for all.
All over the world, young people are stigmatised and discriminated against in relation to their sexual and reproductive health. Stigma, discrimination and the violation of human rights are intimately connected, reinforcing and
legitimising each other. Their manifestations are varied, occurring in families and communities, in health services, at places of work, and in schools.
5. Health equity in economic and trade policies
There is a silent, ongoing, global war between motor cars and people. It is silent because, though it kills many times more people than armed conflicts and terrorist acts combined, it seldom hits the headlines in the way they do. It is global because, though it started in the rich world just over a century ago, it has spread throughout the world and is now spreading like wildfire through poor countries;or poor communities within rich countries.
At the December 2005 Hong Kong ministerial meeting, developed countries forced through a controversial set of services demands thay prepared the ground for a final push to expand the GATS. This new paper analyses benchmarks, plurilateral request-offer, domestic regulation and other pressure tactics so that non-governmental organizations, elected representatives, developing countries and ordinary citizens can intervene to counter them.
A long-standing fight by several developing countries to amend the WTO's TRIPS Agreement to oblige members to get patent applicants to disclose the source of origin of biological resources and associated traditional knowledge took a step forward in early June when six countries proposed the text of new provisions to be added to the TRIPS Agreement. The paper takes forward in a text for amending the TRIPS agreement what several developing countries had for several years been arguing for in various fora within the WTO (as well as outside the WTO (for example, in the Convention on Biological Diversity and the World Intellectual Property Organisation).
Over the past two years, discussions on a World Intellectual Property Organization (WIPO) Development Agenda have provided a forum for Member States to challenge the current trends in intellectual property (IP) policy-making and work towards a system that is more consistent with development commitments and needs. The second session of the Provisional Committee on Proposals for a WIPO Development Agenda (PCDA), from 26 to 30 June 2006, will provide an opportunity for Member States to consider proposals in clusters of issues2 and submit a decision for a WIPO Development Agenda to the WIPO General Assembly in September 2006 that will dictate the future of these discussions.
A consultation held on 6 June at the WTO on the relationship between the TRIPS Agreement and the Convention on Biological Diversity (CBD) ended with positions among members remaining unchanged on the issue of disclosure of the source of origin of biological resources and associated traditional knowledge. A paper was presented by Brazil, India, Pakistan, Peru, Thailand and Tanzania (joined by China and Cuba). But the US, Australia and others said that negotiation based on any text is premature, as there were differences in views.
The July 2005 G8 summit in Gleneagles delivered promises on debt, aid, trade, security and climate change. This report examines progress one year later. Debt cancellation has resulted in extra spending on health and education in poor countries, but is not reaching enough of the world's poor. Aid figures show huge increases but include large debt write-offs for Iraq and Nigeria. Oxfam is concerned that the growth in aid in key G8 nations is not enough to meet the promises made at Gleneagles.
After a negotiating process that lasted many days and that was closely watched by dozens of health and development NGOs, the World Health Assembly adopted a resolution on 27 May that established a working group to come up with a global strategy on intellectual property, health research and development, and new medicines for diseases that especially affect developing countries. The resolution was seen by many as the biggest achievement of this year's WHA, and was hailed by many public interest groups that had supported the developing countries, led by Kenya and Brazil, that had first advocated the resolution.
The World Health Assembly adopted a resolution that urges member states to improve coordination at the national level between international trade and public health, requesting the World Health Organization (WHO) to help its member states to do this. The resolution calls for governments to promote a better dialogue on trade and health, and gives health ministries a place at the table with other government agencies involved in trade issues, establishing mechanisms to enable this.
6. Poverty and health
In September 2000, world leaders gathered at the United Nations for the Millennium Assembly promised to halve extreme hunger and poverty, halt the spread of HIV/AIDS and provide universal primary education, all by 2015. The series of targets, known as the Millennium Development Goals (MDGs), also include promoting gender equality, reducing child and maternal mortality, ensuring environmental sustainability and building a global partnership for development. Salil Shetty spoke to IPS about the current status of the MDGs.
A number of studies have looked at who benefits from public sector funding of health services. Different conclusions are drawn about the best way to reach the very poor, depending on the health system in question, the broader social, economic and political context, and the conceptual and ideological approaches underpinning the studies. A key area of debate concerns the respective benefits of non-targeted strategies, such as provision of universal free health care services, versus specific, targeted strategies for reaching the very poor.
A year after the G8 agreements were reached, the question remains: Has anything changed? What has been done thus far? What action has been taken to implement change and how? What do these plans hold for Africa? Will they alleviate the developmental pressures that the African governments and the African people face? Or will they simply diversify the already-apparent symptoms of poverty? This conference proposed to investigate the complex issues surrounding poverty, debt relief, healthcare, and other related matters in Africa in a cross-disciplinary setting.
The World Health Assembly concluded its annual session at the end of May with the adoption of a resolution that could change the concept of drug research and development, and open the door to a system that gives the world's poor greater access to medicines. The resolution approved by the Assembly, the supreme decision-making body of the World Health Organisation (WHO), urges the 192 member states to make the manufacturing of pharmaceuticals a strategic sector, thus committing themselves to making the research and development of medicines consistent with public interest needs a priority.
7. Equitable health services
Antenatal care (ANC) is a widely used strategy to improve the health of pregnant women and to encourage skilled care during childbirth. In 2002, the Ministry of Health of the United Republic of Tanzania developed a national adaptation plan based on the new model of the World Health Organisation (WHO). In this study we assess the time health workers currently spent on providing ANC services and compare it to the requirements anticipated for the new ANC model in order to identify the implications of Focused ANC on health care providers workload.
Attempts to date to promote the sexual health of young people have tended to focus on prevention, education and counselling for those who are not yet sexually active, while the provision of health services to those who have already engaged in unprotected sexual activity and faced the consequences, including pregnancy, STIs or sexual violence, has lagged behind. This document presents a review of the literature documenting existing experience with the provision of services for sexually transmitted infections (STIs) to adolescents.
8. Human Resources
Malawi’s health service is struggling under the burden of HIV and AIDS and tuberculosis (TB). Its health workforce has only limited capacity to cope due to severe staff shortages, poor salaries and working conditions, high levels of HIV and AIDS-related deaths and chronic absenteeism due to illness among staff. Without a strong health workforce, community members may have an important role to play in providing HIV and TB care. Médecins Sans Frontières describes an example of community involvement in district level HIV and TB care. The study focuses on Thyolo district, a rural region of southern Malawi with 458,976 inhabitants, of which an estimated 41,000 are living with HIV. It covers a two-year period from January 2003 to December 2004.
Medical professionals working in the public sector often supplement their salaries through second jobs in the private sector. Their dual job activities have both positive and negative implications for the public health sector. What policy options exist for regulating dual job holding and what is their likely effect?
The paper reports on a survey of recently arrived international nurses working in London, to assess their demographic profile, motivations, experiences and career plans. The Philippines, Nigeria and South Africa were the three most commonly reported countries of training (in total, more than 30 countries of training were reported). Sixty per cent of the nurses from sub-Saharan Africa and more than 40% from South Africa and India/Pakistan/Mauritius were aged 40 or older; the youngest age profile was reported by the Australia/New Zealand/USA nurses.
The lack of Human Resources for Health (HRH) is increasingly being recognised as a major bottleneck for scaling-up anti-retroviral treatment (ART), particularly in sub-Saharan Africa whose societies and health systems are hardest hit by HIV/AIDS. This country case study of Swaziland describes the current HRH situation in the public sector and identifies major factors that contribute to the crisis, describe policy initiatives to tackle it and base on these a number of projections for the future. It also suggests some areas for further research that may contribute to tackling the HRH crisis in Swaziland.
This article describes how the association between the presence or absence of health personnel and the health status of a population tends to be seen as simplistic, and proceeds to address a range of other factors. The Briefing examines the case for a two-tiered health training system, one for global markets and the other for local markets. It also examines options for outsourcing healthcare to regional centres in poorer countries as a way to assist with retention and return.
A new global partnership that aims to improve the world's shortage of doctors, nurses, midwives, and other health workers was launched at last week's World Health Assembly in Geneva. The announcement came six weeks after the World Health Organization made the issue a priority in its annual report, in which it called for a global action plan to tackle the shortage of an estimated 4.2 million health workers.
9. Public-Private Mix
Business is being urged to use its resources and expertise in partnership with the public sector to improve sub-Saharan Africa’s weak healthcare systems in a White Paper, From Funding to Action: Strengthening Healthcare Systems in Sub-Saharan Africa, launched today by the Global Health Initiative at the World Economic Forum on Africa in Cape Town.
Public services are being liberalized world wide, opened to foreign service providers, often turned into private services through privatization, commercialization, marketization, and deregulation. Yet the privatization of public services means that many, many people can no longer benefit from such services because they cannot pay, or because they do not belong to the social class for whom the private services are intended. The document discusses how little is known about the changes taking place in services long-considered to be a public "right", or about the widening social disparities that result from liberalization.
10. Resource allocation and health financing
Charging patients for basic health care hits the poorest members of society the hardest. Many fall into debt or simply do not seek care from public health services. The Commission for Africa has called for basic health care to be free for everyone. How would this impact on already under resourced health services?
Nets treated with insecticide have proved to be an effective method of reducing malaria. Before increasing the scale of this intervention, however, policymakers need to be fully informed of the costs involved and the effect that the scaling-up will have. Cost-effectiveness has been measured in trials, but what does the intervention cost in practice?
The appearance and rapid spread of resistance to anti-malarial drugs has created a crisis for effective treatment in Africa. Consensus is growing that the only realistic treatment option will be a move away from treatment with one drug (monotherapy) to the more expensive combination therapies, particularly artemisinin-based combinations. However, a potential obstacle to the introduction of this new type of treatment is that it costs up to ten times more than monotherapy. There is concern that if poor patients’ families have to bear the cost of the drug combinations, they might delay treatment or avoid it altogether.
In the first ever project of its kind, the World Economic Forum’s Global Health Initiative has brought together a range of stakeholders to identify how business could partner with the public sector to improve healthcare systems in Sub-Saharan Africa. The resulting White Paper for consultation collects the views of diverse stakeholders on the barriers to effective healthcare systems in the region, and identifies opportunities for business to use its knowledge and skills to help tackle the problems through new public private partnerships. If turned into action some of the strategic interventions identified in this paper could contribute to improving access to health for millions of Africans.
This paper attempts to lay the basis for a gendered analysis of the scope, coverage and impact of the main components of social assistance in South Africa. This gendered approach draws attention to the serious gaps in knowledge about the scope of the social assistance system and its socio economic effects. More work is needed on the welfare system as a provider of employment, on the effects of the balance of public-versus private sector provision on gendered patterns on employment, on the dynamics of the care economy, and on the interaction between these.
An emerging consensus on solutions, combined with fresh scrutiny and a windfall of new financing, are prompting major donors to revamp years of failed efforts to stem malaria's mortal toll. The growing support from the Bill and Melinda Gates Foundation, enriched this week by a $31 billion gift from Warren E. Buffett, will provide still more impetus for change. US A.I.D. is reported to be shifting its focus from mainly backing the sale of subsidized mosquito nets in Africa to giving more of them away to poor people; to providing combination drugs given the growth of resistance to older, cheaper medicines and to supporting large-scale programs to spray insecticides, including DDT.
11. Equity and HIV/AIDS
In early June 2006, United Nations members are meeting in a follow-up to the successful UN special session in 2001, which pushed the world to take AIDS more seriously.The nations now are supposed to be reporting on whether their targets are being met, and devising a plan of action for the next few years. Instead, they are watering down the original plan.
African civil society organisations have denounced a political declaration adopted today by world leaders attending a United Nations AIDS meeting in New York. At the High Level Review Meeting of the UN General Assembly, which closed on 2 June 2006, member-states negotiated a political declaration, which African activists have described as 'utterly retrogressive' and 'a sham.
Three weeks after the African Union - the highest decision-making regional authority in Africa - endorsed a Common Position on HIV and AIDS, African delegates in New York are reneging on the strong commitments they made to providing access to services for HIV prevention, care and treatment to all those who need them in Africa.
The following is a statement by his excellency, Mr. Festus G. Mogae, President of the Republic of Botswana, at a panel discussion on "Breaking the cycle of HIV infection for sustainable AIDS responses". The statement was made at the United Nations General Assembly High Level Session on HIV/AIDS in New York.
At the recent UN meeting on AIDS, international organisations were disappointed that the declaration adopted by governments was weak on commitments to fight the disease, and that vulnerable groups have been left out in the document. The article outlines some of the concerns expressed by the participants.
This report examines the administrative, technical, managerial guidance and strategic leadership that WHO provided during the initiative and includes evaluations of three levels of WHO: headquarters, regional offices and country offices. The report identifies future collaboration opportunities between WHO and partners and gives recommendations for the "way forward".
Some HIV-positive people in Kenya are selling their antiretroviral drugs to buy food. Some people register at more than one treatment site so they can obtain extra drugs, which they then sell, Patricia Asero, a member of the Kenya Treatment Access Movement, said. She added that some HIV-positive people who get their antiretroviral drugs from a single treatment site sometimes sell their medications to buy food. These trends have raised concerns about drug-resistant strains of the virus developing in Kenya.
From 22–24 February 2006 MPs from Ghana, Kenya, Malawi, Mozambique, Namibia, Zambia, Tanzania and Zimbabwe met in Johannesburg and deliberations at the meeting centred around three major themes related to parliamentary oversight of HIV and AIDS: the challenges and opportunities relating to the parliamentary structures and the environment within which MPs operate; the extra parliamentary partnerships that could strengthen parliamentary oversight of HIV and AIDS such as partnerships with civil society and the media; and the benefits of and practical suggestions for a network of African MPs at regional and Pan African level. These themes are discussed in this report.
International organisations working on AIDS gave their assessment of the worldwide response to the disease, which is increasingly afflicting women and girls. This happened in advance of a UN special session on AIDS that took place on May 31-June 2. Despite the failures so far, there were important lessons that could be learnt.
12. Governance and participation in health
A new document has been published by the name of "Bringing a Change: Communicating to Communities on Sensitive Themes like Sexuality and Domestic Violence". This document is based on an international workshop organised by AIFO/Italy in October 2005.
As the population of Africa rapidly urbanizes it may be possible to protect large populations from malaria by controlling aquatic stages of mosquitoes. This report presents a baseline evaluation of the ability of community members to detect mosquito larval habitats with minimal training and supervision in the first weeks of an operational urban malaria control program.
13. Monitoring equity and research policy
The World Health Organisation (WHO) has taken an important step to reform the global system for supporting medical research and development (R&D). The organisation’s governing body has just passed a new — hotly-debated — resolution to set up a new intergovernmental working group that will immediately start work to "draw up a global strategy and plan of action." This will include a new framework to support sustainable, needs-driven, essential R&D work on diseases that disproportionately affect developing countries.
The IRIS/USAID project on developing poverty assessment tools has collected data on the poverty status of 12 low-income countries, adapting measurement tools for country-specific use. This paper proposes a methodology to construct an international poverty tool, or set of tools, that are easily applicable to a range of political economies.
This paper provides a summary of the empirical and policy-related literature on the multifaceted relationships between gender inequalities and foreign direct investment (FDI). It reviews the research on the impact of FDI on investment, productivity, trade, employment, wages and working conditions.
The Commission on Health Research for Development concluded that “for the most vulnerable people, the benefits of research offer a potential for change that has gone largely untapped.” This project was designed to assess low and middle income country capacity and commitment for equity-oriented research.
Activist researcher Ravi Narayan, a member of the Foundation Council of the Global Forum, speaks of the necessity for all groups working towards people’s health, including researchers, to listen to each other. Hard evidence is essential for progress he says – especially evidience collected and analysed by researchers in least developed countries.
This paper examines an aspect of the problem of measuring inequality in health services. The measures that are commonly applied can be misleading because such measures obscure the difficulty in obtaining a complete ranking of distributions. The nature of the social welfare function underlying these measures is important. The overall object is to demonstrate that varying implications for the welfare of society result from inequality measures.
The World Mortality Report 2005 provides a broad overview of mortality changes in all countries of the world during the latter half of the 20th century. The main objective of this report is to compile and summarise available information about levels and trends of mortality and life expectancy for national populations; allowing a comparison of mortality data from different sources, and permitting an assessment of gaps in information, as well as insight on performance with respect to Millenium Development Goals.
Research on reproductive health in developing countries has produced a growing evidence base. But translating this evidence into appropriate health policy remains a slow process. What factors influence the use of evidence by clinicians and policymakers? And what enables or prevents them from putting research findings into practice?
14. Useful Resources
The AIDS Vaccine Advocacy Coalition (AVAC) has launched the AIDS Vaccine Clearinghouse, a comprehensive and interactive source of AIDS vaccine information on the internet. The website provides a gateway to information and a link to people and organizations interested in AIDS vaccine advocacy, research and global delivery.
Physicians for Human Rights has complete a Guide to Using the Global Fund to Fight AIDS, Tuberculosis and Malaria to Support Health System Strengthening in Round 6. Round 6 has great potential for advancing health system strengthening efforts in many countries, and we strongly encourage applicants to take advantage of this potential. It is especially useful for those involved in preparing Global Fund proposals, or who have the capacity to influence (or interest in influencing) these proposals.
This Compendium is to help you find HR tools appropriate for your work. The tools and resource documents included in the Compendium have been reviewed by two or more people with HR expertise and have selected based on usefulness and easy availability. Most of the tools are available free electronically.
15. Jobs and Announcements
A vacancy for a Health Economist has arisen for the expanding health economics and systems programme, based at the offices of AIHR in Johannesburg. This position will focus on a programme of work evaluating the impact of HIV/AIDS to private businesses in Southern Africa, including the costs and benefits of providing antiretroviral therapy (ART).
Strengthening health systems to improve public health results is finally on the agenda of many global and bilateral players. We would like feedback from developing country stakeholders from all sectors and regions of the world about whether your needs are being addressed by these initiatives and what are the gaps. Your input will help shape the future of the Health Systems Action Network (HSAN). The 30 people submitting the most relevant and constructive ideas will be invited to participate in a 2-day meeting in Toronto, August 18-19 (all expenses paid).
On the 10th anniversary of the Health Promoting Schools Conference, which was first held at UWC in 1996, the UWC Health Promoting Schools Project is to host a national Health Promoting Schools Conference at the University of the Western Cape. It will draw together academics and researchers from universities and research councils in South Africa; stakeholders from the Departments of Health, Education and Social Development; the Western Cape Reference Group for Health Promoting Schools; and relevant non governmental organizations. You are cordially invited to submit abstracts of papers and posters related to health promoting schools. Deadlines: for abstract submissions 28 June 2006, for early registration 12 July 2006.
The Southern Africa Trust, in partnership with the Mail & Guardian newspaper, announces the establishment of the DRIVERS OF CHANGE award. The DRIVERS OF CHANGE award has been established to hold up living examples of innovative practices, inclusive attitudes, and effective processes that build social trust and create the best conditions to make a real and lasting difference in the lives of people living in poverty. The closing date for entries is Friday 25 August 2006.
This fellowship programme is for female students in Sub-Saharan Africa or Least Developed Countries (LDCs) who wish to pursue postgraduate training leading to a doctorate degree at a centre of excellence in the South outside their own country. For 2006, the deadline for receipt of applications has been extended to 31 July 2006.
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