Fidel Castro, leader of the Cuban revolution, passed away on Friday 25 November. He was a towering figure and one of the defining leaders of the 20th century. Leaders across Latin America sent tribute. Chile's Michelle Bachelet called him a 'leader for dignity and social justice in Cuba and Latin America", while El Salvador's president, Salvador Sánchez Cerén, said “Fidel will live forever in the hearts of those of us who fight for justice, dignity and fraternity.” As China’s official news agency Xinhua noted, he was “a pioneer in battling ... neoliberal globalisation, foreign debt and exploitation of natural resources.” CLASCO in Argentina pointed to his role, together with the Cuban people, of pointing to an alternative of a world "without injustices, without exclusions, without exploitation" ("Fidel era un hombre, como tantos otros. Pero Fidel se transformó, y lo hizo junto a las luchas del inmenso pueblo cubano, en un horizonte, en una promesa, en un destino utópico: el de construir un mundo sin injusticias, sin exclusiones, sin explotación; un mundo emancipado, liberado, solidario").
The transformation in Cuba was profound. Manuel Garcia Jr reflected the day after Fidel's death on the transformation he experienced first hand in 1959 Havana: "Every person, every place, every moment exuded the same sense of uplift. I was immersed in a national sense of freedom, and it soaked into my psyche and bones. This experience permanently magnetized my political compass, so that regardless of verbal arguments and logical constructs in later years, my compass always points my sympathies toward freedom for any people". The nearly 60 years since of struggle in Cuba, a small island of 11 million people, often battling powerful global forces, unquestionably generated some contradictions. Ahmed Kathrada in the Mail and Guardian notes that "history will always judge people differently based on who is writing it".
He also notes, however, together with many other voices from Africa, that Fidel Castro came from "a generation of leaders, who envisioned a more equitable society, based on mutual cooperation, especially between developing nations" and that he was one of the foremost supporters of Africa's liberation movements and anti-colonial struggles. The internationalism of Cuban people in Africa has been sustained to today: whether in the support by Cuban troops of Angola's resistance to an apartheid military attack in the 1970s, whether through providing medical education in Cuba for thousands of African doctors over many years, or sending many Cuban doctors to African countries, including the many who came to West Africa to help in the efforts to control Ebola in 2014/5. At the same time, Castro also pointed to the rift between rich and poor in African countries, as he did at the speech to the South African parliament in 1998.
Whatever the context and debates, Fidel was an unwavering champion of health justice, of the right to health and of progress in social determinants like literacy and food security. He was a driving force of a universal health care system in Cuba that is a responsible for making Cubans some of the healthiest people in the world. As the journal MEDICC noted in a tribute the day after his death: "Over the years, President Castro took an abiding interest in health and was at the forefront of promoting advances in health care, research and medical education: establishing rural hospitals and a national network of hundreds of community-based clinics, making prevention a cornerstone of training and service; generating extraordinary investments in biotechnology to develop novel vaccines and cancer therapies, and specialized services for Cuban newborns with heart disease. Finally, he considered the most significant “revolution within the revolution” to be the creation in the 1980s of the family doctor-and-nurse program, posting their offices on every block and farmland in Cuba. The outcomes of these efforts were not achieved by one man, but by 500,000 Cuban health workers, who were able to count on health as a government priority. Together, they faced dengue and neuropathy epidemics; and the scarcity of medicines, including for HIV-AIDS patients, after the collapse of the socialist bloc and tightening of the US embargo on Cuba in the 1990s. Their dedication has won a healthier nation".
It falls to us to continue the struggle for health justice with the same compass, solidarity and tenacity.
Editorial
Mark your calendars. On December 1, the globe will celebrate World AIDS Day. The theme, as it has been for the last two years, is "Stop AIDS: Keep the Promise." This is to serve as a reminder to the world community of its promise to among other things provide universal access to treatment, reduce prevalence rates, and implement effective prevention programs. As the prevalence rate of those living with HIV continues to climb in most countries in southern Africa, it is clear that we are far from fulfilling this promise by 2010, the campaign’s target year.
Almost a third of those living with HIV live in southern Africa. Despite the infusion of funding and the attention of national governments and international bodies, the prevalence rate in the region (surprisingly, apart from Zimbabwe) is continuing to rise. In Botswana, Swaziland, and Lesotho over one-fifth of the population is infected with HIV. The high prevalence rate fails to be matched by adequate access to treatment. Access to anti-retroviral therapy in sub-Saharan Africa has increased in the last year but remains at a miserable 28%.
As anyone living in southern Africa knows, the tentacles of the virus reach across all sectors of the community, but they tend to prey more on those who are the most removed from access to and the protection of the law—among them, women, children, prisoners, and those living in poverty.
Despite this or maybe because of this, the law remains an underused weapon in the fight against the effects of HIV and AIDS in the southern Africa region. Apart from South Africa—where the galvanizing work of the Treatment Action Campaign, AIDS Law Project, and others supported by a robust Constitution and judiciary has resulted in significant legal successes—there have been few cases brought on behalf of those infected and affected by HIVand AIDS in the region. In Namibia, the AIDS Law Unit of the Legal Assistance Centre successfully brought a case challenging the Namibian military’s denial of employment to an HIV positive individual who was otherwise physically fit.
In Botswana, the courts have issued decisions on a handful of cases involving the privacy rights of HIV positive individuals. In the rest of the countries in the region, courts have yet to issue a single significant legal decision on an HIVand AIDS related case.
In recognition of the underutilization of the law and litigation in southern Africa, the Southern Africa Litigation Centre established a new HIV and AIDS programme focusing on providing resources, support, and training to lawyers and advocates in the region to bring cases supporting the rights of those infected and affected by HIV/AIDS in national and regional courts. The programme does not intend to duplicate the groundbreaking work already being done by local, national, and regional organizations on these issues, but will aim to bolster the work of local and other regional actors to increase the use of the law and litigation to advocate for the rights of those living with HIV, and those rendered vulnerable by the pandemic.
Accessing the law through litigation can be a powerful tool for changing policy and social attitudes. Litigation can also provide a public platform on which the voices of those generally silenced can not only be heard but magnified. In South Africa, the role of lawyers and litigation in exposing the hypocrisy of the apartheid state and ultimately contributing to its demise is undeniable. More recently, a Constitutional Court decision, Minister of Health and others v Treatment Action Campaign and others, requiring the South African government to make nevirapine, a drug known to significantly reduce the likelihood of mother-to-child transmission of HIV, available in all public hospitals and clinics resulted in the drastic reduction of mother-to-child transmission.
This is not to say that the law and courts alone can stem the devastating impact of HIV and AIDS, or that litigation is the appropriate strategy all of the time. The use of the law must be pursued in tandem with other advocacy tools, including public education and campaigning. In addition, legal victories have little meaning without the close involvement of local community-based organizations, and networks of people living with HIV, who can ensure the translation of a successful court decision into concrete change in the reality of people’s lives.
I am not naïve. I do not think the use of courts and the law will miraculously change the progression of the pandemic. But if we are to have any chance of turning the tide we need to use all of the tools available to us in fighting this epidemic.
Priti Patel is Project Lawyer for the Southern Africa Litigation Centre’s (SALC) new HIV/Aids Litigation Programme; she can be contacted via the SALC website at http://www.southernafricalitigationcentre.org/salc/. Visit the EQUINET website www.equinetafrica.org for further information on rights as a tool for equity and health systems responses to HIV and AIDS. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org.
The word “crisis” is becoming more common than water. Multiple crises are converging- economic, climate, energy, food and social. After a long period of speculative financial boom, media in the wealthy countries of North America and Europe are filled with apocalyptic stories of financial crisis, unnerving the people in these countries, who still collectively hold almost 90% of total world wealth. For the half of the world’s adult population who own barely 1% of global wealth, however, the crisis has been going on for decades.
The chronic crisis for this significant majority of the world’s people has been evident in more than a generation of unemployment, landlessness, loss of assets, and deprivation, that has further grown during the financial booms of the last decades. During a period characterised as “economic success” in the highest income countries, malnutrition and food insecurity grew in the poorest countries in Africa, falling international prices reduced returns on production and a food supply chain increasingly controlled by a few transnational corporations was able to further drive down producer prices, especially threatening women smallholder food producers. What was a boom for the import/ export firms, shipping companies, large-scale farm enterprises, financiers and officials who tapped into these commercial and financial circuits, was a deepening economic and social crisis for women and children.
In 2008 attention began to be paid to this food crisis. Like the financial crisis, the food crisis has been growing over decades of aggressive agribusiness. The scale and cost of this liberalized and speculative food production system is now, however, outstripping the possibilities of the usual emergency relief response. The alarming increase in child malnutrition in east and southern Africa post 1990 signals the failure of this model of agriculture for the populations of the region, even while it offered growing profits for largely foreign owned agribusiness.
Repeated outbreaks of disease also signal that people, usually in poor communities, are bearing the brunt of failed policies. Cholera is an avoidable disease that is prevented through safe water and sanitation systems. Zimbabwe has experienced a growing cholera crisis since August. By the first of December the United Nations reported 11,735 confirmed cases of cholera and 484 deaths in Zimbabwe. With the decline in functioning of clean water supplies, people’s mobility and a breakdown of the health sector’s capacity to contain the disease, the cases and fatalities continue to rise. Notwithstanding the economic decline in the country, Zimbabwe has the national wealth to secure basic water supplies and health care. The Zimbabwe Doctors for Human Rights correctly call the failure to do so a violation of human rights.
The globalization of media brings these crises to public attention with increasing speed. But does increasing awareness of such crises bring change?
While change often emerges from crisis, the last three decades suggest that this is not inevitable, particularly if the response fails to challenge the causes of the crisis.
The current financial crisis is possibly the deepest in recent history, but not the first. When the long boom of post-war economic growth ground to a halt in the 1970s, the response to financial decline was an aggressive pursuit of market policies, liberalisation and the opening of countries to transnational corporations. In the 1980s, after a spree of private bank lending, when heavily indebted countries were unable to pay back loans, the International Monetary Fund stepped into the financial crisis to bail out the Northern banks by offering loans to the indebted countries, restructuring their economies towards even greater liberalisation and market reform. These responses have generally served to protect existing wealth and the liberalised and speculative models of economic development that have both deepened inequality and that have been associated with the current crisis.
The response to the current financial crisis has starkly demonstrated the choices made over what merits protection. We have for some time known from United Nations data that saving several million lives annually by bringing safe water and sanitation to all would cost $10 billion a year. This money has never been found. Yet in October 2008, in one week, the US government provided a bail out package to the banks of $250 billion, 25 times this amount.
We are also seeing signs in the response of an efficient global machinery shifting the burdens of the financial and food crisis to the most vulnerable. According to the international non government organisation, GRAIN, players in the finance market - investment, equity and other funds – are turning to land as a strategic investment asset and haven for investment funds, even while the food and fuel crisis are driving acquisition of land for wealthy populations food and fuel needs. The organisation’s website lists over 20 such large investments in African countries alone, and notes an escalating trend. This month the South Korean firm Daewoo unveiled plans to lease one million acres of land (a land area the size of Belgium) in Madagascar, to meet Korean food needs. While loss of faith in markets may be triggering business to seek these deals, and deepening financial insecurity may trigger governments in Africa to make such deals, local farmers and communities are least consulted, and from the evidence of trends to date, are most likely to lose control over land, food and economic security.
So while powerful interests are oddly comfortable today talking about financial, energy, food, climate and other crises, there is silence on the crisis of injustice.
The increasing control of the world’s wealth by a diminishing number of players in the face of wide deprivation of the majority of people is a crisis of injustice. The pursuit of private wealth through appropriating collective natural, social and economic resources in a manner that undermines long term survival is a crisis of injustice. The failure of governments, nationally and globally, to meet basic human rights and needs when the resources are there is a crisis of injustice.
The quest for justice thus becomes a focus of ordinary people’s responses. There are many examples of this. In Zimbabwe this week, the Chitungwisa Residents and Rate Payers Association filed a lawsuit this month against the Zimbabwe National Water Authority for the lack of safe drinking water. While overshadowed by the scale of and necessary emergency responses to the cholera crisis, this action is nevertheless one by affected residents to call to account those in authority for how decisions are being made, how resources are being used and for whom power is being exercised. In this newsletter there is similar report of health activists calling leaders of high income countries to account: “For the developed country governments now to use their dominant position in our current system of global economic governance to deal with their own (largely self-inflicted) problems, while ignoring the much greater and longer-standing grievances of the developing world and the profound and urgent global challenges of ill-health, poverty and climate change, would be a betrayal”. As the legitimacy of current policies and institutions are being fundamentally challenged by the multiplicity of crises, more people are beginning to call it what it is- a crisis of injustice.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org.
In a landmark moment on May 21 2010, the World Health Assembly adopted the Code of Practice on the International Recruitment of Health Personnel. It marks the culmination of a decade of advocacy on the recruitment and flow of skilled health workers, particularly from Africa to high income countries. In 2001 Southern African Development Community (SADC) health ministers called recruiting health workers from their understaffed, overburdened health systems ‘looting’ and observed that the outmigration of skilled people ‘further entrenches inequitable wealth and resources’. In 2009, despite having 25% of the global disease burden and 60% of people living with HIV, Africa had only 1% of global health spending and only 2% of the global health work force. It is clearly inequitable to lose health workers from low income countries with high health need to the richest countries in the world with significantly lower disease burdens.
Migration is not the sole factor leading to understaffing. In 2000, WHO estimated that African-born doctors and nurses working in high income OECD countries represented no more than 12% of the total shortage in the region. Inadequate production, limits to health worker training, employment and conditions imposed by resource shortages and fiscal thresholds, the disincentive of falling real wages in the health sector and other factors have been cited for shortfalls. Neither are the drivers for migration solely due to pull factors from high income countries. Economic, political, social and health system conditions in Africa are significant push factors driving migration.
In 2004, motivated by African countries, the World Health Assembly (WHA) requested the Director-General to develop a code of practice on the international recruitment of health personnel and to give consideration to the establishment of mechanisms to mitigate the adverse impact on developing countries of migration. Notably African countries sought to address both ethical recruitment and compensation for the losses they were experiencing through migration, including lost public investments in training, weakened capacities in health systems, loss of expertise and social disruption. Estimates set this at $60 000 in training costs alone for each doctor. In 2001 WHO estimated that South Africa lost US$37 million annually in direct financial losses in training costs, against OECD report of a combined (multilateral and bilateral) total education assistance received by the country in 2000 of US$35.5 million. Further, having experienced continued and rising outflows and foreign employment of health workers even in the face of codes such as the 2001/4 UK Code of Practice, African countries were concerned about how to ensure compliance with any instrument for managing recruitment. Within the SADC region, more binding measures were being used, such as the 2006 South African policy on recruitment and employment of foreign health professionals, which forbade individual applications from identified developing countries, in particular from SADC countries.
After six years of advocacy and work on the issue, the 2010 WHA adopted the global Code of Practice on the International Recruitment of Health Personnel. Its development has included multi-stakeholder consultation and review, including civil society through the Global Health Workforce Alliance, and the WHO regional forums. EQUINET was one of the more than 75 organisations making submissions on the draft. Country submissions on the draft submitted to the Assembly through the WHO Executive Board continued to reflect polarised positions on certain issues (see A63/INF.DOC/2 at http://apps.who.int/gb/e/e_wha63.html). The consensus outcome on the code was thus cause for specific recognition of role of the USA and African delegations in reaching agreement. The new Code of Practice is now the fourth WHO global legal instrument. The Framework Convention on Tobacco Control (FCTC) and the International Health Regulations are legally binding international treaties, while the Code of Practice on the International Recruitment of Health Personnel and the International Code of Marketing of Breast-Milk Substitutes are both voluntary instruments.
The new Code includes ten articles advising both source and destination countries on how to regulate the recruitment of health personnel, as a core component of national to global responses to health systems strengthening. The text makes clear that it is voluntary, and serves as a reference for countries in establishing or improving more binding national laws, policies, bilateral agreements and other international legal instruments on health worker recruitment. It links “properly managed” recruitment to health systems strengthening, especially in developing countries, and to safeguarding the rights of health workers, including their labour and social rights. It raises that countries should mitigate the negative effects and maximise the positive effects of migration on the health systems of the source countries, should plan workforces to reduce dependency on migration and should facilitate circular migration. It provides for gathering and sharing of data and information on international recruitment of health personnel.
Will it address the equity concerns that African countries have raised?
The commitment to developing countries, to health systems strengthening, to fair treatment of migrant workers and to ethical recruitment all signal that the code is a major step towards just outcomes.
Equity is less explicitly addressed within the code than in the debates that led to it. There is no reference to compensation. This was resisted by countries such as Canada, UK and Australia, who did not sign the earlier 2003 Commonwealth Code of Practice in part for its reference to this. Even reference to “mutuality of benefits” or “balancing” of gains and losses included in earlier drafts has been removed in the final draft. The code does make reference to the obligations of governments to protect population health and to equitable health systems. It recognises the “negative effects of health personnel migration on the health systems of developing countries” (Article 3.2), and the greater need of developing countries to health systems strengthening. In its remedies, while Article 5.1 seeks to ensure that both source and destination countries derive benefits from international migration, it does not include any reference to balancing or fairly distributing these benefits. Measures of technical assistance, training and other areas of support are thus included as means to “promote international co-ordination and co-operation on international recruitment of personnel” (Article 5.2), and not as measures of redress for negative effects of migration.
Perhaps this outcome reflects the balance of resources, political forces, power and formal evidence. The resource flows between source and receiving countries are neither simple to collect nor manage. The costs and returns accrue at different levels to individuals, households, communities, private and public sectors. Many of the flows and the measures to manage them lie outside the health sector, in economic, tax, immigration, employment, social security and other areas.
Nevertheless, these constraints and the goodwill around the code should not make it a smokescreen for the continuing research, innovation and dialogue needed to build on the code to further improve fairness and equity in managing these flows. The code has not limited itself to health sector measures, as some measures proposed such as “circular migration” will have implications for immigration, citizenship and labour market laws. Further, an explicit commitment to equity in Article 5.7 provides that “member states should consider adopting measures to address the geographical maldistribution of health workers” could be read to call for measures and resources at national, regional and international level. The code should thus be taken as a platform from which to further explore, develop and raise through its future review at WHA the options for measuring and fairly managing the resource flows between countries, including through tax and funding measures.
Taking the voluntary code to binding agreements and practice is the next front of action, as is monitoring and raising evidence to inform implementation for the next formal global review of the code at the 2012 WHA. Both areas raise challenges if countries in the region are to keep the push for equitable outcomes: to overcome information and evidence gaps, to inform and negotiate fair bilateral agreements, and to ensure that bilateral agreements reinforce and do not disrupt agreements that encourage skills production, circulation and retention within the region, such as the SADC protocols and strategies on education and training, on the movement of persons and on attracting and retaining health professionals.
Experience on prior codes suggests that civil society can play an important role in advancing implementation if effectively engaged. In particular, health workers, and especially female health workers, should not become commodified ‘objects’ to be traded in negotiations, but actively informed and involved through their associations.
Philemon Ngomu of the Southern African Network of Nurses and Midwives (SANNAM) reminds us, further, that the code is only one of a number of measures to address the conditions affecting recruitment and migration: “The very negative implications of political unrest and socio-economic crisis are major driving factors, and the code should not be taken in isolation of peace keeping and socio-economic and welfare initiatives. We cannot stop brain drain without addressing these issues”. When countries report back to the next United Nations General Assembly on the code, as feedback on Resolution 64/108 on Global Health and Foreign Policy, hopefully they will raise this, and make the point that the code is a significant milestone, but not a finishing line, in the path towards the fairer outcomes for health that African Health Ministers sought in 2001.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org. The next newsletter will provide the text of the code and all final resolutions from the World Health Assembly. Interim documents can be found at http://apps.who.int/gb/e/e_wha63.html
Following meetings of senior African education sector officials, experts and stakeholders on the eve of the Conference of Ministers of Education of the African Union (COMEDAF) in April in Abuja, Nigeria, the Africa Public Health Alliance and 15% plus Campaign called on African Education Ministers to prioritise the development of an African Multi-sectoral Human Resources Development Plan as a pre requisite to meeting Africa's development goals.
In a statement by the organisation, its coordinator Mr Rotimi Sankore stated that "While universal free, or affordable education is a development goal in its own right, the education sector also has a special role in developing the human resources that are a pre-requisite for meeting all of Africa's overall development goals"
Elaborating further he observed that in virtually every key sector of the economy and society, most African countries are operating at between 25 percent to 75 percent of the required human resources capacity, with the health sector particularly affected. Citing the conference host country Nigeria as an example, he noted that Nigeria has only about 25 percent of the doctors it needs, about 45 percent of nurses and midwives, and about 12 percent of pharmacists, a feature linked to poor performance in key areas such as maternal and child health.
With similar or worse gaps in various areas such as the engineering fields, it's no surprise that many African countries are lagging behind in overall human and social development.
Along side this is the crucial matter of overall poor investment in health, human and social development issues, with 33 African countries investing well below $40 per capita in health, compared to Cuba at $642 per capita, or Costa Rica at $413 per capita, both countries closer to African country development levels but with better health outcomes.
As the Africa Public Health Alliance 15% + Campaign we note that even if we suddenly had all the financial resources required for health services tomorrow morning, we would well find that most African countries do not have the human resources capacity to effectively absorb and utilise the financial investment.
No entrepreneur will ever purchase a hundred airplanes for an airline, and then employ only twenty five pilots and expect the other seventy five planes to fly. Yet this is the scenario in most African countries, where there is a strange expectation that we can meet the Millennium Development Goals and other development targets without the pre requisite human resources and infrastructure.
Considering that Africa's population is set to double from current one billion to two billion by 2050, it is imperative that Africa's education ministers work with other sectors of economy and society to prioritise in each country and at reqional level, the development of a Human Resources Development Plan that identifies what level of human resources are required for each sector, what is currently available, and what policy and investment is required to fill the gaps in the shortest possible time.
Public statement of the Africa Public Health Alliance 15% + Campaign 25 April 2012 at the Conference of African Ministers of Education Abuja 26/27 April 2012. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please contact media@africapublichealth.net.
Up to two-thirds of all Africans in east and southern Africa (ESA) live in rural areas, three-quarters of them living below the poverty line. Agriculture contributes 35% to the southern African regional GDP and 13% of total export earnings. In addition, about 70% of the population of the region depends on agriculture for food, income and employment. The recent widespread food crisis in the region that pushed more than sixteen million people into severe food shortage is further evidence that agriculture and food security still play a fundamental role in determining the development and health of the poorest in the region.
The Regional Network for Equity in Health in Southern Africa (EQUINET) recognising the importance of food security in health equity, commissioned a paper that explores equity concerns around food security and nutrition within the SADC and East Africa region, drawing information from available secondary data. The paper aims to analyse the current food security and nutrition situation in the region and the health and equity issues and policy concerns arising. EQUINET has commissioned this analysis of the determinants of the current situation, and the policy influences that enhance or undermine equity in food security and nutrition, to propose areas for policy and programme engagement and for research and debate by EQUINET.
This paper argues that there are at least five good reasons why food security and nutrition should be given high priority in actions to improve health equity and socio-economic development across the region:
1. Poverty, hunger and under-nutrition are getting worse in ESA, even though they are improving in almost every other region. This undermines the achievement of UN Millenium Development Goals in this region.
2. Instead of the potential virtuous cycle that could be created between improved nutrition and improved economic wellbeing, ESA is currently caught in a vicious cycle of worsening poverty, hunger and under-nutrition accentuating income and health inequalities and increasing vulnerability.
3. Proven effective interventions indicate that public policy can make a difference, that nutritional improvements can be effected, even under conditions of poverty, and that these can have positive impacts on economic wellbeing.
4. Implementing public policies that address food security provides an opportunity to deal with the demands of AIDS, the challenges of the competing signals from global trade to health and development and the challenges to equitable public policy in the current governance of the food supply system.
5. Confronting hunger and nutrition provides one further area where alternatives can be built that promote policy objectives of justice and equity. This calls for interventions that build a multi-disciplinary and integrated response to food security and nutrition, especially focused upon gender inequalities, community control over productive resources and fair trade - ie one that is shaped on food sovereignty.
This analysis suggests that equity in health will be difficult to achieve in this region unless there more explicit attention is paid to the underlying nutrition and food security determinants. These in turn are being shaped by larger forces such as trade rules, corporatisation of the food supply chain, HIV/AIDS, gender inequalities etc. However we can start to identify areas of common action that would strengthen equity in food security, nutrition and health outcomes.
At a minimum an equity programme should focus on:
- Building civil - state alliances around a programme of action that links a food sovereignty perspective with the equitable public policy that supports this.
- Promoting further assessment of the links between trade and health in the region to feed into advocacy for trade policies and agreements that strengthen public health.
- Supporting, informing and evaluating policies and initiatives that provide safety nets to those most affected by negative effects of trade and agricultural policies and of HIV and AIDS.
- Continuing to identify how gender inequalities exacerbate the impact of globalisation and HIV and AIDS on the poorest families and decrease the efficiency of policy responses and propose programme and policy responses for these problems.
* The full article is available at http://www.equinetafrica.org/bibl/equinetpub.php
* Please send comments to admin@equinetafrica.org
* Treatment Action Campaign (TAC)/AIDS Law Project (ALP) Memorandum on the United States/Southern African Customs Union Free Trade Agreement Negotiations. Prepared by: Jonathan Berger (Law and Treatment Access Unit, AIDS Law Project) and Njogu Morgan (International Desk, Treatment Action Campaign.
Introduction
On 4 November 2002, United States Trade Representative (USTR) Robert Zoellick formally notified US Congressional leaders of President Bush's intention to initiate negotiations for a free trade agreement (FTA) with the Southern African Customs Union (SACU), which includes Botswana, Lesotho, Namibia, South Africa and Swaziland. These negotiations are now underway, with the next round scheduled for 23 February 2004 in Namibia. As far as we are able to ascertain, the negotiators plan to conclude their discussions in or around October 2004, with a US-SACU FTA being signed before the end of the year.
The Treatment Action Campaign (TAC) and the AIDS Law Project (ALP) believe that trade between nations, when conducted within the framework of a reasonable and fair set of rules that adheres to the triple-bottom line of environmental, social and commercial sustainability has the potential to act as a tool for attaining developmental priorities. Our support for the ongoing negotiations would therefore be predicated on the agreement strictly adhering to these principles. Yet the US position, as clarified in Mr Zoellick's correspondence with Congress, raises cause for concern.
In his letters to the Speaker of the House of Representatives and the President of the Senate, Mr Zoellick set out reasons for entering into such negotiations, as well as the USTR's “specific objectives for negotiations with the SACU countries”. In particular, Mr Zoellick raises the following US objectives:
“We plan to use our negotiations with the SACU countries to address barriers in these countries to U.S. exports - including high tariffs on certain goods, overly restrictive licensing measures, inadequate protection of intellectual property rights, and restrictions the SACU governments impose that make it difficult for our services firms to do business in these markets. We also see the negotiations as an opportunity to advance U.S. objectives for the multilateral negotiations currently underway in the World Trade Organisation (WTO)." In our view, a number of the specific objectives identified have the potential to undermine the financing and provision of health care services in SACU countries, both in the public and private health sectors, as well as the rights of people living with HIV/AIDS. In particular, if translated in binding commitments, many of these objectives have the potential to limit the ability of the South African government in discharging its constitutional obligations, primarily in respect of the right of access to health care services. In our view, such undertakings would be an unconstitutional exercise of power.
This memorandum highlights our concerns in respect of two key areas: intellectual property (IP) and trade in services.
Intellectual property
With respect to intellectual property rights, the US government's specific objectives are as follows:
" - Seek to establish standards that reflect a standard of protection similar to that found in U.S. law and that build on the foundations established in the WTO Agreement on Trade-Related Aspects of Intellectual Property (TRIPs Agreement) and other international intellectual property agreements, such as the World Intellectual Property Organisation Copyright Treaty and Performances and Phonograms Treaty, and the Patent Cooperation Treaty.
“ - Establish commitments for SACU countries to strengthen significantly their domestic enforcement procedures, such as by ensuring that government agencies may initiate criminal proceedings on their own initiative and seize suspected pirated and counterfeit goods, equipment used to make or transmit these goods, and documentary evidence. Seek to strengthen measures in SACU countries that provide for compensation of right holders for infringements of intellectual property rights and to provide for criminal penalties under the laws of SACU countries that are sufficient to have a deterrent effect on piracy and counterfeiting.”
Quite clearly, the US sees the SACU negotiations as an opportunity to extract standards of intellectual property protection in excess of what the Agreement on Trade-Related Aspects of Intellectual Property (or TRIPS) currently requires. This is consistent with its approach to other regional and bilateral trade negotiations. A review of a range of such trade negotiations initiated by the US indicates that it has sought to extract greater concessions than those provided under existing international trade rules, largely to the detriment of developing countries.
To meet "standards of protection similar to that found in U.S. law", SACU nations would be required to adopt a range of TRIPS-plus provisions, including limiting compulsory licenses to national emergencies or to governmental, non-commercial use only. This is clearly in conflict with the Declaration on the TRIPS Agreement and Public Health adopted at the WTO Ministerial Conference at Doha in November 2001, which unambiguously states that "[e]ach Member has the right to grant compulsory licences and the freedom to determine the grounds upon which such licences are granted". Further, SACU members would be required to bar parallel trade, to extend patent monopolies for administrative delays, to link drug registration rights to patent status, to enhance protections for clinical trial testing data and to adopt criminal enforcement for patent violations, including improvidently granted compulsory licenses.
In short, the specific objectives in respect of IP would significantly undermine the ability of SACU member states' to make use of the regulatory flexibilities and public health safeguards identified in the Doha Declaration. If implemented, the negotiating objectives would severely limit access to essential medicines used in the prevention and treatment of a range of health conditions, including but not limited to HIV/AIDS. In addition, by seeking to impose TRIPS-plus provisions on SACU members, the USTR would be violating the principal negotiating objectives in the US Trade Act of 2002, which require "respect [for] the Declaration on the TRIPS Agreement and Public Health, adopted by the World Trade Organisation at the Fourth Ministerial Conference at Doha, Qatar on November 14, 2001", as well as Executive Order 13155, which deals specifically with access to "HIV/AIDS pharmaceuticals or medical technologies".
Trade in Services
With respect to trade in services, the US government's specific objectives include pursuing "disciplines to address discriminatory and other barriers to trade in the SACU countries' services markets." As mentioned above, the US plans to use the negotiations to address "overly restrictive licensing measures" and "restrictions the SACU governments impose that make it difficult for our services firms to do business in these markets."
If implemented, these negotiating objectives would render a range of legislative provisions in the South African Medical Schemes Act, for example, as unlawful. Such provisions increase access to health care services, by ensuring that unfair discrimination on the basis of health status is prohibited and by ensuring that medical scheme beneficiaries are guaranteed a minimum package of care, regardless of financial contribution.
It is not only trade in health care services that is of concern to TAC and the ALP. Similar arguments apply with equal effect, for example, to any regulatory steps taken by the state to ensure access to financial services for people living with HIV/AIDS. In our view, the state has a constitutional obligation to regulate the insurance services industry in such a manner, to ensure that people with HIV/AIDS have access to life cover and funeral benefits, as well as access to insurance services necessary for accessing financing for housing.
Conclusion
The ALP and TAC are concerned that the US/SACU FTA negotiations have the potential to result in binding commitments on SACU member states that undermine access to health care services, the rights of people living with HIV/AIDS and the ability of such states to comply with their domestic, regional and international human rights obligations. In our view, such an agreement would not only unlawfully conflict with certain national constitutions and human rights instruments, but would also serve to advance the interests of the US at the expense of the health and welfare of the people of Botswana, Lesotho, Namibia, South Africa and Swaziland.
* Please send comments for publications in the Letters section of Equinet News to editor@equinetafrica.org
Sally Theobald, Ireen Makwiza REACH Trust, Malawi; Erik Schouten, Ministry of Health, Malawi and Management Sciences for Health; Andrew Agabu, Andrina Mwansambo, National AIDS Commission, Malawi.
Why the move to universal access when we haven’t yet met the 3 by 5 target? What does universal access actually mean? Does this new focus on universal access offer an opportunity for advocacy for equity?
The focus on universal access has its roots in the Special Session of the UN General Assembly (UNGASS) declaration in 2001 and was further reinforced by discussion at the International AIDS Conference in Bangkok in 2004 and the G8 Summit in Gleneagles, Scotland, 2005. The onus is for countries to define – through consultative processes – what ‘universal’ access means rather than working to global targets and put together plans and processes to meet universal access. These country consultative processes should in theory feed into regional consultation processes. For southern and east Africa, these will be held in Zimbabwe from 7-10 March, 2006 and will, in turn, shape the Africa Wide consultation 4-6 May, 2006 and the Global Steering Committee.
While there are sceptics, this may be seen as an opportunity to raise the profile of equity concerns. EQUINET’s work on antiretroviral therapy (ART) in the context of health systems reported on the EQUINET website (www.equinetafrica.org) raises two overarching and inter-related equity challenges:
1. How can we address barriers to access to quality treatment and care – by gender, age, socio-economic status and geographical coverage?
2. How can we ensure that ART delivery strengthens rather than undermines the broader public health system?
Countries have been asked to consider main barriers to scaling up which will be fed to the Global Steering Committee for action. In Malawi, for example, initial barriers highlighted include:
* Constraints to ensuring adequate sustained financing, and therefore to planning ahead, for scaled up AIDS responses:
This calls for sustainable and responsive funding for the provision of ART and for the strengthening of public health systems. This is critical to ensure that we continue to be able to provide ART to those in need. The current Global Fund for AIDS TB and Malaria process of proposal writing for 5 year programmes and resubmitting after 2 years is problematic, as it can result in decision making delays and risks of interrupted supplies of ART, HIV test kits and other supplies.
* Too few trained human resources, and health and social systems constraints:
We need to build and sustain a healthy and motivated workforce to provide ART and to meet the broader health needs of our citizens. This means investing in training and developing supportive working environments to retain our workers and address the brain drain. However, despite our best efforts the numbers of professional cadres will not be adequate by 2010. We also need to think creatively about who constitutes ‘human resources for health’, and how to deliver services through building partnerships with lay health workers, NGOs, private sector providers and community based organisations. Such partnerships and decentralisation of health provision will enhance the access of poor women and men to HIV and AIDS Treatment and Care.
* Barriers to reliable access to commodities and low-cost technologies (e.g. condoms, injecting equipment, medicines and diagnostics):
There is need for use of TRIPs flexibilities, and for pharmaceutical companies to not only reduce the cost of drugs but also ensure long-term fair access to patient-friendly ART regimens for adults and children. Diagnosis and treatment of paediatric AIDS is made difficult due to the unavailability of simple and affordable technology for diagnosing HIV in children, and the lack of paediatric formula. The current first line regimen for adults is based on fixed dose combinations (FDCs) and with the advantage that patients only have to take 2 tablets a day. Scaling up programmes in resource poor environments relies heavily on these simplified regimens which ease the supply chain and instructions to patients on adherence. If the next generation of regimens is not available as FDCs (our current second line regimen consists of 7 tablets per day) the scale up of ART will be heavily compromised.
* Stigma and discrimination, inequity, gender discrimination and insufficient promotion of HIV-related human rights:
We need to be active in addressing stigma and ensuring that gender equity and rights based approaches underpin action. In Malawi we have a policy on equity and ART. The focus on universal access provides an opportunity to advocate to implement this and monitor progress.
These challenges to universal access resonate clearly with EQUINET’s equity focus and work. Make sure your voice is heard in these consultation processes at country, regional and global level. You can also join an e-mail based consultation with civil society organisations and networks to provide direct input into a Global Steering Committee on Universal Access which is currently being hosted by ICASO. Send your feedback to: universalaccess@icaso.org The ICASO press release for more information on the consultation process is available at:
http://www.healthdev.org/eforums/cms/showMessage.asp?msgid=9701
Please send feedback or queries on the issues raised in this editorial or requests for further information on EQUINET and REACH Trust’s work on equity and health systems strengthening in ART outreach to admin@equinetafrica.org
The concept of global health security underpins the current framework for global preparedness and response to emerging infectious diseases. The Global Health Security Agenda –a collaboration between governments– was launched in 2014, aiming to make our interconnected world safe from infectious disease threats. The governments involved in the Global Health Security Agenda focus on strengthening their countries’ capacities for detection, response and prevention.
In the context of public health emergencies, the Agenda has received financial and political support from international organizations and almost 50 countries. However, there is tension between the aims of global health security and governments’ mandate to ensure national security. The 1994 United Nations Development Programme’s Human Development Report first introduced the concept of human security, referring to security of citizens as individuals rather than that of the states in which they live. We posit that the use of the term global health security can have a negative unintended effect on the ultimate goal of improving health for all. There are three reasons why this term potentially privileges the security of the state rather than the security of individuals.
First, global health security, in its current use, is largely focused on protecting high-income countries against public health threats coming from low- and middle-income countries. Ebola virus, Marburg, Zika virus, dengue, chikungunya, Rift Valley and Lassa fevers, originated in low- and middle-income countries. If the Agenda is used to prioritize global health risk depending on the origin of infections, resource allocation may become even more skewed towards high-income settings. To ensure that a health security agenda is an integral part of national and foreign policy of each country, political attention and coordination between national ministries is needed as well as support from the national security budget.
Second, global health security tends to emphasize disease containment to protect national security rather than the prevention of future local outbreaks. Disease containment is common practice in the control of emerging infectious diseases. A national security perspective often results in unilateral, neo-colonial and/or short-term solutions designed to protect national borders. For example, many countries and airline companies imposed travel restrictions during the 2013–2016 Ebola virus disease outbreak in western Africa, contrary to World Health Organization recommendations.
Third, we argue that respect for human rights and values such as equity and solidarity should underlie each national security agenda. Such values are consistent with the motives of many people who provide health services in public health emergencies. Health security agendas should aim to build resilience to future outbreaks of infectious diseases, and require a long-term systems approach based on surveillance and national health system strengthening.
Protecting the world from infectious disease threats requires that national governments share the responsibility of serving those most in need, wherever they live. We believe that the concept of global health security should be expanded to include solidarity and sustainability. In this way, we will be able to develop a long-term approach and overcome the limitations of current responses to global health emergencies.
This editorial appeared first as an open access editorial in the WHO Bulletin in December 2016 at n/volumes/94/12/16-171488/en/.
The African Union (AU) African Mining Vision envisages a mining sector on the continent that contributes to the continent’s development, not only in terms of its economic growth, but also through mining processes that are “safe, healthy, gender and ethnically inclusive, environmentally friendly, socially responsible and appreciated by surrounding communities.” An increasing number of multinational companies from all regions globally are extracting mineral resources in east and southern Africa (ESA), but how far are these extractive industries (EIs) delivering on this vision of flourishing, healthy communities in their vicinity?
Notwithstanding the price fluctuations in the sector, EI exports have yielded significant returns, with oil, gas and mineral exports from the continent estimated in 2009 to be worth roughly five times the value of international aid inflows. They have, however, been associated with rapid but unsustainable growth and high levels of inequality, especially where they have limited forward or backward linkages into the national economy, and where they do not adequately invest in or protect the social and economic development of local communities.
A demand for socially responsible EI practice has already led to over 25 international standards, codes, performance standards and guidance documents from United Nations (UN) institutions, international agencies, including the International Finance Corporation, civil society and from business itself. The standards relate to business and human rights, to labour, health, environmental and social obligations, to socially responsible investment and practice and to transparency in governance of the sector. The international standards relating to health in EIs are detailed in a recent EQUINET report (Discussion paper 108) and policy brief available on the EQUINET website. As a condition for granting mining or prospecting rights, they cover duties to assess and prevent health, social and environmental risks and to ensure fair process and health, social and livelihood protections for communities that are relocated due to mining. During the mining processes, they include prevention of harm to the health of workers and surrounding communities, making fair fiscal contributions to health care and ensuring fair benefit and transparency in their operations. They also include post closure obligations in relation to any longer term health and social harm.
Recognising regional need and benefits, African states have resolved to harmonise standards and laws for the sector at sub-regional level, in west Africa, through ECOWAS, and southern Africa, through SADC. A number of ESA countries, such as South Africa, Mozambique, Zambia and Kenya, have also set in place initiatives to bring local standards and practice for EIs in line with global best practices.
The rapid expansion of the sector into new areas, the legislative gaps in countries with newer sectors, the differences in power between multinational actors and under-resourced states and communities, amongst other factors, have led to various areas of harm and conflict that call for such rights and duties to be made clear. Notwithstanding the employment, income and fiscal contributions they bring, EIs have been reported to bring health risks for workers and surrounding communities. These risks arise from hazardous working conditions and degraded or polluted environments, from the displacement of local people, several thousand in some cases, without adequate replacement of living conditions, resources, services and livelihoods, and from generous tax exemptions that limit EI contributions to social services. The EQUINET discussion paper summarises some of this published evidence. It also reports evidence of discontent or protest from local communities, who feel excluded from decisions and frustrated by grievance handling mechanisms. Indeed, the African Commission on Human and People’s Rights has established a Working Group on Extractive Industries, Environment and Human Rights Violations in Africa to examine and propose measures to prevent and provide reparation for such negative impacts, while civil society campaigns, like ‘Publish what you pay’ have sought greater transparency in EI operations. These conditions suggest that it would be timely to give more attention to realising the intentions to harmonise regional standards on EIs and to ensure that health is included within this.
An analysis of the laws on EIs and health in the ESA region in Discussion paper 108 indicates some general findings across the region: There is generally protection in current ESA laws of occupational health for workers employed by EIs, of duties to the environment, and of fiscal and post mine closure duties. There is, however, weaker protection in current ESA laws of the health and social wellbeing of communities displaced by mines, of families living around mines and of health duties post-closure, such as in relation to chronic diseases. In the laws analysed, fewer countries included duties on forward and backward links with local sectors, communities and services.
It was however a positive finding that where there are gaps in the law, there are also clauses in the law of one or more individual ESA countries that are aligned to international standards that may guide what may be included in the laws of others.
Such ‘good practice’ clauses could inform the content of harmonised regional standards. Their origin from ESA countries of different size and income also suggests that it would be feasible to apply them more widely across the region. The EQUINET discussion paper and policy brief at http://tinyurl.com/gr6yyza present suggested clauses for regional guidance on health in EIs (and the laws they derive from), in line with international and continental standards.
Implementing the vision of a socially responsible, healthy and inclusive mining sector clearly calls for more than law. In relation to health, there is evidence of the need for strengthened enforcement and practice, such as to revisit over-generous fiscal exemptions, to integrate health more centrally in tools for and approvals from impact assessment, to strengthen public sector co-ordination and capacities to monitor and prevent health risks, and to provide public information and meaningful mechanisms for community voice and agency in measures to protect their health. However, having harmonised regional standards may help to raise awareness and understanding amongst the different public sectors, private actors and communities of their roles, rights and duties in relation to health in EIs, and give support to the social and institutional processes and measures needed to promote healthy practice.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. You can read further evidence in EQUINET Discussion paper 108 Corporate responsibility for health in the extractive sector in East and Southern Africa at http://tinyurl.com/zm7afbk and Policy brief 42 at http://tinyurl.com/gr6yyza