When I joined the Global Fund in 2003, my main responsibility, as the Manager of Online Communications, was to help the organisation deliver on its commitment to transparency. One of the conditions set forth by donors was the ability to trace every granted dollar to make aid recipients accountable for how it would be spent. This meant, among other things, developing and maintaining a website that quickly became a central repository of all Global Fund data and information. We were praised for the unprecedented level of openness that this made possible. But over time, I realised that something was (and still is) missing.
If you Google “Global Fund” + AIDSfor news stories, the overwhelming majority of results are articles that are reactive (i.e. based on official announcements, press releases and conferences) or that make reference to the Fund only indirectly or anecdotally.
Apart from experts in donor governments and a handful of technical partners, Aidspan and the likes, very few local organisations or people take advantage of Global Fund transparency to trigger open and well-informed discussions on aid effectiveness. How can this be when all the data and documents are “just a mouse click away”? Close to $20 billion were disbursed in a few years. Where did it all go? Who got it? To do what? With what success?
The Fund’s website should be an extraordinary tool to get the facts right on those questions. It should be a gold mine of stories for local journalists, civil society organisations (CSOs), activists and parliamentarians in recipient countries. But, for the most part, they aren’t panning for this gold. What is transparency all about if it doesn’t translate into increased accountability at country level, and if people and communities for whom the Global Fund was created don’t use it to keep pressure on grantees, to voice their concerns and claim their rights?
The reality is that using Global Fund data to make recipients accountable is out of reach to most concerned people because they lack access to the Internet, because they don’t have enough time or the technical skills – and because there are obstacles to freedom of information and speech.
Global Fund transparency, as it is practised today, is more of a barrier to journalists and in-country activists than anything else: intimidating piles of reports filled with obscure language, countless files and downloadable materials that reassure technocrats in donor capitals but that don’t say much about the reality of what happens to the funds when they hit the ground. Understanding, processing and making use of this information requires learning about technical jargon, Global Fund internal processes, and the roles and responsibilities of different local partners. One needs to be familiar with web searching techniques and data processing methods, and to have some basic communication skills to translate often indigestible data into a plain, common language that non-technical audiences can understand.
Last, but not least, trying to make the powerful accountable in countries with no such tradition is a risky game for the few activists and concerned citizens who dare to do so. With the rise of the “Open Government” and “Open Data” movements in Africa and elsewhere, people may fear less for their lives than they used to, but threats and intimidation are still very much a daily reality for local watchdogs.
This leads to a strange paradox. As I heard recently: “That is almost the flip side of transparency. It’s very easy to use transparency if actually you want to drown people in information. I know it’s a tactic for lawyers: just give too much information to people, and it will be difficult for them to really figure out what is important.” Certainly, the Global Fund did not create this complexity consciously and voluntarily, but the result is the same: mountains of data and files that have the effect of shielding grantees and the Fund’s bureaucracy from too much scrutiny.
Today, in the wake of the Global Fund, a growing number of international organizations have committed to making their information on aid spending easier to find, use and compare. More than 120 UN agencies, multilateral banks, bilateral donors and NGOs have already endorsed the IATI (the International Aid Transparency Initiative) and have agreed to convert their data into a common standard. While this is a major step in the right direction, a simple lesson should be drawn from the Global Fund’s experience: Opening up databases is not enough for change to occur in the way local accountability happens. Rather, change requires a real commitment to accompany those for whom this data is made available as they make their first steps in the maze of aid transparency.
Here is what I think needs to happen.
Build capacity to use Global Fund data. Local watchdogs need help to stay afloat in the aid data deluge, to learn how to use the tools of transparency to have impact. While their work may not require the same level of technical sophistication as global watchdogs, they need training. They need to be able to understand who does what and where to find the information. They need to acquire watchdogging skills, using real-life case studies and guidance based on local needs. Watchdogs usually don’t focus on one single aid provider; no organisation would be justified in developing such a programme in isolation. Therefore, the capacity building should be a shared responsibility, and a combined and coordinated effort, by all concerned parties, such as the IATI signatories and some global or regional players in the field of transparency. The Global Fund has the credibility to take the lead on this. It should sit down with IATI partners to explore how a step-by-step, scalable, replicable and carefully targeted capacity-building programme could be implemented. As a critical side effect, such an initiative could provide some recognition to participating local aid monitors, thus breaking their isolation and protecting them in the exercise of their democratic rights.
Declare war on gobbledygook. Besides data, transparency is first and foremost about communicating in plain language. How much sense does it make for thousands of people, including the Secretariat’s own staff, to have to turn to a newsletter like the GFO to understand the rules of the game of a multi-billion dollar transparent organisation? The Global Fund should elevate proper communications with implementers (and others) to a top priority. The Fund should stop relying on technical staff to draft documents that are meant for wide distribution. It should reinforce the capacity of its Communication Department by adding writers who can translate complex policies and procedures into plain language.
If the Global Fund were to support and encourage local watchdogs, this would constitute a valuable early warning system for the Fund – one that complements the work of the local fund agents and the Office of the Inspector General. Building the capacity of local watchdogs to use transparency could greatly reinforce the Fund’s own risk management and fraud prevention efforts, at little cost. The Global Fund should also tackle its poor communications with implementing countries by addressing the Secretariat’s capacity issues in this field. With the 2015 MDG deadline on the horizon and the development community bracing for what comes next, with pressure on the Fund to improve its oversight mechanisms, and with the need for the Fund to position itself for a possible redefinition of its mandate, these measures could reassure donors about its capacity to be a truly different business model in international development.
The Global Fund should renew its commitment to transparency and take bold steps to promote wide use of its transparency in recipient countries. Information is power. It’s time to give power to those for whom the Global Fund was created so that transparency can fully achieve what it is meant for.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. Robert Bourgoing joined the Global Fund in its early days, in 2003, and was a senior member of its communications team until last year. He is a trained lawyer and an experienced journalist, and currently works as an independent consultant. This commentary was originally published in Global Fund Observer (GFO) Issue No. 215 on 23 April 2013, produced by Aidspan.
Editorial
The Independent Panel for Pandemic Preparedness and Response (https://theindependentpanel.org), tasked by WHO with reviewing the global management of the COVID-19 pandemic has fulfilled its terms of reference. But despite the best efforts of the panelists, it did not meet the moment. The world might still need an Independent Panel -- but one that is transparent, accountable and participatory.
This Independent Panel report does summarize many of the issues the world has witnessed in the past 14 months: weak pandemic preparedness, lugubrious bureaucracies, and government passivity. It poetically describes global inequalities, including the stark sacrifices of healthcare workers. However, its narrow recommendations sidestep many of these tough challenges in favour of expanding global governance: a Global Health Threats Council with heads of state, adopting new global statements and treaties, greater funding and authority for WHO, and a massive new $10 billion pandemic financing facility. It calls for countries to unite to establish a new international system for outbreak monitoring and alerts.
Some of these recommendations are sensible, others less likely, but in seeking to avoid assigning blame, the panel ducks accountability, and its vision falls short of the scale of the problems revealed by COVID-19.
The recommendations on vaccine access exemplify this. The panel urges funding for COVAX, a worthy goal; but COVAX’s 20% coverage targets cannot reach global herd immunity and prevent the spread of potentially dangerous new variants, and there is no clear plan for the remaining 80%. The panel called for high-income countries to speedily negotiate an intellectual property waiver and donate 1 billion doses by September 1 to low- and middle-income countries. Given the global need of 10 billion doses today, as Madhu Pai argued in his powerful intervention at the launch event of the report, this is vaccine charity, not vaccine equity. The panel does not address the stark inequalities among countries that have fueled the virus.
Troublingly, considering that several of the panelists have been outspoken human rights advocates in the past, the Independent Panel also sidestepped numerous grave human rights abuses in the COVID-19 pandemic: praising the world’s most brutal authoritarian lockdowns as models, without a single caveat about government overreach. In particular, as critics have pointed out, the report omits mention of Chinese suppression of health data, though it is well-documented that this has caused numerous real headaches for WHO.
In March 2020, China’s State Council cracked down on independent research, issuing a directive requiring political vetting of any research on the coronavirus. A Chinese scientist publishing the coronavirus genome sequence on an open platform had his laboratory closed. Over 800 Chinese individuals were sanctioned by police for COVID-related speech, and individual citizen journalists were disappeared while patients who organized online had their chat groups deleted. This is all consistent with the modern history of China’s health system struggling with whether to report up or censor outbreak alerts, from HIV to SARS to, most recently, H1N1.
Given this tortured history with health data, which has been repeated in other countries, it would have been reasonable for the Independent Panel to query when and whether the world will learn of the next outbreak of a new virus. If a UN panel cannot state that suppression of scientists is incompatible with the International Health Regulations, or even with the founding principles of the UN itself, how many doctors might hesitate to blow the whistle?
However, this aversion to sensitive political realities threads through the report, which mentions human rights only once, at the end. The report does describe staggering global inequalities, but without recommendations, though these could have been drawn from many sources: guidance from the UN Human Rights Office, from UNAIDS, from global associations of nurses and other medical workers, or even from the panel’s own commissioned background papers .
These omissions are concerning, but rather than blaming the panellists, we might reflect on the largely closed process. A process grounded in a robust, public consultation with civil society and community voices, frontline health care workers and trade unions, might have produced a different result.
To put an end to and recover from a catastrophe on the scale of COVID-19 requires greater scope. A democratic and public review of what happened and what did not happen in each region, with the public participating to reflect on what we lived through and bore witness to, could build the global public momentum for real learning and change.
Such open and transparent processes have taken place effectively as part of transitional justice in many countries. For example, we can reflect on the Global Commission on HIV and the Law: a global commission on a pandemic hosted by UNDP, it included regional desk reviews based on open submissions, public hearings recorded and archived online, and participation of community activists, who could then use the recommendations and tools that came out of the process to advocate for law and policy reforms at the national level. Its reports continue to be a reliable – and independent -- resource for scholars, officials, policymakers and activists.
An independent commission on pandemic policy could enable wider consultation that creates a lasting historical record, greater trust in science, and a global movement for transformational change. Are we ready to face the difficult truths that such a panel might show us?
This oped is reproduced with permission from Geneva Health Files Newsletter #57 (https://genevahealthfiles.substack.com/p/at-risk-covax-plans-to-vaccinate ) The report of the Independent Panel for Pandemic Preparedness and Response ‘COVID-19: Make it the Last Pandemic’ is included in this newsletter issue and the launch of the report can be viewed at https://www.youtube.com/watch?v=_-OSqIrF0qA&t=2662s. Please send feedback or queries on the issues raised in the oped to the author at sara.davis[at]graduateinstitute.ch.
The World Summit on Sustainable Development included a strong civil society presence, although one, tellingly, kept separate from the governmental proceedings of the main conference. In hosting their own Peoples Summit, civil society groups drafted proposals that were aimed to feed directly into the governmental discussions on a daily basis.
Groups at the Peoples Summit were gathered according to geographic or issue commonality. Equinet was represented in the health, womens and Africa caucus. As the summit drew to a close it became increasingly apparent that whilst NGOs achieved a great deal in their own deliberations, these discussions were becoming increasingly irrelevant in relation to influencing the outcomes within the main Sandton-based governmental discussions. This drew a great deal of anger from civil society groups, with many feeling forced to disassociate themselves from the event. At the same time others, under the banner of the Summit Civil Society Secretariat, seemed to display greater willingness to concede success for the summit, despite clear indications that the critical issues for civil society and sustainable development were being blatantly ignored.
For the Africa caucus, this division paralleled differing views held on the effectiveness of NEPAD. Despite much discussion and agreement on a number of priority areas, their declaration, printed in full below, failed to agree on a unified position and it was eventually agreed that, where NEPAD is mentioned, the draft should contain both points of view.
The Johannesburg Declaration of African Civil Society Organisations
We representatives of African Civil Society organisations meeting during the World Summit on Sustainable Development reaffirm our demand for commitment to the achievement of sustainable and equitable development in Africa.
The Rio Summit marked international commitment to providing political, financial, and technological support for its version of achieving the interlinked goals for human centred, environmentally sustainable and culturally sensitive development, and, poverty reduction.
A decade later, it is evident that the development situation particularly, poverty in Africa has escalated. There has been insufficient commitment by African governments to the ideals of Rio and inadequate financial and technological support by development partners for Africa’s development priorities. The capacity of the people of Africa to lift themselves out of poverty, food insecurity and illiteracy has been undermined by many factors, including declining levels and terms of trade, increasing debt burden, declining overseas development assistance and private investment flows, increasing marginalisation in world relations from globalisation, unfavourable prescriptive donor policies, environmental deterioration, partly from increased exploitation of the natural resource base of the continent, HIV/AIDS prevalence, and, conflict and wars.
We resolve to fully utilise the opportunity offered by the Johannesburg commitment on sustainable development to work towards ensuring urgent and renewed commitment, by African governments and development partners, backed by time bound implementation actions, monitorable deliverable and identified sources and levels of resources, that will assure the achievement of the Millenium Development Goals and Targets in Africa and accelerate the realisation of our sustainable development vision for Africa within ten years.
We, civil society organisations of Africa, envision an African society, characterised by unity in diversity, equality, equity and justice that guarantees the fundamental needs of its people, is participatory and accommodates the interests of all stakeholders in decision-making processes, including the empowerment of women in all areas, and ensures democracy and human rights in which poverty is reduced to a minimal level through knowledge based, culture sensitive and people centred development that is environmentally, socially and economically sustainable..
We recognise the UN secretary General Kofi Annan’s WEHAB initiative as a contribution to the Draft Plan of Implementation of the Johannesburg summit for the WSSD while it seeks to provide focus and impetus to action in the key thematic areas of Water, Energy, Health, Agriculture and Biodiversity that are integral to a global approach to the implementation of sustainable development.
We call for clear processes and transparent criteria to be defined and adopted through the participation of stakeholders in the implementation of partnerships emerging from the Johannesburg Summit
We urge all African Governments to commit themselves to the challenges posed in the “Earth Charter”.
We acknowledge that for the WSSD to ensure the achievement of our vision of Africa it should address the following issues:
a) poverty eradication, b)emergence of African regional groupings and alliances, including the Africa Union and NEPAD c.)human resource development including education, health and combating HIV/AIDS, TB, Malaria and avoidable diseases of poverty, d)Africa and globalisation, e.)sustainable agriculture and food security, f.) water and sanitation, g)natural resource management, including desertification and land degradation, h.)energy, I) science and technology including indigenous knowledge systems and the legal recognition of the rights of local communities, j) democratic governance, k) rule of law, respect for human rights and freedoms, l) gender equity, m) armed conflict and warfare
We call for a commitment by all Governments to reach agreement for a timetable for the phasing out of harmful subsidies of fossil fuels and agree on targets and timeframes for increasing the share of renewable energy supply for Africa.
We recognise that achieving our sustainable development goals requires a supportive international environment, particularly in the areas of macro-economic policy, market access and fair trade, debt relief, ODA and conditions for leveraging private capital flows, human development, technology transfer, capacity development and full implementation of multilateral environmental and sustainable development Conventions and their Protocols. We call for strong and immediate action.
We recognise that while globalisation may bring new opportunities and challenges for sustainable development in Africa, the uneven distribution of wealth and apparent benefits further marginalizes the continent’s role in the world economy. Special attention should be given to grassroots communities where such benefits do accrue.
We acknowledge that peace is a prerequisite for sustainable development and call on African Governments and the international community to adopt measures to ensure a peaceful and stable environment for Africa’s sustainable development.
We reaffirm our engagement with NEPAD, despite our insufficient involvement in its formulation, and urge African leaders to partner with African Civil Society organisations in all processes for its refinement, implementation and monitoring. We are concerned that NEPAD does not replicate structural adjustment programmes, which have increased poverty and inequality on the Continent.
We reaffirm that sustainable development requires active participation of women and men on equal footing at all levels of decision making, implementation. Monitoring and evaluation. We call for the integration of gender equity in all aspects encompassed within Agenda 21, the Millenium Development Goals and the Johannesburg commitment on Sustainable Development.
We reaffirm the unconditional need for African Governments themselves to initiate appropriate steps to ensure good governance as a major prerequisite for sustainable development.
We commit ourselves to the monitoring of the implementation of Agenda 21, the Millenium Development Goals and the Johannesburg commitment on Sustainable Development through existing and newly formed African regional, National and Local NGO coalitions on sustainable development.
When my comrades and I disrupted Minister of Health Manto Tshabalala-Msimang’s speech at the Health Systems Trust conference, a public health official taunted one of the Treatment Action Campaign (TAC) members by saying: “How did you get HIV anyway?” We also received an angry letter from a man who feels our demand for treatment is unfair. This article is written for them. It is also written for people like Western Cape African National Congress health spokesperson, Cameron Dugmore, who called us bullies for disrupting the minister.
First, I apologise unconditionally to the minister for referring to her personal appearance during our disruption. Any reference to the personal appearance of an opponent to discredit them is wrong. It’s also wrong because it undermines the dignity of the protest of thousands of TAC volunteers and allows people who need to curry favour with officials a cover for their lack of courage and morality. It is also no excuse to say that I was angry, because a few minutes before my own anger against indifference became uncontrollable I had told a comrade whose mother had been hospitalised with a CD4 count of 54 and raging tuberculosis that she should use her anger to demonstrate peacefully. But there are many things I do not apologise for. I do not apologise for holding Tshabalala-Msimang and Minister of Trade and Industry Alec Erwin responsible for thousands of HIV/Aids deaths. Second, neither the TAC nor I will make any apology for making the minister of health, any politician or bureaucrat feel uncomfortable through a disruption of any meeting, office or event where they may find themselves. Hundreds of premature, painful, awkward, silent and screaming deaths of children, men and women daily are caused by the failure of the government to implement a comprehensive treatment and prevention plan for HIV/Aids.
To Dugmore and the other detractors of our campaign who call us bullies, let me ask: were you at the many lawful marches to Parliament to give memoranda to the minister and the president begging for HIV treatment? Perhaps you did not see our march of about 15 000 people on the South African Parliament asking the government to sign a treatment and prevention plan on February 14? What about our early pickets of Parliament, drug companies and the United States government? Civil disobedience is action of last resort for us, because exhaustive efforts at engagement have not worked. Let me ask further: did you attend any of more than 10 submissions to various parliamentary portfolio committees begging, cajoling, charming and arguing for HIV treatment? Did you attend any of more than 30 interfaith services held by the TAC and our allies across the country appealing to the conscience of the health minister and the government? Do you know that we tried quietly to persuade Dr Ayanda Ntsaluba, Dr Nono Simelela, Dr Essop Jassat, Dr Ismail Cachalia, Dr Saadiq Kariem, Dr Kammy Chetty, Dr Abe Nkomo and other doctors who are members of the ANC to ensure that the government change its policies or to let their scientific training, their Hippocratic oaths and their consciences allow them to speak the truth? Maybe you also tried to persuade them that real loyalty to the ANC and the ideals of the Freedom Charter required open criticism after numerous private pleas? Have you reminded the ministers of health and trade and industry that they are undermining the ANC’s traditions of freedom, equality, solidarity and dignity?
Do you remember that the health minister and her supporters in Cabinet really represent the anti-democratic traditions of the former Stalinist states that supported them? Perhaps one should expect people who denied the existence of the Gulag or applauded the invasion of Czechoslovakia, Hungary, Poland and East Germany by Soviet troops and called the latest Zimbabwean election legitimate to deny the existence of HIV/Aids and the efficacy of antiretrovirals? Did you attend hundreds of community meetings addressed by TAC volunteers across the country to educate ourselves and our people about HIV, prevention and treatment? Did you help late into the night, in support of the government, to develop a court case against the drug companies to reduce the prices of all medicines including HIV/Aids medicines? Do you remember how the health minister spurned the TAC after the case? Do you know the anguish of the person who made the poster that said: “Thabo your ideas are toxic”? Were you at the funeral of Queenie Qiza (one of the first TAC volunteers) or did you hear Christopher Moraka choke to death after appealing to Parliament to reduce the prices of medicines? Maybe, like me, you avoided the funeral of my cousin Farieda because I cannot face the pain of death? Did you feel as encouraged as we were by the Cabinet statement of April 17 2002? Are you as disappointed a year later that so little has been done? Were you there when we illegally imported a good quality generic anti-fungal drug (Fluconazole) and shamed drug company Pfizer for profiteering?
Maybe you followed the TAC/Congress of South African Trade Unions’s treatment congress where unemployed people, nurses, scientists, cleaners and trade unionists invited the government to develop a treatment plan? Do you remember our meeting with Deputy President Jacob Zuma that led to a promise that a treatment and prevention plan would be developed by the end of February 2003? Did you miss the word-games played by the government over negotiations at the National Economic and Development Labour Council (Nedlac)? Are you one of the people who phone Nedlac regularly to hear when the government will return to the negotiating table? Or, are you one of the people too busy taking care of someone dying but who have a little pride in your heart when an activist says to the president: “Comrade, you are not listening to our cries. You are denying the cause of our illness. You are not helping us get medicines.” After countless attempts at talking, public pressure and even a court case to prevent HIV infection from mother-to-child, the government allows the deaths to continue while it plays the caring, right-minded diplomat in Africa and the Middle East. Politeness disguises the moral and legal culpability of these politicians and officials. We believe that the personal crises faced by many of our families, friends, nurses, doctors, colleagues and their children should be turned into discomfort and a crisis for the politicians and bureaucrats who continue to deny our people medicine.
The fact that the health minister is obstructing the departments of health, finance, labour and the deputy president’s office from signing and implementing a treatment and prevention plan costs our society more than 600 lives and many new HIV infections every day. The government uses Parliament, Cabinet, provincial governments and all its resources including the Government Communication and Information Service, in the person of comrade Joel Netshitenze, or health communications officer, Joanne Collinge, to justify its denial of life-saving medicines to people who need them. It uses these resources to protect the reputation of the minister of health. And you add your voices to their chorus? When will you join reason, passion and anger to win treatment for people living with HIV/Aids and a decent public health system for all?
The TAC will win in this campaign because its members act in good faith. And when we win, we will sit down on any day with the government for as long as it takes to tackle all the difficult problems of HIV/Aids and the health system. These wounds between ourselves and the government will not be healed easily. But they will heal easier than the pain of the millions who are denied life-saving treatment and those who have succumbed to that pain.
* Zackie Achmat is the Treatment Action Campaign’s chairperson
* See the Equity and Health General section of Equinet News for more news on this issue.
We hereby demand that a police docket be opened to investigate the deaths of the many thousands of people who died from AIDS or AIDS related illnesses and whose deaths could have been prevented had they been given access to treatment. We further demand that the Accused be arrested and charged with the offence of Culpable Homicide for negligently causing the deaths of these people. The details of the charge and a summary of some of the facts which form the basis of the Charge are attached. We believe that many thousands of people can bear witness to this horrible crime.
ACCUSED NO. 1
NAME: MANTOMBAZANA EDMIE
SURNAME: TSHABALALA-MSIMANG
OCCUPATION: THE MINISTER OF HEALTH, SOUTH AFRICA
ACCUSED NO. 2
NAME: ALEXANDER
SURNAME: ERWIN
OCCUPATION: THE MINISTER OF TRADE AND INDUSTRY, SOUTH AFRICA
THE CHARGE
THE PEOPLE versus MANTOMBAZANA EDMIE TSHABALALA-MSIMANG alias "MANTO", MINISTER OF HEALTH (RSA) and ALEXANDER ERWIN alias "ALEC", MINISTER OF TRADE AND INDUSTRY (RSA). Hereinafter respectively referred to as Accused No. 1 and Accused No. 2.
Both accused are charged with the crime of culpable homicide in that during the period 21 March 2000 to 21 March 2003 in all health care districts of the Republic of South Africa, both accused unlawfully and negligently caused the death of men, women and children. They also breached their constitutional duty to respect, protect, promote and fulfill the right to life and dignity of these people.
1. Both accused Ministers knew that failure to provide adequate treatment including anti-retroviral therapy for people living with HIV/AIDS would lead to their premature, predictable and avoidable deaths.
2.In their capacities as Ministers in the government of South Africa, both accused had the legal duty and power to prevent 70% of AIDS-related deaths during this period through developing a treatment and prevention plan, providing medicines and using their legal powers to reduce the prices of essential medicines for HIV/AIDS including anti-retroviral therapy.
3. Both accused Ministers had in their possession scientific, medical, epidemiological, legal, social and economic evidence of the devastation of potential and actual AIDS deaths on individuals and communities. They not only ignored this evidence but suppressed it.
4. Both accused Ministers consciously ignored the efforts of scientists, doctors, nurses, trade unionists, people living with HIV/AIDS, international agencies, civil society organisations, communities and faith leaders to develop a treatment and prevention plan, to make anti-retroviral therapy available and to ensure that medicine prices in the public and private sector were reduced to save lives.
5. Both accused Ministers were under a legal duty, by virtue of their public office and the provisions of the Constitution of the Republic of South Africa, to provide access to health care services by reducing the price of essential medicines for HIV/AIDS including anti-retroviral therapy, and by providing them through the public health sector. They remain under this legal duty.
6. Both accused Ministers negligently failed to carry out their legal duties. Their conduct in failing to make these medicines available to people who need them does not meet the standards of a reasonable person, and in particular a reasonable person holding the position of Minister of Health or Minister of Trade and Industry.
7. During the period 21 March 2000 and 21 March 2003, this failure caused the death of between 250 and 600 people every day as a direct result of premature, avoidable and predictable AIDS-related illnesses.
THE PEOPLE versus MANTOMBAZANA TSHABALALA-MSIMANG (Minister of Health) (hereinafter referred to as The Minister of Health) and ALEXANDER ERWIN (Minister of Trade and Industry) (hereinafter referred to as The Minister of Trade and Industry)
CHARGE: Culpable Homicide (unlawfully and negligently causing the death of another human being)
SUMMARY OF SUBSTANTIAL FACTS
1. During the period 21 March 2000 to 21 March 2003, many people throughout the Republic of South Africa died from AIDS or diseases caused by AIDS.
a.) Information on the prevalence of HIV/AIDS and HIV/AIDS related deaths each year has been available to both Accused Ministers throughout their terms in office.
b.) It is estimated that at least 600 people in South Africa die from AIDS-related illnesses each day.
c.) In the past 12 years, the HIV sero-prevalence among first time antenatal clinic attenders, as indicated by the Minister of Health's own Department's Annual Antenatal Clinic surveys has risen from 0.76% in 1990 to 10.44% in 1995 to 28.4% in 2001. Based on these surveys, it is estimated that there are currently 5 million South Africans infected with HIV. The latest survey estimates that 15,4 percent of women under 20 years, 28,4 percent of women between 20 and 24 years and 31,4 per cent of women between 25 and 29 years are living with HIV/AIDS. The survey further notes that "high HIV prevalence rates have significant implications on the future burden of HIV-associated disease and the ability of the health system to cope with provision of adequate care and support facilities."
d.) In the Department of Health's Second Interim Report on Confidential Enquiries into Maternal Deaths in South Africa (1999), non-pregnancy related sepsis mainly caused by AIDS was recorded as the leading cause of maternal deaths. In the Report, 35.5 percent of women whose deaths were reported were tested for HIV and 68 percent of these were HIV positive. The Report noted that HIV is significantly under-diagnosed.
e.) A study by the Medical Research Council, estimated that about 40 percent of adult deaths aged 15-49 that occurred in 2000 were due to HIV/AIDS and that, if combined with the deaths in childhood, it was estimated that AIDS accounted for about 25 percent of all deaths in 2000 and was the single biggest cause of death. The Report continued that projections indicate that, without treatment to prevent AIDS, the number of AIDS deaths with grow within the next 10 years to double the number of deaths due to all other causes. The Report estimates that approximately 200 000 people died of an AIDS-related illness in 2001 alone. The Minister of Health was directly involved in attempts to suppress this report.
f.) A report issued by Statistics South Africa on 21 November 2002 entitled Causes of death in South Africa 1997-2001: Advance release of recorded causes of death, indicates that unnatural causes still remain the leading cause of death. However, the report states that HIV-related deaths are significantly under-reported. One reason advanced for the under-reporting is that such deaths are often recorded as TB or pneumonia-related. Of particular significance is the finding that patterns of mortality shifted dramatically over this period, primarily as a result of HIV, TB and pneumonia-related deaths. In 2001, for example, 8.2% of all recorded deaths were attributable to unspecified unnatural causes, down from 15.3%.
g.) In contrast, 34.6% of all recorded deaths in 2001 were attributed to HIV, TB, influenza/pneumonia and "ill-defined causes of death", up from 29.5% in 1997.
h.) The largest single impact of HIV/AIDS on the public health sector lies in the hospital sector. Research commissioned by the Department of Health (Abt Associates, 2000) indicates that, in the year 2000, an estimated 628 000 admissions to public hospitals were for AIDS related illnesses, which amounts to 24% of all public hospital admissions. As more people who are already HIV positive become sick each year, this demand for hospitalisation will increase steadily every year in the absence of significant alternative interventions. In financial terms, the cost of hospitalising AIDS patients in public facilities was estimated at the time to amount to at least 12.5% of the total public health budget.
2. Many of these people would not have died if they had access to anti-retrovirals
a.) HIV/AIDS is a progressive disease of the immune system that is caused by the Human Immunodeficiency Virus (HIV).
b.) When left untreated HIV profoundly depletes the immune system and may prove fatal because of the inability of the body to fight opportunistic infections such as tuberculosis, pneumonia and meningitis.
c.) The scientific evidence indicates that without effective treatment, the majority of people with HIV/AIDS die prematurely of illnesses that further destroy their immune systems, quality of life and dignity.
d.) Early diagnosis, clinical management, medical treatment of opportunistic infections and the appropriate use of anti-retroviral therapy prolongs and improves the quality of life of people living with HIV/AIDS.
e.) Anti-retroviral drugs are a class of drugs that suppress viral load activity and replication. When used effectively they reduce the volumes of HIV to undetectable levels in the blood. This leads to immune reconstitution. It also prevents and delays the destruction of a person's normal immune system.
f.) In its HIV/AIDS Policy Guideline, entitled Prevention and Treatment of Opportunistic and HIV-related diseases in Adults (August 2000), the Department of Health (which operates under the direction of The Minister of Health) has recognised the efficacy of anti-retroviral treatment, stating as follows: "Current research also strongly indicates that suppressing HIV viral activity and replication with anti-retroviral therapy or Highly Active Antiretroviral Therapy (HAART) combinations prolongs life and prevents opportunistic infections".
g.) The Medicines Control Council, has the statutory duty to investigate and determine whether medicines are suitable for the purpose for which they are intended, and whether their safety, quality and therapeutic efficacy is such that they should be made available in South Africa. They have registered various anti-retroviral drugs for treatment of people who have HIV/AIDS.
h.) The World Health Organisation (WHO) has included anti-retrovirals on the Core List of its Model List of Essential Drugs (12th edition, April 2002). The Minister of Health is aware of the inclusion of anti-retroviral medication in the World Health Organisation's Essential Drugs List.
i.) With access to anti-retrovirals people with HIV/AIDS are able to lead longer and healthier lives and it directly results in an improved quality of life and the restoration of dignity, allowing people with HIV/AIDS who were previously ill to resume ordinary everyday activities, such as work.
j.) A comprehensive plan to treat people living with HIV/AIDS as advocated by civil society organisations, faith based organisations, scientists, health care workers, trade unionists, activists and communities over the past four years, would have reduced the number of people dying of AIDS related illnesses and would have mitigated the horrendous impact of AIDS on people in South Africa.
3. Both Accused were aware of need to make anti-retrovirals available to prevent these deaths.
a.) The Minister of Health has had direct knowledge of the serious impact of HIV/AIDS and the need for care and treatment of people living with HIV/AIDS, before she took up her position as Health Minister. As early as 1994 The Minister of Health was a key drafter or the NACOSA National AIDS Plan for South Africa 1994 - 1995. (The Plan states that "The number of people becoming ill as a result of HIV infection is already high and will continue to increase dramatically over the next few years. The health care systems will have to cope with this increase and strengthen their ability to provide HIV/AIDS care in order to reduce the impact of HIV/AIDS on individuals, their families and communities"). In terms of this Plan, it is also clear that The Minister of Health was fully aware of the need to broaden access to treatment for people living with HIV/AIDS ("In dealing with HIV/AIDS, an essential drug list should be developed, based on the efficacy of the drugs in the clinical management of the disease, as well as on costs and availability? As research develops and knowledge about treatment expands, it may be necessary to add drugs to those which are routinely supplied. All drugs and medicines should be available as widely as possible").
b.) The Minister of Health and the Minister of Trade and Industry were aware of the Joint Statement issued by the then Minister of Health, Dr Nkosazana Dlamini-Zuma and Treatment Action Campaign, which confirmed that all treatment for HIV/AIDS and all related medical conditions is a basic human right (30 April 1999). At the time, the Minister of Health called on all sectors to pressurise companies to unconditionally lower the price of all HIV/AIDS medications to an affordable price for poor people and countries.
c.) The Minister of Health has herself confirmed that "access to affordable drugs is a matter of life and death in our region" (World AIDS Day speech, 1 December 2000). During this speech, The Minister of Health also emphasized that access to drugs should be improved and that "drugs at current prices remain unaffordable". The Minister of Health, in her capacity as Minister of health, and as a doctor, knew that action had to be taken to reduce the prices and that she could use her legal power to procure or produce generic anti-retrovirals and other essential HIV medications.
d.) In its Cabinet statement of 17 April 2002, Cabinet, and the Accused as members of the Cabinet, recognised that anti-retrovirals can improve the conditions of people with HIV "if administered at certain stages ... in the progression of the condition, in accordance with international standards."
e.) After taking up office, The Minister of Health and the Minister of Trade and Industry have consistently been reminded of the need to improve access to treatment for people living with HIV/AIDS since 1999 (e.g. Speech by Edwin Cameron at the 2nd National Conference for People Living with HIV/AIDS on 8 March 2000, in the presence of the Minister of Health; the Call for a Global March issued in March 2000; COSATU's Submission on HIV Treatment to Health Portfolio Committee on 10 May 2000; letter by TAC requesting meeting with President and Minister of Health on access to treatment dated 20 March 2000).
* To read the full indictment please click on the URL provided.
In the same month that it reaffirmed the 1978 Alma Ata Declaration’s commitment to “the fundamental right of every human being to the enjoyment of the highest attainable standard of health” in its October 2018 Declaration of Astana, the World Health Organisation (WHO) launched, with much fanfare and hubris, its “first investment case” for 2019-2023, as a proposal that could “save up to 30 million lives”.
Despite the rhetoric of the Astana Declaration, the WHO appears to be in a political moment where it is under pressure to justify, in economic terms, its existence as a global governance structure for health. To convince the doubting reader, the investment case promised “economic gains of US$ 240 billion” as the return to be made on increasing annual country contributions by US$10 billion to enable the WHO to meet its annual budget of US$14 billion.
Two things are striking. Firstly, the investment case purports to lay the basis for “a stronger, more efficient, and results-oriented WHO …and … highlights new mechanisms to measure success, ensuring a strict model of accountability and sets ambitious targets for savings and efficiencies.” This is the language of the private sector.
There is nothing wrong with working more efficiently, but the WHO should be placing health equity and human rights at the centre of its work and should guard against efficiency and managerialism coming at the expense of equity and social justice. The bureaucracy and inefficiency of the WHO needs addressing, but the idea that the solution lies in the application of New Public Management is a political choice, rather than a necessary outcome of clear analysis.
Secondly, the parlous state of WHO funding is not a coincidence. It is the result of a systematic decline in assessed contributions by member states, particularly the United States, over past decades. Whereas assessed contributions were 75% of WHO’s budget in 1971, the Peoples Health Movement and others showed in 2017 that this is now about 25% of the institution’s budget and that countries that do pay, choose to put most funding into voluntary contributions. Voluntary contributions can be tied to particular programmes, meaning countries can determine the work of WHO through funding dependence. WHO’s budget has also been stagnant for the past eight years, which is why the organisation now has to go cap-in-hand, clutching a seemingly miraculous investment case argument, to beg for the budgets it has been starved of for the past decade.
It is astonishing, but deeply revealing, that the WHO has to justify human life in monetary or investment’ terms. Who would have thought the Constitution of the World Health Organization which 70 years ago heralded the enjoyment of the highest attainable standard of health as one of the fundamental rights of every human being would end up in such abysmal decline?
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. The WHO Investment case referred to in the editorial can be found at https://tinyurl.com/yavqzjvk
While economics is not World Health Organisation (WHO)’s core expertise, the impact of poverty and income maldistribution on population health clearly justifies the organisation working with other agencies within or outside the UN system to focus much more attention on questions of disparity. Things being the way they are right now, it is thus difficult to make sense of the shrinking scope of WHO’s role in global health governance.
One factor could be the wide and ambiguous use of slogans about ‘stakeholders’ and the fait-accompli of ‘multi-stakeholder platforms’ and ‘public-private partnerships’. The term ‘stakeholders’, bundling together public interest civil society organizations with international NGOs, private sector enterprises and philanthropies under the term ‘non-state actors’, appears to endow all of these private ‘stakeholders’ with the right to a ‘seat at the table’, with only the tobacco and arms industries declared off limits. Such ‘sitting rights’ jeopardize people’s human rights as enshrined in various instruments, including the right to health.
‘Donor’ countries (the US in particular) continue to push the WHO towards working with industry through such ‘multi‐stakeholder partnerships’, rather than giving it the chance to implement regulatory and fiscal strategies that could make a real difference. Bilateral funders and big philanthropies demand that WHO provide data according to their particular interests, beyond the compilation of country-reported statistics. They focus on providing technical interventions, and introduce a bias away from interventions on the right to health or social determinants.
This treatment of WHO is part of a wider onslaught on the UN system generally. The whole UN system is held hostage to short-term, unpredictable, funding. The freezing and periodic withholding of countries’ assessed contributions and tightly earmarked voluntary contributions creates dependence on private philanthropy. It applies a sustained pressure to adopt the multi‐stakeholder partnership model of program design and implementation that gives global corporations an undeserved ‘seat at the table’.
If the WHO reform is to realise the vision of its Constitution, it will require a global mobilization around the democratization of global health governance, within the wider global mobilization for human rights and equity in global economic and political governance. Globalization has created new collective health needs that cross old spatial, temporal and political boundaries. In response, we need global health governance institutions that represent the many, not the few; and that are sufficiently agile to act effectively in a fast-paced world and capable of bringing together the best ideas and boundary-shattering knowledge available.
Yet the WHO seems strangely detached from the broader political turmoil and changes unfolding around the world. WHO may point to its 193 member states and claim to be universally representative, but it is far from politically inclusive. Like the alienation felt by millions around the world, many members of the global health community have turned elsewhere to move issues forward and get things done. We thus see a steady decline of WHO, clinging to obsolete political institutions and bureaucratic models, yet kept alive by member states as an essential public institution. This decline is not because WHO is not needed, but because it has not adapted to and is not publicly financed for a changing world. It is not the WHO that we need today.
Political innovation must thus become a fundamental part of the process of WHO reform. We need to think: How might virtual and interactive town halls improve communication between global health policy-makers and the constituencies they serve? How might the closed world of global policy-making be opened up and strengthened through virtual public consultations, feedback and monitoring systems? How might the concept of global citizenship become institutionalized within our global health institutions, especially WHO?
We also need to challenge the re-legitimation of the ‘free trade agenda’ in health that has strengthened intellectual property (patent) protection regimes despite their well-known negative consequences for public health. We need to question the mantra of the ‘realistic costing of outputs’ that prescribe programme implementation models where programmes comprise a set of planned outputs from prescribed activities with known costs. This approach leaves little, if any, room for flexibly managing complexity in planning and implementing systems. It makes health actors, including WHO, wary of the longer term implementation processes needed in health systems, partly because they disrupt ‘production schedules’ demanded by funders.
These models also contradict our understanding that health care is just one of the factors influencing health and can only be considered part of the solution. As the 2008 WHO Commission on the Social Determinants of Health stated, “Social injustice is killing people on a grand scale and constitutes a greater threat to public health than a lack of doctors, medicines or health care services”. The conditions under which people live and work, their socioeconomic development, education, housing and other conditions have a major impact on health behaviours and outcomes. A robust analysis of the root causes of the preventable global disease burden is thus essential to understand which ‘stakeholders’, or duty bearers, are part of the problem and which are part of the solution. Consistent with human rights principles and the findings of the 2008 Commission report, such analysis enables us to identify which can be trusted to have a seat at the policy table.
This influence of social injustice on health and the analysis of root causes of preventable disease appears most obscured in the influence of external funders over health ministries in the global south. It keeps them focused slogans such as ‘development assistance’ and ‘public-private partnerships’ that in their design serve the agenda of the richest 1%. In so doing it sustains a world view of the beneficence of private enterprise and that accepts as natural and unchanging conditions of global inequality and environmental degradation.
This editorial draws on points raised in the work of PHM and other colleagues, including K Detavernier, M Kok, K Lee, D Legge and E Pisani. For further information visit the PHM website at http://www.phmovement.org/ . Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
Thumida Maistry will be leaving Equinet as at the end of October 2002. Equinet is grateful to Thumida for her energetic commitment to the network. She has been working for the past three months on background work for an advocacy plan for Equinet that will be more substantively taken up in 2003. Programme co-ordination will continue to managed through TARSC as always and communications should be directed to admin@equinetafrica.org.
Population health deals with health beyond the individual. It addresses the combined impact of social determinants such as environment and social structure and includes health care. With the role of pharmacists traditionally centering on the supply and distribution of medicines, pharmacists, particularly in low and middle income countries, have been viewed as having little to do with population health. Yet ironically, the community pharmacy is often the first port of call for most people with minor ailments. Pharmacists are thus strategically positioned to provide essential services that promote, maintain and improve the health of the population in the broadest sense.
Pharmacy is an age old profession that deals with the science of making and administering medicines. Over the years, the profession has evolved to encompass a wide range of service areas. In high income countries these areas and roles are well defined and structured. In low and middle income countries, this is not the case. Often pharmacists in these counties have to carve their own individual career pathways that may not bear any relationship to their professional training. In most cases however, pharmacists in low and middle income countries work in dispensing roles, mainly in community pharmacies.
In high income countries, pharmacists routinely engage in public health programs such as disease screening, pregnancy testing and counseling, immunization and counseling for at-risk populations among others roles. In lower income countries, where ironically the need is greater, pharmacists’ involvement in population health is at best minimal.
Economic growth in low and middle income country economies is taking place at a rate faster than ever, but key health and demographic indicators remain stunted. The time is ripe for the profession of pharmacy to stand up and be counted, and for pharmacists to play a more central role in population health.
The community pharmacy holds a number of benefits as a setting for public health interventions. With extended opening hours and no appointment needed for advice, community pharmacies are more accessible than other settings. In some high income countries it has been reported that on average at least nine in every ten residents visit a community pharmacist at least once a year. In lower income countries, even though this frequency may be smaller, the services that local pharmacies provide to the community could have much greater impact. For instance, community pharmacies could be a source of information related to health and well-being that could have far-reaching impact in communities that lack access to such information. Clients who visit a pharmacy to seek information may also obtain other products they need, giving a return to both the pharmacist and the client.
For pharmacists to assume population based roles both they as a profession and the community they work in need to believe that they are capable and suitably trained for it. This calls for a change in the way pharmacists are viewed and ere behave. Pharmacists must be comfortable with roles in population health and view them as opportunities. Studies have reported that while pharmacists valued population health functions, they were more comfortable with achieving health improvements through medicines. There is thus need for interventions to improve the confidence of pharmacists in using their skills for population health. From the community side, the public need to shift their view of pharmacists to see them as professionals that are also involved in population health services.
There are many ways that pharmacists could be involved in health promotion. They could carry out or be involved in education programmes on safe and effective medication as well as on other community health-related topics, such as exercise, health and nutrition. In major cities in Africa where pharmacies are readily accessible, this is a ready-made opportunity to provide valuable information on HIV and AIDS, on teen pregnancy and on other health risks. The increased use of the emergency contraceptive pill in some Africa countries may make people less concerned about pregnancy, but raise the risk of HIV transmission, undermining prevention programmes. On issues such as these, pharmacists should be in the frontline of providing information and protecting the public from such unintended consequences. Pharmacists can be involved in educational programmes that start at an early age, such as through school health programmes, to help children develop good health practices that can continue into adulthood. Their education programmes could also reach out to community leaders, legislators, regulators, public officeholders, school officials, religious leaders among others.
We also suggest that pharmacists participate in population health policy development. By linking social factors, lifestyles and the environment, in a holistic manner, to utilization of medicines, pharmacists can broaden the scope of prevention and population health. They can ensure that policies are formulated with a better understanding of the relationship between drug therapy and the many other factors that affect health outcomes.
These are some examples, and we propose that there be wider dialogue on how pharmacists can play a vital role in maintaining and promoting population health, especially in low and middle income countries. This should include participating in global, national, state, and institutional efforts to promote population health and integrating these efforts into their practices. There should be a role for pharmacists in improving community health through population-based care; in developing disease prevention and control programs; in providing health education; and in collaborating with local authorities to address local need.
To achieve this, the onus is on the profession to view such roles as opportunities and not as unnecessary burdens, and to take the next steps.
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 www.equinetafrica.org, http://www.muchs.ac.tz/ and www.pharmasystafrica.com
Throughout Southern Africa, there are few programmes to protect the health of workers, or occupational health. Public funding in the region for occupational health services and the enforcement of occupational health laws generally comes from tax or social security funds. However these funds are inadequate to do more than run basic systems. Programmes to develop personnel, do research or expand services into new areas such as for informal sector workers or for women, rural or other marginalised workers, often relies on aid from high income countries.
These areas are some of the more challenging areas of occupational health, and often those with greatest burdens to population health. They are thus important for workers, communities and countries. Yet as aid funded, the developmental objectives for such programmes are often set by funders, with little in-country stakeholder consultation, and with relatively unpredictable financing.
Two recent Southern African regional programmes have deviated from this. These are the Swedish International Development Agency funded Work and Health in Southern Africa (WAHSA) programme and the Fogarty International Centre funded University of Michigan Southern African programme in Occupational and Environmental Health. To their credit, and strongly contributing to positive features noted in the evaluation of these programmes, the international partners involved in both the WAHSA and Michigan programmes made efforts to consult with relevant stakeholders in the region. Nevertheless their objectives and support are still subject to the priorities of their funding agencies.
The “Paris Declaration on Aid Effectiveness” (the “Paris Declaration”) in 2005 established new ground rules. At the 2005 conference convened by the high income OECD countries, but also including developing country representation, a revised and co-ordinated approach to development aid was promised. The Paris Declaration aimed to better manage the process of providing aid; ensure alignment with national development strategies and encourage beneficiary control and leadership in development programmes.
There is already recognition of some gaps between the noble promises and the outcomes to date. A 2009 OECD report commented on some fragmentation of effort, observing that ‘‘the international development effort now adds up to less than the sum of its parts’’. Sixteen Sub-Saharan countries were noted to have between 24 and 30 external funders, and eight of these to have between 15 and 20 external funders, suggesting that the rationalisation intentions of the Paris Declaration have not been met. The north – south network ‘Reality of Aid’ (http://www.realityofaid.org/) noted that there has been limited community participation in setting in-country agendas for aid. In their January 2007 newsletter, the network argue that the influence of external funders in recipient country policies has persisted through funder -imposed conditions on funding. This was highly contentious during the discredited Structural Adjustment Programmes of the 1980’s, and a United Nations Conference on Trade and Development report in 2000 identified eighty two governance-related conditions out of an average of one hundred and fourteen conditions for each IMF and World Bank agreement in Sub-Saharan Africa.
Despite the promise of better co-ordination, the Paris Agenda has also left a significant gap in partnership on occupational health, despite recognition of the contribution of employment and workplace risks to health equity in the recent report of the WHO Commission on the Social Determinants of Health. Funding for occupational health does not seem to be on the agenda of any major bilateral funder (excluding foundations such as the US Fogarty International Centre and the US National Institutes of Health). Given negative experiences of early termination of long term external funding support to occupational health in the region in the 1990s, the Paris Agenda offered optimism for sustained predictable support to this neglected area. Instead, since 2005, two bi-regional externally funded programmes in Southern Africa (WAHSA) and in Central America (SALTRA) met early termination, as the funding agency realigned from regional to country support.
As the Paris Agenda discussions recognised, achieving meaningful impacts in health outcomes or in institutional policies, capacities and practices calls for long-term time frames and commitments to plans, backed by predictable resources and clear processes for monitoring, evaluation and reporting. Uncertain funding leads beneficiaries and funding partners alike to focus on quick returns, rather than deeper impacts. Funding agencies, partners and local recipients may thus set and focus on meeting targets that seem feasible in short term time frames to justify use or continuity of funding, while not adequately yielding the long term gains from these investments. So, for example, numbers trained may be given more attention as targets than longer term structural outcomes, such as the integration of trained personnel into positions in institutions where they are able to influence policy and practice.
Past experience with development aid in this area has raised more questions than answers. How do national and regional organisations involved in a neglected area like occupational health strengthen self determined planning, resourcing and negotiation of programmes and partnerships in conditions of volatile external aid? How can unpredictable, limited and often inadequate funding be organised to support longer term capacity development? How can just demands for accountability and effectiveness be aligned to equally just demands for predictability and recognition of complexity? How best can the self interests of different partners be made explicit, negotiated and factored into partnerships from the beginning?
One way of addressing national leadership must be for countries to improve their own resources for occupational health, not just to run the systems, but to enhance and improve them. If we pursue “fair trade not aid”, then occupational health could be funded in a sustainable manner from improving returns on economic activities and strategic resources in the region. During the structural adjustment era, occupational health responsibilities were deregulated and corporate obligations and taxes reduced to attract foreign investment (which often did not materialise). The public health costs of structural adjustment in Africa are now recognised through the Macroeconomic Commission on Health. Claims for improved public funding for the health sector have had greater recognition, such as in the 2001 Abuja commitment made by African heads of state. There has not been a similar recognition for improved regulation and funding for occupational health. Yet as production and financial activities are increasingly globalised, with recognition of the environmental, economic and social obligations this generates, so too should investment in occupational health be prioritised and located as a matter of international responsibility, in line with fair trade, economic justice and rights to health.
It is time for a movement from within and beyond the trade unions, occupational health, economic and trade justice communities to link with the public health and health justice activists to raise occupational health within global, regional, national and local agendas. To support this with sustained and self determined action within the region, we need to strengthen regional organisation and networking to provide evidence for and engage with local and regional policy, including with intergovernmental forums such as SADC, to ensure sustainable domestic and regional resourcing of occupational health, and to advocate on the priorities for occupational health in the region within the international community.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For more information on occupational health in the region visit the EQUINET website and the WAHSA website at www.wahsa.net