In 2000/1 South Africa endured a cholera epidemic that spread throughout the eastern coastal region and to other provinces. It resulted in 265 deaths in five provinces and 117,147 people, mostly in the KwaZulu-Natal province, were infected. The epidemic was, according to the World Health Organization, the biggest such outbreak in Africa for the reporting period.
According to rural development researchers and the South African government, the policies of cost recovery had disadvantaged those for whom even a small charge of about R20 a month was too much. At its epicentre, those who could not afford new charges implemented in August 2000 were returning to traditional and untreated water sources and were falling victim to the disease.
The government declared the cholera epidemic an emergency and promised to provide a free six kilolitres of water to every household every month. A Municipal Services Project Occasional Paper 10, “Still Paying the Price: Revisiting the Cholera Epidemic of 2000–2001 in South Africa” examined the extent to which the response to the epidemic has led to sustained provision of safe water and improved sanitation to the poor. The evidence presented in the report suggests that there is a clear relationship between cost recovery for water, indifferent management leading to interruptions in supply, and vandalism.
In two communities - one at Nqutshini, a small settlement near the town of Empangeni on the banks of the Mhlatuzi River; and the other at Nkobongo, a developing low-cost housing area with continued informal settlements near Ballito, 40km north of Durban - there was some concealment and denial of the disease because of the stigma it carries.
In a number of cases where people fell ill, the family members were uncertain how to respond. Often the cholera victim tried to conceal and deny the disease, and this led to significant delays in seeking treatment. In one instance, a young girl died after hiding her symptoms for some time; in another, an older man had to be heavily persuaded before going to the hospital. The stigma associated with cholera complicated the acceptance of the need to avoid using river water, to treat this water, and, if sick, to seek medical assistance.
There were varying responses to the messages put out by the authorities on radio and television and carried by the Community Health Workers. Many in Nqutshini found it difficult to acknowledge that the river, from which they had always collected water, should be the carrier of disease. Some accepted that the water they were collecting from the river may be contaminated and need treatment, but others did not. Some saw the warnings against using river water as a way of forcing people to pay the monthly charges. It appears that for a period water was treated with Jik (bleach) by many, but this dropped off rapidly when the bleach was no longer available for free.
Scepticism about the official view was also associated with ideas reflecting a view of hostile external forces aiming to undermine the community, e.g. the belief by some that whites were spreading the disease through low-flying aeroplanes. In all cases, the MSP report on the epidemic presents vivid personal recollections of those who were afflicted, the dread it evoked, and the speed at which people’s health declined.
Comparisons between conditions during the epidemic in 2000/1 and at the time of fieldwork in 2003 revealed a number of improvements: Most people now accessed piped water closer to their residence or through yard connections and most used Ventilated Improved Privies (VIPs). Most people at the time of the survey felt their water to be safe to drink and did not treat the water.
However, there were ongoing complaints of frequent interruptions in the water supply through vandalism, burst pipes and for non-payment. In the two communities, the state was not providing Free Basic Water as promised, although the communities are both poor and thus generally vulnerable to cholera. At Nqutshini piped water was not flowing at all. Partly because of the dysfunctional water supplies, there was increased water storage by community members - an additional factor associated with cholera.
The incidence of diarrhoea among children in the household was found to be associated with extreme poverty, as were problems with accessing sufficient water, the ability to pay for water and the household having prior experience of cholera. All these factors - in particular the continued cycle of water-related disease in households over time - point to poor health conditions and continued vulnerability to disease among those living in extreme poverty.
The government’s policy of Free Basic Water has been unevenly implemented and greater attention needs to be given to meeting the needs of the rural poor and those in poor peri-urban communities who would most benefit from its provision. Poor communities need a reliable water service, which requires better municipal management. Interruptions lead to long storage of water, which poses a health risk to those who consume this water. Communities and households with a prior experience of water related diseases seem most vulnerable to recurrence. Health and municipal authorities should give priority to those communities with a history of water-related disease to end the cycle of disease.
The Municipal Services Project is a multipartner research, policy and educational initiative examining the restructuring of municipal sservices in southern Africa. See http://www.queensu.ca/msp/ to contact the project at Rhodes University South Africa to obtain copies of the full report.
Editorial
In May the World Health Assembly (WHA) will review progress on the implementation of its 2010 Resolution WHA 63.16 passing the WHO Global Code of Practice on the International Recruitment of Health. This was only the second non-binding code passed by WHO, after the 1981 Code on Breast Milk Substitutes, and its adoption was greeted with relief and optimism given the effort that went into it. Much of that pressure and momentum came from African regional bodies like the African Union, Southern African Development Community and ECSA Health Community and from their member states.
The Code contains some robust provisions for improvements of the health workforce within African countries and for responsibilities across countries, such as through bilateral agreements and leverage of international and national resources for the health workforce. The Code calls for health worker training and management systems within stronger health systems. It calls for coordination mechanisms that involve all players at national level. It sets provisions for information systems and data to monitor this. Article 7.2 of the Code provides for setting up and maintaining a database of laws and regulations on health personnel recruitment and migration. Although non-binding, it promotes accountability between countries as a means to track implementation, with a requirement for information on implementation on provisions of the Code to be reported to the WHO Secretariat every three years, and to the WHA.
So the stage was set for implementation, and the most enthusiastic implementation could have been expected from African countries. However in 2013 the activity, discourse on issues of health worker migration and sense of achievement and optimism that greeted the adoption of the Code are conspicuously absent.
In the report drafted by the Secretariat for presentation at the 2013 WHA only 13 African countries had established designated national authority, and by the end of 2012 only one African country had reported to the Secretariat on Code implementation. In total 81 countries had designated authorities and 48 had reported, but most of these were European countries. It seems thus that the situation has little changes since EQUINET last reported on this in an editorial in March 2012.
So if Africa continues to bear the brunt of the health worker crisis, if African stakeholders and countries have been so vocal and active in pushing for and negotiating for the Code up to its adoption, what is the reason for this lull in activity? Whither Africa?
The same questions asked in March 2012 are still pertinent. Why have African countries been slow to take advantage of the provisions of the Code to leverage benefit from them? Why have so few African countries established designated authorities to drive implementation of the Code or established bilateral agreements drawing on the Code to improve and retain their health workforces? Why has only one African country so far reported on the Code?
It will be important to understand these issues to inform future global health processes. The development process for the Code took nearly a decade since first mooted at WHO level, and longer taking other forums into account. In such a protracted process, the realisation of the Code may be interpreted as an end in itself. The champions for the Code may have changed, with loss of institutional memory, and those active in its negotiations may have moved on to other tasks at hand. Some have argued that the content of the Code does not reflect the original wishes of African countries for compensation or reparations, or for mutual benefits to be spelled out clearly. This may contribute to apathy for its implementation. As a voluntary, non-binding instrument it may be seen to have little effect. It may also be possible that without an active civil society lobby and with limited dissemination of information on the Code to local stakeholders there is weak pressure for its implementation.
The lull in activity since the adoption of the Code could be a lost opportunity to ride the tide of momentum and goodwill that characterised its adoption, a loss that may be difficult to reclaim. However there is still time for the concerted effort of the government and non-government players that played a role in the development of Code to apply their collective effort to ensure its implementation and to realise its benefits. At minimum the Code should be widely disseminated, discussed and follow up areas identified for national policy and diplomacy to support the training, management systems, health systems strengthening, coordination mechanisms, information systems and databases needed to ensure more equitable management across countries of health personnel recruitment and migration. There is need to set up mechanisms for institutional memory and processes that would run regardless of changes in personalities or of individual decision makers.
As a bottom line we are asking for the momentum and vigour that African health ministers, senior officials, professionals and civil society brought to the negotiation of the Code. It is not acceptable for African countries, having worked so hard and done so much to have the Code in place to let it fall at the implementation stage. As we approach the 2013 World Health Assembly we hope that the roaring fire of African voice that led to the Code has not become so hoarse during the negotiation that it is no longer audible!
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. The authors of this editorial are working on a research programme in EQUINET associated with the ECSA HC Strategic Initiative on Global Health Diplomacy to explore diplomacy on the Code. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
In the 1990s and early 2000s leaders of African countries persistently called for compensation for the loss of publicly trained health workers from low income African communities to the high income communities of Europe, North America and Australia. A November 2011 British Medical Journal paper by Edward Mills et al reported on the magnitude of the loss to health worker training investments in African countries to be US$2.17bn, ranging from $2.16m for Malawi to $1.41bn for South Africa. At the same time the benefit to destination countries of recruiting trained doctors was estimated at $2.7bn for the United Kingdom and $846 mn for the United States.
Despite acknowledgement that migration is driven by social, political and economic causes, it was deemed justifiable to take actions to more fairly manage these flows and their consequences. African countries made submissions in various international forums for governments of destination countries to notify governments of source countries on the number of health workers employed, their professional status and their contractual rights and obligations, and to provide equal treatment to migrant and local health workers. In addition, the African countries urged for restrictions on unethical recruitment and employment practices and proposed that compensation for losses from permanent migration could be organised through investment and tax remittance arrangements, and through technical and other resource inflows to support health professional training in Africa.
Responding to these pressures in the context of a crisis of health worker shortages in many African countries, in 2004 the World Health Assembly resolved to develop a multilateral response through a non-binding code of practice on the international recruitment of health workers. After consultation and negotiation, the Code of Practice on the International Recruitment of health workers was adopted at the 2010 World Health Assembly, almost 20 years since the World Health Organisation members agreed on such a code, the 1981 International Code of Marketing of Breast Milk Substitutes. Strong compliance by African countries with provisions of this code would advance us towards the diplomatic “finishing line” in the effort to more fairly manage health worker migration.
Regrettably however, by June 2011 (the latest reporting available) only 48 countries had reported even their National Authority for the code to WHO, with only 13 of these from Sub-Saharan Africa and only seven from the 16 in east and southern Africa (Kenya, Mauritius, Swaziland, Uganda, Democratic Republic of Congo, Angola and Namibia). More may have reported since then. The low reporting of even this administrative information raises concern about how far the code is known and implemented, and whether the reporting at the 2012 WHA will be an active tool to raise both its positive impacts and its shortfalls, or a passive bureaucratic ritual.
The 2010 code sets out the responsibilities, rights and ethical responsibilities of stakeholders to ensure fair recruitment and equitable treatment practices for the health workers who would have migrated, including to avoid recruiting health workers within existing domestic contractual obligations. Health workers are also obliged to be transparent about their contractual obligations.
In relation to health workforce development and health systems sustainability, the code discourages active recruitment from countries with critical health workforce shortages; encourages utilization of code norms as a guide when entering into bilateral, regional, and multilateral arrangements to further international cooperation and coordination; identifies the need to develop and support circular migration policies between source and destination countries; encourages countries to develop sustainable health systems that would allow for domestic health services demand to be met by domestic human resources; and places particular focus on the need to develop health workforce policies and incentives in all countries that support the retention of health workers in underserved areas.
The code appears to be a milder instrument than what African countries pushed for given that it is not legally binding. Its voluntary nature makes it a weak instrument as there are no specific commitments to return investments in stabilising the socioeconomic conditions of health workers or supporting training in low income countries. The code has become ‘the response’ to policy discussions on the relative costs and benefits of health worker migration. It does not fully address the African concerns that motivated to its negotiation and final adoption, but its presence has curtailed further discussion of these concerns.
One of the measures to assess the impact of the code is through monitoring its implementation and tracking the action taken by WHO member states. Member states are obliged to report to the WHO Secretariat on their actions on the code every three years, beginning in 2012. Given that the code is not fixed, and that its contents are considered as dynamic and subject to review, monitoring becomes one of the tools for keeping alive issues and concerns that were not fully addressed.
With the WHA only three months away, states, civil society and health worker associations should look for signs of progress, or otherwise, in the areas covered by the code, and ensuring that these are raised at the Assembly. Some of the questions this raises are:
Are there national coordination mechanisms for all relevant stakeholders and partners to facilitate policy dialogue and implementation on health workers?
Has there been any development of policies and practices since 2010 encouraging circular migration (such as migration within countries in east and southern Africa) and return migration from destination countries?
Is there policy or law requiring recruiters to follow ethical recruitment practices that covers state and private and non state actors?
Are there positive developments in collaboration of source countries and destination agencies or countries to sustain health worker development and training? Are there any new bilateral, regional, multilateral arrangements – soft law instruments – on health workers between source and destination countries?
Are there any new development assistance efforts (including mechanisms for compensation) to support coordination and collaboration on health worker migration between destination and source countries?
Are the regional bodies keeping and publicly reporting an annual scorecard of performance in the region against the agreed key indicators?
If the feedback on these questions indicate that the global code, as has been the case for many of its international precursors, is a useful signal of policy intent but not effective for managing costs and benefits, then the initial demand of the African countries for a more fair deal on the migration of health workers fairness still needs to be raised and addressed. African countries should use the forthcoming WHA in May of 2012, to strongly scrutinize developments around the implementation of the code. The results of this first assessment should help point towards concrete action to be taken on the implementation of the code.
Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat: admin@equinetafrica.org. For further information on the code visit http://www.equinetafrica.org/bibl/docs/Polbrief28%20Code.pdf
At this year’s World Health Day the WHO will be launching its annual report which focuses on human resources for health. In Africa, as we have raised in previous editorials in this newsletter, we are experiencing a ‘global conveyor belt’ of health workers flowing from rural, primary health care level in the public sector to urban, private care; from poor to rich areas and countries in the region and from the continent, with its high health needs and under-resourced health services to developed, high income countries such as USA, Canada, UK and Australia. The loss of public investment and social resources in this outflow is significant and outweighs any returns in remittances or aid for education.
However health workers will certainly continue to go to where they can work in adequately resourced health services, in decent jobs and where they can secure their own family needs. This draws attention to the much wider question of how in Africa we secure the resources to retain and value our health workers, and more widely to meet our population health needs. The latest EQUINET discussion paper, written by Patrick Bond and produced jointly by EQUINET with the Centre for Economic Justice in southern Africa points to a South-North drain of African wealth that undermines the resources for health and development, and that increases our dependency on the global North, and our loss of health workers.
The 2005 Commission for Africa report leaves the impression of a continent receiving a vast inflow of aid, with rising foreign investment, sustainable debt payments and adequate remittances from the African diaspora to fund development. Our discussion paper tells a different story: of significant and dramatically rising flows of resources out of Africa northwards, draining the continent of the important resources needed to address its own development, including in health. The paper synthesizes data about the outflow of Africa’s wealth, to reveal factors behind the continent’s ongoing underdevelopment, as the basis for proposing policy measures to reverse these flows.
The statistics speak loudly of a continent being progressively dispossessed of its wealth, and thus the resources it needs to improve health and human development:
* A debt crisis with repayments in the 1980s and 1990s that were 4.2 times the original 1980 debt levels, and annual debt repayments equivalent to three times the inflow in loans and, in most African countries, far exceeding export earnings, leaving a net flow deficit of by 2000 of $6.2 billion.
* Unequal exchange in trade and trade liberalisation policies that have lowered rather than increased Africa’s industrial potential and exacted an estimated toll in sub-Saharan Africa of $272 billion over the past 20 years.
* Flows of private African finance that have shifted from a net inflow during the 1970s, to gradual outflows during the 1980s, to substantial outflows during the 1990s.
* Falling foreign direct investment (FDI) from roughly one third of FDI to third world countries in the 1970s to less than 5% by the 1990s, and a shift to highly risky speculative investment in stock and currency markets – with erratic and overall negative effects on African currencies and economies.
Africa is commonly and mistakenly represented as the (unworthy) recipient of a vast aid inflow. Aid flows in fact dropped 40% during the 1990s, and the phantom aid that flows back to the source countries in technical and administrative costs was estimated in one study to be $42 billion of the 2003 total official aid of $69 billion, leaving just $27 billion in ‘real’ aid to poor people.
There is also a perverse subsidy in the extent to which industrialised countries exploit the global stock of non renewable natural resources . This takes place through the extraction of minerals and natural resources from Africa by Northern investors with little investment in return and few royalties provided. It also takes place through use of global goods like the earth’s clean air. Forests in the South absorbing carbon from the atmosphere are estimated for example to provide Northern polluters an annual subsidy of $75 billion. A method for measuring resource depletion used by the World Bank suggests that a country’s potential GDP falls by 9% for every percentage point increase in a country’s dependency on resource extraction. This implies, for example, that Gabon’s people lost $2,241 each in 2000, based on oil company extraction of oil resources,
These outflows deplete the resources available for productive and human development. They are felt most heavily by women and poor communities, and undermine progress towards the achievement of human security for the majority of African people.
They imply that the first step to effect genuine growth and to deliver welfare and basic infrastructure is for African societies and policymakers to identify and prevent the vast and ongoing outflows of the continent’s existing and potential wealth.
Current global reform agendas do not address these outflows. While they point to debt and unfair trade, they do not seek to reverse the outflow of African wealth.
Campaigns to reverse resource flows and challenge perverse subsidies are emerging from grassroots struggles and progressive social movements, such as those in Africa that are resisting privatisation and commodification of basic services, pressuring for rights to generic anti-retroviral medicines and resisting encroachments on human development through trade and macroeconomic policies that intensify inequities.
These grassroots struggles can be consolidated by national governments and regional co-operation to improve disclosure of financial flows and apply policies within Africa to prevent the outflows and encourage the ‘stay’ of domestic investment resources. The paper points to some options - systemic default on debt repayments, strategies to enforce domestic reinvestment of pension, insurance and other institutional funds; national-scale regulation of financial transfers from offshore tax havens; clearer identification and renegotiation of tied or phantom aid; and improved calculation and negotiation around of the costs of FDI (not simply the benefits), including natural resource depletion, transfer pricing and profit/dividend outflows.
EQUINET welcomes the focus on this year’s World Health Day on one area through which Africa is bleeding- its loss of human resources. We would however urge that to deal with this effectively in the continent, and address the inequity globally in the resources needed for health and human development goals, we need to deepen the debate. In 1998 EQUINET highlighted that a critical dimension of equity is the power and ability people have to make choices over health inputs and their capacity to use these choices towards health. For Africa this must surely include bringing control over the resources for health and development back within the continent.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org . EQUINET work on economic policy and health is available at the EQUINET website at www.equinetafrica.org
The WHO and Government of Brazil sponsored Conference on the Social Determinants of Health held in late October turned out to be a case study of how expectations materialized in a war of brackets added to the text of the original Rio Political Declaration on Social Determinants of Health (www.who.org ). The rich countries’ brackets and ‘toning-down-relativisation-adjectives’ won, despite fierce debate. This begs the question: Are United Nations declarations predictable?
The frustration in the halls ran so high that no less than three alternative declarations made it to the floor of the final day. One from the Peoples Health Movement (www.phmovement.org ), one from the Latinamerican Association of Social Medicine (www.alames.org ) and one from the International Federation of Medical Students’ Associations (www.ifmsa.org).
Dr Michael Marmot, chair of the Commission on Social Determinants of Health that produced the 2008 report said: …”Closing the gap in a generation is a rousing call. Did the World Health Organization’s Commission on Social Determinants of Health really believe it to be possible? Technically, certainly. …the evidence suggests that we can make great progress towards closing the health gap by improving the conditions in which people are born, grow, live, work and age. …..In the three years since ‘Closing the Gap in a Generation’ was published, there is no question that there is much to make us gloomy: the global financial crisis and the steps put in place to deal with it have worse impacts on the poor and relatively disadvantaged; the persistence of bad governance nationally and globally; climate change and inequitable measures for mitigation and adaptation and, in many countries, an increase in health inequalities….”
The weaknesses were clear. WHO Member States were reluctant to discuss or redress the power relations that year-in-year-out reproduce health inequalities. The social determinants of health cannot be addressed by just fixing policy coherence and inter-sectoral action in health as is being called for. Obscuring these realities of power under platitudes about inter-sectoral action and policy coherence across sectors only helps to perpetuate the continuing violation of the right to health. In fact there is significant policy coherence across sectors, including the health sector, influenced by currently dominant conservative economic policies which have also promoted a market approach in health care financing. Irrational global trade liberalization, capital flight and a continued unfair regime of patents, especially of medicines are clearly maintaining health inequalities. Comprehensive primary health care, with proactive community involvement, is the fundamental guide for an equitable health system. The progressive privatization of health care provision over the last three decades has seriously weakened capacities to organise comprehensive primary health care.
It is thus the stubborn combination of poor social policies and programmes, unfair economic arrangements, and bad politics that are depriving large numbers of people of opportunities to lead healthy lives. Reducing health and nutrition inequalities is critically dependent upon changes in the functioning of the global economy. Differences among countries; between social classes; between men and women; between corporations and communities result from the interaction of the different axes of power which end up critically determining which actions will be taken and which will not on the social determinants of health and nutrition. A willingness to transfer real power to communities is thus key to deal with the existing unequal power relations and with the measures taken to tip them in favour of dire community needs.
Despite the committed role all representatives of the Brazilian government and civil society in bringing out the deficiencies above, in the final Declaration, no mention was made of redressing the unequal power relations that lie at the base of the determinants. The Declaration thus proposes an apolitical agenda. In this respect it is a step back from the recommendations of the WHO Report on the Social Determinants of Health.
Peoples Health Movement and Alames in their declarations insist that the institutions, corporations and governments which promote the current state of affairs need to be confronted if there are to be any shifts in the way the social determinants of health are addressed. These declarations make specific proposals for how to do this. For example, WHO has led the way in developing a global regulatory regime for tobacco control and should do the same for the food industry. The financial sector needs to be held accountable for the economic crisis and contribute to addressing the vast resource gap in health by paying a small tax on financial transactions.
The Conference at best served for leaders to acknowledge social determinants of health as an ‘issue’. But it leaves us with the lingering question: Can the health and nutrition sector take upon its shoulders the tackling of the social determinants of health? We are the sector that picks up the pieces of a sick society. Putting our own house in order will not be enough.
The declarations referred to in this editorial are included in the newsletter. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. The views expressed in this editorial are the authors. For more information on the issues raised in this op-ed please visit the website of the World Conference on Social Determinants of Health http://www.who.int/sdhconference/en/ and of Peoples Health Movement at www.phmovement.org
The debt relief movement is poised for a historic day this October 1st when G-7 finance ministers discuss 100% multilateral debt cancellation for impoverished countries. Debt cancellation would free up significant funds for development, including fighting AIDS and strengthening health systems. You can help make this happen.
If you are a health professional, please lend your name to an international health professional sign on letter that will reach all G-7 finance ministers and presidents/prime ministers before this important meeting. This letter is copied below. If you would like to add your name, please respond by September 20th to aidsact@phrusa.org with your full name, degree, affiliation, and state/country.
International Health Professional Sign-on Letter
September, 2004
Dear G-7 Presidents and Prime Ministers:
We write to you as health professionals from diverse countries in Africa, Asia, Latin America and the Caribbean, North America, Europe, and Australia who strongly support debt cancellation for poor countries. Debt cancellation is a prescription urgently needed to help heal seriously ailing health systems – some of which cannot even provide minimal care – in many of the countries in which we live and work.
Debt cancellation would free large sums of money, funds that should be used to build stronger and more equitable health systems, which are desperately needed if the fight against AIDS and other killer diseases is ever to be won. Right now we are losing that fight. AIDS alone kills about 3 million people per year, as another 5 million people becoming infected with HIV annually. At the end of June 2004, fewer than 10% of people in developing countries in urgent need of AIDS treatment were receiving it. In light of the health crises that many of our countries face, debt cancellation is necessary on human rights and humanitarian grounds. We therefore urge you to endorse 100% multilateral debt cancellation for impoverished countries when the issue is discussed at the meeting of G-7 finance ministers this October 1.
We know that poor countries need this debt relief urgently. African countries alone are collectively spending about $15 billion per year servicing their debts to wealthy creditors, including multilateral institutions. The fifteen focus countries of the U.S. President’s Emergency Plan for AIDS Relief spent $10.3 billion servicing their debts in 2001; this is more than the $9 billion these countries are scheduled to receive over the Emergency Plan’s entire five years. The World Bank, IMF, and regional development banks are typically the largest creditors of the most impoverished nations.
Relief from debt could be instrumental in enabling countries to meet AIDS treatment targets, as well as other health goals. Your governments all support the World Health Organization’s (WHO’s) 3 by 5 initiative, which aims to get 3 million people in developing and middle-income countries on AIDS treatment by the end of 2005. Yet treatment goals cannot be achieved without health workers. And as so many of us know through our own experiences, many countries, particularly in Africa, have nowhere near the necessary numbers of health personnel. For example, WHO and the World Bank have reported that Tanzania and Chad, both countries that would benefit greatly from debt cancellation, require their health workforces to triple and quadruple in size, respectively, to achieve the Millennium Development Goals.
The connection between suffering health systems and the debt payments that limit funds available to them is palpable. To a significant degree, the severe shortage of health workers in Africa is a symptom of acute underinvestment in health systems, many of which suffer from too few staff, too few supplies, and too few drugs. This underinvestment is a central cause of the migration of health professionals to wealthy nations, where health systems are stronger and pay is better. Creating the conditions that will enable health professionals to remain in their home countries and allow them to provide the best care possible for their patients will cost money. Health care workers will continue to leave if they are unable to meet the charge of our professions: serving our patients. Our colleagues will continue to emigrate so long as they do not have medicines for their patients, or functioning equipment, or proper supervision. And they will continue to leave so long as they cannot support their families or be confident of their own safety. They need fair salaries, equipment to protect themselves from occupational infections of HIV and other diseases, and psychosocial support to help cope with the constant death and stressors they face.
Full multilateral debt cancellation for impoverished nations could go a long way towards meeting people’s right to the highest attainable standard of health. Indeed, debt relief that countries have received under the Heavily Indebted Poor Countries (HIPC) initiative has already begun to do so. In Malawi, savings from debt relief have paid for extra staff and support in primary health centres, nurse training, and improving the supply of essential drugs in health facilities. In Mozambique, debt relief funds helped increase the number of children receiving immunizations for tetanus, whooping cough, and diphtheria. Debt relief savings have also helped fund primary health care in Uganda, including salaries of health care workers, while countries including Uganda and Cameroon have used debt relief savings to help finance HIV/AIDS programs.
Debt cancellation is an excellent investment not only in people’s health, but also in countries’ economic well-being. Increased spending by impoverished countries in health, education, and other fields that promote human development, which will result from debt cancellation, goes hand-in-hand with economic growth. As WHO’s Commission on Macroeconomics and Health has highlighted, investments in health will increase worker productivity, creating economic gains that would far exceed the initial cost to creditors of debt relief. Debt cancellation will help put countries that are economically marginalized and heavily dependent on foreign aid onto paths towards economic autonomy and integration in the world economy. By contrast, without debt cancellation and other investments to reverse the spread of and treat people with HIV/AIDS, decreased worker productivity will make countries increasingly dependent on foreign assistance and unable to participate in the global economy.
We therefore urge you to support 100% multilateral debt cancellation for impoverished countries, including HIPC countries and as well as non-HIPC countries that are in need of this relief. We hope that your finance ministers will announce your governments’ support for such an initiative at their October 1 meeting. And we encourage you to work with countries whose debts are cancelled to ensure that their savings from debt payments are used on poverty reduction and human development. Countries can establish mechanisms to ensure that savings from debt services payments are used to reduce poverty and to promote human development. Uganda has established a Poverty Action Fund into which savings from debt relief are channelled, and which includes a series of procedures to ensure that the debt relief savings are well spent. Other countries, including Tanzania and Malawi, have established similar mechanisms.
We also encourage you to work towards a permanent solution to the debt of impoverished countries – including for countries that do not receive 100% multilateral debt cancellation and for any new debt assumed by those countries whose debts are cancelled – by creating a new understanding of what level of debt countries are expected to repay. In particular, we urge you to announce that from this time forward, countries will be neither obliged nor expected to make debt payments that would compromise their ability to meet their people’s basic needs or otherwise fulfill their people’s human rights.
We are health professionals. Our job is to heal. So it pains us to see debt payments siphoning away funds that could go far towards enabling our colleagues and ourselves do our jobs and meet the needs of the patients we serve. We fervently hope that you will help enable us to be the healers that we were trained to be.
Sincerely,
[If you would like to add your name, please respond by September 20th to aidsact@phrusa.org with your full name, degree, affiliation, and state/country.]
An EQUINET partner, the Centre for Health Policy at Wits University, has released a report examining policies in the SADC region on the retention of human resources for health. This report has been prepared for the Health Systems Trust (HST), South Africa and the Regional Network for Equity in Health in Southern Africa (EQUINET). It presents a review of issues in the regional policy context that are of relevance to the retention of human resources for the health sector (HRH) within the region, based on a rapid appraisal in selected countries and at regional level.
This work specifically focussed on the actions needed to stem the flow of international migration by encouraging the retention of health staff within countries. A particular concern raised across countries is staff retention in the public and rural services that preferentially serve the poorest populations. Importantly, policy documents and national respondents see the problems of retaining staff in these locations (the push factors underlying migration) as linked to the factors that undermine motivation and productivity. Policies to address retention issues (and so encourage health workers to stick and stay in country settings) are, thus, also likely to address poor motivation and weak productivity. In addition, these three sets of problems often go hand in hand with poor health worker attitudes and behaviours towards patients. So tackling these problems may have double benefits for health system performance – contributing to adequate availability of competent staff, as well as enhanced staff responsiveness to patients.
The report presents the findings of this work in sections 3-5 covering:
- Review of current international and regional HRH policy initiatives of relevance to the Eastern and Southern Africa region;
- Review of national level policy environments, with specific consideration of Malawi, South Africa and Tanzania;
- Implications for the future role of EQUINET in supporting implementation of HRH policy initiatives within the region.
In summary, the report notes that:
- encouraging HRH retention requires a complex package of actions/ /working through different entry points, rather than single policy actions;
- implementation of any HRH retention policy package is challenging because of the need to coordinate efforts across a wide range of governmental actors as well as get the support of a range of external actors;
- regional co-operation to support country level action to encourage retention appears to be, as yet, little developed, although recent discussions within the African Union and SADC, provide possible bases for such co-operation;
- current international initiatives may provide regional opportunities for addressing HRH problems (as a core constraint on health system development), but also hold the danger of over-burdening health systems, and in particular leadership and management within them.
In supporting initiatives to promote HRH retention within the region we suggest that EQUINET could, in broad terms, engage with others in providing a focal point for regional networking in support of HRH policy action. Such networking could, more specifically, focus on two sets of activities (see section 5 for details).
First, analytical work could fill current gaps by supporting cross-country analysis of the implementation of financial incentives, developing ideas and proposals around how to strengthen non-financial incentives and monitoring the impact at country level of externally driven initiatives on HR issues or initiatives (such as those for HIV/AIDS) likely to have impact on HR.
Second, dialogue and engagement with key actors (such as parliamentarians, senior health and other civil servants, professional groupings) could be supported by the development of policy briefs on key issues and collaboration with WHO AFRO, SADC, NEPAD and the AU.
* The report, which is available from http://www.equinetafrica.org/bibl/page.php?record=594, was presented at a "Policy and research meeting on equity in the distribution of health personnel in southern Africa" in August. The meeting:
- provided an update and recap on major policy issues and positions on HRH in east and southern Africa at the country and regional level;
- presented brief summaries of the work that has been done under auspices of EQUINET;
- identified policy positions and issues that require further research;
- explored capacity building and policy intervention within the region;
- identified priority issues in order to deliver clear agendas for action; and
- identified some key collaborations to assist in taking the work forward effectively.
The meeting report will be available on the EQUINET website at the end of September.
The urgent need for medicines to save lives, families and the fabric of our communities today impels a group of applicants (which includes the Treatment Action Campaign, unions and doctors) to launch a complaint with the Competition Commission in South Africa against two major international drug companies, GlaxoSmithKline (GSK) and Boehringer Ingelheim (BI). The complaint charges these corporations with excessive pricing in respect of several key drugs for the treatment of AIDS. The drugs are: RetrovirAE (zidovudine or AZT), 3TCAE (lamivudine), CombivirAE (AZT/lamivudine) and ViramuneAE (nevirapine).
This is a novel step that engages South Africa's sophisticated competition regulatory system in an effort to secure justice and rationality in drug pricing in the AIDS epidemic. Tens of thousands of people in our country are dying every year because of excessive prices for these medicines and because of government's lack of determined action to reduce the prices.
People living with HIV/AIDS, our doctors and nurses, the Treatment Action Campaign (TAC), the Congress of South African Trade Unions (Cosatu) and the Chemical Energy Paper, Printing, Wood and Allied Workers Union (CEPPAWU) have decided to act jointly against continued, unjust and insupportable drug company profiteering. South Africa needs affordable medicines now.
According to the World Health Organisation, the most commonly recommended triple drug therapy for HIV/AIDS is the combination of CombivirAE AZT/lamivudine) and ViramuneAE (nevirapine). We are placing the following powerful evidence before the Competition Commission: a month's supply of this treatment regimen at retail prices costs R1176.00 from Glaxo and Boehringer. By contrasts, the best-priced generic internationally cost R276.00 per month. The stark fact is that for the cost of one treatment from the brand name companies four people with AIDS can be treated on generics. We have additional evidence of excessive pricing for individual drugs.
Excessive pricing or profiteering by GlaxoSmithKline and Boehringer Ingelheim is directly responsible for premature, predictable and avoidable deaths of people living with HIV/AIDS, both children and adults.
For nearly four years, TAC and our allies have campaigned globally for drug companies to issue unconditional voluntary licences, against a royalty payable to the corporations of 4-5%, to allow generic competition and the lowest prices. This is a rational, fair and life-saving proposal. The drug companies have ignored it. Now we are asking the Competition Commission to investigate the complaint and to refer it to the Competition Tribunal.
We seek the following relief:
An order that GlaxoSmithKline and Boehringer Ingelheim stop the excessive pricing practices; A declaration that the excessive pricing conduct is a prohibited practice for purposes of damages claims by all persons who can establish that they have suffered loss or damage as a result of the prohibitive practice concerned; and An administrative penalty against the companies.
We are taking this action to ensure that:
The right to life is placed before profiteering; People living with HIV/AIDS who work can afford to buy medicines to save their lives; Children living with HIV/AIDS will get access to antiretroviral medicines; Medical schemes can afford to treat people living with HIV/AIDS without going bankrupt; Employers can treat their workers on a sustainable basis; and that Government shakes off the denialist paralysis and develop a national treatment plan.
We call on all people in South Africa and across the world to support this action taken by people living with HIV/AIDS, health care professionals, TAC, Cosatu and Ceppawu. We urge everyone to call on all drug companies to immediately issue unconditional voluntary licences for antiretroviral medicines to save the lives of millions in our country and across the world.
* Note: Equinet jointly with Oxfam GB will shortly be putting out a call for applicants for a grant looking at equity issues in relation to HIV/AIDS and particularly treatment access.
There is increasing global focus on building resilient and responsive health systems to improve population health. It raises questions: What constitutes a resilient health system? Is it one that is able to absorb shocks? Is it one that is able to anticipate shocks and engage with their political and economic determinants? To what extent has this language of resilience enabled an approach towards sustaining health systems in the most economically efficient manner feasible, with minimal public sector investments? And what does this mean for people’s rights to health?
A retrospective look at lessons from key moments in health policy, research and practice sheds light on some of these concerns. Key documents such the 1974 Lalonde Report, the 1978 Alma Ata Declaration on Primary Health and the 1986 Ottawa Charter from the first International Conference on Health Promotion focused policy attention on health systems built on prevention of health problems and promotion of good health. The Alma Ata Declaration emphasized investments in primary health care and highlighted that people have a right and duty to participate individually and collectively in the planning and implementation of their health care. The policy focus moved away from medicalized health systems to more inclusive ones, with community-engagement based on human rights principles.
There was however a shift in health policy from the last 1980’s. Primary health care approaches and health promotion strategies were criticized for being unmanageable, lacking clear measurable targets and being costly to sustain. Alternative, selective approaches were advanced, focused on specific diseases and measurable, cost effective interventions. Disease specific programs grew for key areas such as HIV and AIDS, tuberculosis, malaria and maternal health, with funding mainly targeting these programs. Funding and incentivizing disease specific intervention targets carries the risk of weakening wider primary health care measures, including for community participation in health decision making. A disease focus can ignore determinants of epidemics and other ‘neglected’ diseases, and set up parallel programming siphoning key health personnel from the wider health system to the better resourced diseases specific projects. These effects lead to health systems that have weak links to communities and wider health problems, that are neither resilient not responsive and that leave people exposed to outbreaks of epidemics, such as Ebola virus disease and cholera.
The mindset of efficiency over-riding other considerations in health systems was heavily reinforced in the late 1980s and early 1990’s, when the World Bank and the IMF introduced neoliberal structural adjustment programs as a condition for loans. The major budget cuts to the social sectors, including health, from these programmes are well documented. Economic models that imply that public expenditure on systems and social roles is wasteful or inefficient combined with a pressure of reduced public funding for health services, as reported in EQUINETs regional equity analyses in 2007 and 2012, reducing investment in comprehensive primary health care despite its pro-poor benefit and reinforcing the narrow disease focus. It also enabled the health sector to be judged by the same principles as other areas of the market, within development frameworks that heavily promoted the ‘free market’, despite the global market being anything but free. At national level, poverty reduction strategy papers that were seen as dealing with ‘transitional poverty’, segmenting it as an unfortunate by product of an essentially positive approach, metamorphosed into national development plans that conceptualised national health policies and strategies more from an economic than a public health perspective.
As raised in various reports, including by EQUINET, Oxfam and the Municipal Services Project, and by S Nishtar in her submission to the 2016 World Economic Forum, this mindset has opened the doorway in the current decade to the commodification of our public health systems in the market place, and in some settings to the sale of public assets or private sector roles that have commercialised the provision of health care and deepened inequities. The effect has been to slowly but surely weaken the role of the state in resilient and responsive health systems. It is therefore not surprising that the private sector role is growing in our health systems in the region, whether in terms of provisioning of services, or in the heavily promoted role of social health insurance and even voluntary and community health insurance (rather than mandatory insurance or taxes) as a vehicle for service funding, with the untested promise in the region of more resources and more efficient funding. As private actors have gained an increasing role in our health systems, they are also giving increasing voice to the private sector in health agenda setting at national and global level, most recently raised in the debates on the Framework for engagement of non-state actors in the World Health Organisation. It is thus not surprising to find that the current proposals on universal health coverage that we hear in the region are dominated by business models centred on health insurance rather than human rights principles.
These trends raise a challenge for us: To carry out research that critically interrogates that assumptions and paradigms introduced into our region and to explore how to defend and advance comprehensive primary health care and human rights based approaches in health systems. This implies more questioning from the region at global level of the assumptions that are driving this role of the market and the private sector in our health systems, and what implications it has for rights-holders and duty bearers. This has two evident implications: it implies that we cannot continue to allow a retreat of the state from the health sector, whether in terms of diminished funding, weakened regulatory power, public health services or participatory governance. It also implies that we bring communities, their rights and evidence, more centrally into the setting of policies, priorities and in shaping services, not simply as a means of taking on unfunded service burdens, but as the central resource for the state and public sector in building resilient and responsive health systems.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.
One by one in December, African countries in east and southern Africa signed interim Economic Partnership Agreements (EPA’s) with the European Union (EU). In a massive fragmentation of regional integration, first these agreements were negotiated in configurations that undermined African regional trading blocks (See EQUINET newsletter editorial May 2007). In November the fragmentation deepened as the east African countries broke from the ESA block to sign interim EU-EPA’s, as did Mauritius, Seychelles, Botswana, Swaziland, Mozambique, Madagascar, Zimbabwe and Namibia, individually. At the same time at the EU – Africa summit in Lisbon in December President Abdoulaye Wade of Senegal said "We are not talking any more about EPAs, we've rejected them", while countries like Namibia signed, but signalled intention to keep negotiating on protections for fledgling industries.
Its not only from Africa that conflicting signals are being sent. From the EU there is stated commitment to the two central goals of the 2000 "Cotonou Agreement": to eradicate poverty and to enhance the gradual integration of African, Caribbean and Pacific countries into the global economy. The EU has signed on to numerous UN and G8 commitments, including those on the Millennium Development Goals, and its own Treaty of Amsterdam. These commit the EU to policy coherence between development objectives and impacts and its policies in other areas, including trade. At the same time the interim EPAs being concluded are clearly focused on establishing free trade agreements strictly compatible with World Trade Organisation (WTO) requirements. While there is some reference to development issues, this is secondary and largely deferred to later dialogue.
Take for example the protection and promotion of public health as a fundamental issue not only for the MDGs, but in the International Covenant on Economic, Social and Cultural Rights (ICESR) (1976) and particularly Article 12. All parties to the agreement have ratified this convention. The EU founding document, the Treaty of Amsterdam commits that “A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities”. The African Charter on Human and Peoples’ Rights (1986) in Article 16, obliges ESA countries to take the necessary measures to protect the health of their people.
Despite this the Interim EPA texts made available in the region:
• Make no mention, as WTO agreements do, of the fact that clauses should be interpreted and implemented in a manner supportive of countries’ right to protect public health.
• Make no provisions for ESA countries to protect their infant industries, especially in small enterprises and in the small scale farming sector that underpins household food security and child nutrition in Africa.
• Make no exceptions to the elimination of import or export prohibitions or trade restrictions in areas such as trade in health workers, health services, essential services and other areas where governmental authorities and restrictions on trade are necessary to regulate provisioning or redistribute resources to meet social development goals, or to protect public health.
• Make no exceptions in clauses relating to internal taxes or charges in the interests of public health.
• Make no reference to “human development” or “social development” in the objectives of the section on economic and development co-operation
• Set no obligations for administrative arrangements or resources to assess or manage the public health implications of the liberalised trade measures proposed, including of obligations to carry out prior health impact assessments of specific areas of trade where there is a likelihood of risk to public health.
Such failure to address human development issues has led to criticism that the current EPA texts do not align with the 2006 adopted European Consensus on Development (2006/C 46/01) or the 2005 adopted EU measures to accelerate the progress towards attaining the MDGs [COM(2005) 132/final 2, COM(2005) 133/ final 2 and COM(2005) 134 final].
While there is pressure to secure WTO compatible agreements, the detailed tariff reduction commitments in the interim EPAs are argued to go beyond the strict demands of multilateral rules for the WTO-compatibility of free trade agreements, with costs to ESA countries. Gains from greater exports to the EU could be overshadowed by the damage done by the largely reciprocal market openings that ACP countries would have to undertake. The interim agreement accessed provides for 80% liberalisation in a period of 15 years. This would allow subsidised European food products, with which local producers would be in no position to compete, to effectively swamp ESA markets. Under the interim deals with East Africa, for example, taxes on two-thirds of imports from the EU would be eliminated with negative consequences for government revenue.
Such agreements are being signed at a time when the Doha Round on development is not yet concluded at the WTO, with Article 24 of GATT still being negotiated. Signing an interim EPA may pre-empt, or worse still weaken these WTO level negotiations. Reminiscent of the days of Structural Adjustment, it has been said that “there is no alternative” to the current trade focused EPAs. But trade experts indicate that alternatives do exist. Beyond significantly greater protection of human development issues in the EPAs’ as exemplified for health above, trade experts suggest that the EU could also have offered alternative trading arrangements under its Generalised System of Preferences (GSP+), particularly given the level of economic poverty and vulnerability in most ESA countries. It was possible for the EU to seek an extension of the waiver at the WTO, particularly given the delay in resolving the Doha round on development, given its significance for Africa. These options were not pursued, suggesting, as noted in an October 2007 analysis by the NordikAfrica Institute, that the primary EU goal for the EPAs was to secure free trade agreements within a strict interpretation of WTO rules.
The interim EPAs send signal an understanding of development and poverty reduction as being essentially driven by trade liberalisation, with development aid as a means of coping with the temporary, negative impacts of this agenda. It suggests that development will follow trade liberalisation and thus that other aspects of development should adjust to the terms of this free trade focused interim EPA.
The singular prioritisation of trade liberalisation, even while argued as “interim” fails to adequately protect basic social rights, such as the rights to health noted earlier. It also fails to adequately meet the EU’s own commitments and treaties and to draw on the EU’s own development experience, and the regulation and subsidies used in the EU to promote industrial and social development and services.
It also contradicts analysis and experience in ESA. After two decades of trade liberalisation policies, Africa Union and UN Economic commission for Africa reports in 2007 highlight uneven growth and growth with poor returns to human development and poverty reduction. Rapid, wide trade liberalisation policies have been associated with falling public revenues, increasing dependency on food imports, increased chronic undernutrition, reduced coverage and quality of and access to essential services, including health care services. In the health care sector, trade liberalization increases growth in formal and informal for profit health care services, with negative impacts on access, quality and segmentation in services, and increased fee barriers to care. Even the World Bank in a 2002 working paper concluded that rapid trade-related integration in Africa had caused or exacerbated social inequality and that those who benefited most were the import/ export firms, transport and shipping companies, large-scale commercial farmers, and financiers and the politicians and bureaucrats who are tapped into these commercial and financial circuits.
A model of development that is driven first through trade liberalization, with later “development” adjustments, negates the lived and historical experience, documented evidence and policy demands of Africa and of many development actors in the EU. Trade Commissioner Peter Mandelson said at a speech to the Civil society Dialogue Group in January 2005, “… I intend this to be a new start for the EPAs – to give the negotiations a new impetus – and to ensure that from now on, until the final implementation of what we will negotiate by 2008, development concerns have pride of place” . It appears his “pride of place” was the same marginalized exclusion the majority of disadvantaged communities in Africa occupy.
The process is not yet over. Some countries have yet to sign. For others, the interim agreements signed in 2007 still need to be ratified and deemed domestically operational, a process that will take to July 1 2008. Ratification in many ESA countries requires parliamentary endorsement. Could the parliaments in Africa and in the EU bring new “people’s” voice to this process and to future negotiations on the EPAs, and with it new attention to the health and development concerns?
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit EQUINET www.equinetafrica.org. or SEATINI (www.seatini.org)