If you cross paths with Robert Zoellick's mother over the next few weeks, please remind her that applications to George Washington University's School of Public Health are due soon. Her son needs to hurry up and submit his paperwork. Mrs. Zoellick might be surprised at the suggestion that her son Robert, US Trade Representative, should go back to school. She might tell you that her dear Robbie already graduated magna cum laude from Harvard's Law School and received an MPP from the Kennedy School of Government. Mrs. Zoellick might say that her son's overqualified for his job. The only problem is that Robert Zoellick has been making a lot of decisions about public health lately - and in that realm, he is terribly uninformed.
Take, for instance, his actions last month at the WTO council. Trade representatives from the other 143 member countries of the WTO decided that the poorest of nations - those without any pharmaceutical manufacturing facilities - should be able to import cheap generic drugs, since they can't pay for the more expensive patented versions. But Mr. Zoellick became the only minister at the WTO to refuse to agree to the measure.
This isn't the first time that's happened. Back in December, Mr. Zoellick did the same thing just before Christmas. The issue was how to implement the WTO's "Doha Declaration" on public health, which the WTO (with Mr. Zoellick's vote) passed in November 2001. That agreement declared that the patent rights of drug companies should be secondary to public health concerns to "promote access to medicines for all." In the agreement, the WTO promised to determine how countries without manufacturing facilities were going to import generic drugs.
But Mr. Zoellick decided that he would "reinterpret" the Doha Declaration. He claimed that the Declaration was not really about promoting "access to medicines for all" (in spite of the wording in the Declaration itself) but it was really only intended to cover a short list of diseases. He came to the table with a list of 15 diseases he thought were suitable. The only problem was that major killers like cervical cancer and pneumonia were not included. Mr. Zoellick said those diseases not on the list were "lifestyle" disorders. So the three million kids who will die from pneumonia in Africa this year better whip themselves back into shape and learn to change their ways. Some of the other trade ministers thought this was a bit perverse, and refused to agree to that deal.
February was supposed to be a finalization of the delayed negotiation process, but Mr. Zoellick came to the table with a new set of rules, once again using his "alternative" theories of public health practice. This time, medicine access would not be restricted to just a short list of diseases, but countries would also be restricted to importing generics only after a "national emergency." So health ministers in Burkina Faso, which is currently in the beginning stages of a major meningitis epidemic, should sit tight and wait for a couple hundred thousand people to die - then they can begin the legislative process to get medicines. Other rules proposed by Mr. Zoellick would be extraordinarily cumbersome. Under the system proposed, if Pakistan wanted to get cheaper drugs from an Indian generic manufacturer, the Indian government would have to pass legislation for Pakistani citizens. How politically pragmatic!
No one mentions, of course, that the very measures Mr. Zoellick is pushing on the poorest of countries are far more stringent than those followed by the United States. Remember the anthrax scare? After only four deaths, Congress was threatening to import generics immediately if Bayer Corporation didn't produce its anti-anthrax drug quickly enough. But other countries, of course, aren't allowed to do the same when they have real public health crises.
I pity Mr. Zoellick's public relations officer, who will no doubt be working long hours to generate an entirely new system of logic justifying the nature of these deals. But, of course, there's plenty of support for Mr. Zoellick and his worker bees at the Washington trade office. It comes from the pharmaceutical industry, as was made explicit at the WTO council. Instead of negotiating with each other, the trade ministers declared they would just circumvent the whole process and start negotiating directly with Pfizer. Companies like Pfizer don't want a break in their global monopoly on prices. But if the most profitable industry in the world can't handle the fact that poor countries represent a tiny percentage of their pharmaceutical market, then our trade ministers need to be able to stand up to them and defend the Doha Declaration.
The industry, and the USTR, claims that generics would undermine their capacity to pay for research and development - that is, the research and development that American taxpayers actually foot most of the bill for. The industry doesn't bother to release it's own tax information, however, which reveals that Merck this year used 13% of its profits on marketing and only 5% on R&D, Pfizer spent 35% on marketing and only 15% on R&D, and the industry overall spent 27% on marketing and 11% on R&D according the Securities and Exchange Commission. That's not accounting for the fact that 52% of new drugs on the market aren't even the result of R&D, but are "me too" drugs that are simple reformulations of old products slapped with new stickers.
The industry still claims that generics will undermine its business, even as it continues to be ranked by Fortune Magazine as the world's most profitable industry for 11 years in a row (having profits as a percentage of revenue nearly three times the rest of the Fortune 500 industry). When confronted with the fact that Africa comprises only 1.3% of the industry's revenues (making its loss equivalent to "about three days fluctuation in exchange rates," according to an industry analyst quoted in The Washington Post), the industry claims that generic drugs will get diverted to the North to undermine its key markets, and cites GlaxoSmithKline's recent loss of AIDS drugs sent to Africa as a case in point. But a look at the GSK case shows that Glaxo failed to even track the shipments and only discovered after a year that its packages to Africa had been shipped improperly, allowing them to be smuggled to Europe. Tracking mechanisms, however, seem to be no trouble for neighbourhood flower shops. Indian generic manufacturers, meanwhile, have shipped medicines for over two decades without a single case of "diversion".
It's time for Mr. Zoellick to learn what it means when 24,000 people die a day from treatable diseases; otherwise, he should take a fraction of the $20 million in campaign contributions pharmaceutical companies donated last year and use it for his tuition at the School of Public Health.
* Read more about the WTO negotiations in the 'Equity and Health General' and 'WTO, Economic and Social Policy' sections of Equinet News.
Editorial
Menstrual health is often mistakenly classified solely as a ‘women’s issue’. Yet with their link to reproduction and fertility, menstrual health and hygiene are not simply women’s issues, but matters of family and national concern. This is even more important in our region given the high share of adolescent females and women of child-bearing age in the population. In addition, the education, survival and health of girls and of women have an impact on the whole family. An appreciation of this impact underpins the global Sustainable Development Goal (SDG) 4 that seeks to ensure inclusive education for all, and SDG 5 that promotes gender equality.
So having just commemorated International Women’s day on 8 March 2018, and ahead of Menstrual hygiene day next month on 28 May, it seems fitting to discuss the issue of menstrual health.
In 2016, ahead of the 11 October global commemorations of the International Day of the Girl Child, UNICEF released a report entitled ‘Harnessing the Power of Data for Girls: taking stock and looking ahead to 2030’ (https://data.unicef.org/resources/harnessing-the-power-of-data-for-girls/). The report presented a rather sombre picture of the state of gender equality in low-income countries, pointing to an unequal division of labour in homes that continues to burden the girl child and impede her educational outcomes.
Zimbabwe, like other countries in the region, has recognised the importance of educating girl children. The country has, over time, made strides with regard to gender parity in education, but still faces gaps in achieving it. To address some of these gaps, the 2005 five-year National Strategic Plan for the education of girls, orphans and other vulnerable children set out to accelerate progress towards universal primary education and to promote equity and empowerment through education. However, with the health, social and economic challenges in the country, the subsequent five-year plans launched in 2011 and 2016 gave more focus to orphaned and vulnerable children. It could have been easy to forget the day-to-day problems girls face with their changing reproductive health. But in a positive step in 2017, the Zimbabwe government introduced a duty rebate on the importation of raw materials (pulp, glue and virgin tissue) used in the manufacture of sanitary wear.
It is not the only country in the region to be taking up these pro-girl child measures.
Kenya has repealed sales tax on sanitary wear. Furthermore, since 2011 the Kenya government has allocated approximately 3 million US dollars to support the distribution of sanitary wear in schools in low-income communities. In 2016, Zambia’s Ministry of Health launched its ‘National guidelines for menstrual hygiene management’. In 2017, the Department of Women in South Africa drafted a ‘Sanitary dignity policy framework’.
In August 2017, I had the opportunity to engage the Deputy Director General of the Department of Women, Mr Prince Booi on this policy framework document. He highlighted that the policy aims to widen access to sanitary wear for extremely poor girls and women, where the provision of this service helps to restore their dignity. The name of this policy framework resonates with me, as it underscores the link between menstrual management and dignity. Girls and women without access to methods and materials for the hygienic management of their menstrual periods experience a cyclical threat to their dignity. Monthly, it can strip away their confidence and may even inhibit their mobility and capacity to carry out physical activities.
In the 1960s in America President Lyndon B Johnson declared ‘a national war on poverty’, using the term ‘dignity deficit’ to highlight the effect on men of unemployment and their inability to provide for their families as breadwinners within the home.
Women were far less in focus at the time. But women’s reproductive health is an even more powerful sign of the dignity deficit as described in 2017 by Arthur Brooks in an essay in ‘Foreign Affairs’ (https://www.foreignaffairs.com/articles/united-states/2017-02-13/dignity-deficit). In it he paints the picture of a polarised America in which the rate of births for unmarried mothers is five times higher in women reaching up to high school education than that of college educated women. This is even more profound in girl children. In my own advocacy work in Zimbabwe I have seen how unintended pregnancies lead to dropping out from school and a social reproduction of vulnerability, unemployment and poverty.
Indeed, when Scottish Member of Parliament Monica Lennon began lobbying in 2017 for a bill to ensure free access to sanitary products in schools, colleges and universities it was profiled as a bid to end ‘period poverty’.
The measures taken by Zimbabwe, Kenya, Zambia and South Africa are thus important equity measures, particularly in overcoming market barriers to menstrual health and dignity. They are also ahead of those taken in many higher income settings. Whilst the City of New York legislated in 2016 for the roll out of free sanitary wear in public schools, homeless shelters and prisons, sanitary wear is still subject to sales tax in other districts in the state and other US states have not followed its example. At the same time, African countries can also look to other countries for further good practice. The 2013 documentary ‘Menstrual man’ and the 2018 movie ‘PadMan’ illuminate the work of Arunachalam Muruganantham in India for example. He confronted gender barriers in championing menstrual management and inventing a low-cost sanitary pad-manufacturing machine that is now used by rural women in India to locally manufacture sanitary pads.
These market measures and initiatives signal a potential shift in the recognition of the importance menstrual health in countries – taking it from a position of being hidden to one that is profiled and addressed in the public sphere, and more importantly an issue that has implications for equity and dignity.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.
Pneumonia is one of the top five deadly diseases for children in Malawi. It causes more deaths than measles, malaria and AIDS combined. Infection with Streptococcus pneumonia and can cause a range of illness, from relatively mild ear infections to fatal pneumonia, meningitis and sepsis. It was estimated by Ministry of Health in 2011 that childhood pneumonia accounted for 18 percent of deaths of children under five years.
This death is avoidable and unnecessary. Childhood pneumonia is preventable through living in a well ventilated housing, avoiding indoor pollution through using improved stoves, pot lids and clean fuels among other factors. It can also be prevented with a simple vaccine.
In November 2011, World Pneumonia Day, Malawi launched and added the new pneumonia vaccine (Pneumococcal Conjugate Vaccine (PCV 13) to its routine immunization chart. Bright Masangwi Chisale (male) was the first child to receive the new oral vaccine in Lilongwe-Malawi. His immunization was presided by Malawi’s Minister of health Hon Dr Jean Kalirani. In 2012, 1.2 million Malawian children under the age of one will be vaccinated against pneumonia. This is being co-financed by the Government of Malawi, with government putting in $0.20c per dose and the Global Alliance for Vaccine and Immunization(GAVI Alliance) putting in $11.17 over three years for each of the 1.2 million children immunized to cover the systems, vaccine and outreach costs. These are huge investments and their effectiveness will need to be tracked in the expected improvements in child mortality.
Vaccines are one of the best technical options for disease prevention. Many vaccines, not all, protect a child for a lifetime. As they are one of the most cost effective interventions to prevent illness, they should be given priority in the allocation of resources, particularly in a low income country like ours with many competing health priorities.
However without GAVI support the introduction of the vaccine would not have been possible as the cost would have been too high. It is encouraging that in 2011 vaccine manufactures gradually reduced vaccine prices. However the costs remain high. Malawi pays 15 cents to 20 cents per dose for its vaccines. But it is estimated that the vaccine for pneumonia cost $2.50 to $3.50 per dose. With Malawi’s total government expenditure on health at $22.00, this cost would be unaffordable. Unless there are further reductions in vaccine price it will be difficult for countries like Malawi to afford these effective technologies to prevent childhood and adult mortality, without depending on external funders.
Even the most effective vaccines will only have an impact if they are actually made available to the children who need them. The need is clearly higher in low income countries like Malawi. So should the funding of vaccines be a matter of ad hoc external funding? Or should vaccines rather be considered a global public good, to be funded more predictably at global level, and equitably allocated to countries based on their populations and need.
It will then be up to the country to ensure vaccine outreach. Low income countries like Malawi are able to achieve high vaccination coverage rates through primary care services and outreach campaigns. Malawi has achieved such high coverage as immunization services are administered by the cadre closest to communities, the Health Surveillance Assistants (HSA), who are trained to administer the vaccine. These cadres are found in the most hard to reach areas, and are given support from Ministry of Health. While the programme has support from World Health Organisation, UNICEF, the GAVI Alliance and civil society, the delivery system through primary care cadres is a primary responsibility of the government.
It is possible to ensure that no child dies from a vaccine preventable disease. However this needs the vaccine industry to continue to make vaccines cheaper and more accessible. It needs global level funding for vaccines with a mechanism for predictable and equitable collection and allocation of global funding of vaccines as a public good. It needs governments to resource a health system that ensures a chain of delivery of the vaccines to the community level cadres and facilities, and to all the adults and children who need them. It needs communities to take up the vaccines.
While the discussion today is on the vaccine for childhood pneumonia, tomorrow it may be other vaccines, such as those for malaria, typhoid or dengue fevers. It is a welcome development to hear that malaria vaccine trials are showing positive results in the sites where they have been tested. A vaccine for malaria will be a major contribution to public health in Africa.
Vaccines alone are not enough to solve all of our persistent health problems. We still need to focus on the deeper causes such as improving indoor air quality, improved nutrition, improved case management/ treatment and strengthening health systems, as this will produce much wider and long term health gain than vaccinations. However, ensuring access to pneumococcal vaccines should be something we do today to protect children’s right to life.
Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat: admin@equinetafrica.org
While individual organisations in civil society in South Africa are known for their struggles to ensure access to medicines, access to water, land shelter and other rights, September 2010 provided an opportunity for civil society across platforms and constituencies to build wider solidarity around poverty and inequality.
Since 1997, civil society in South Africa has gathered every two years to learn from each other, dialogue and debate, propose input into government policies and programmes and strengthen civil society’s role in challenging poverty and inequality. In 2010, this ‘NGO Week’ was on 20th-25th September in Cape Town under the banner of “Building Solidarity to Fight Poverty and Inequality” starting on Monday, 20th September 2010, ending with a Heritage Day Festival on Friday, 24th September 2010.
The week brought together a range of existing civil society campaigns, such as The Right to Health Campaign, The Peoples’ Budget Campaign, 16 Days of Activism for No Violence against Women and Children, Amplifying Feminist Voices and Building a Popular Education Movement. amongst others. The organisations that came together involve and work with a range of constituencies, including women, organised workers, health workers, people living with HIV and religious groups. The organisations included those that advanced issue based campaigns, like the Treatment Action Campaign, Feminist Forum, Women on Farms and the Learning Network, broad sectoral movements like Popular Education Movement and People’s Health Movement and membership based umbrella organisations like the South African Council of Churches (SACC), or the Congress of South African Trade Unions (COSATU). The gathering provided an opportunity for dialogue, self-organized workshops and sharing of case studies across the different groups, to build shared understanding on challenges and approaches to dealing with socio-economic rights. For example the campaign for the right to health, that includes the right to healthy living and social conditions and to access health care, was adopted by all groups as a common cause for all.
Over five hundred and fifty participants from civil society used the discussions and interaction to build and strengthen the kind of cross-cutting civil society platforms needed to tackle the multidimensional nature of poverty and inequality. Resolutions were made on actions that would benefit individual platforms but also have wider and more general impact, such as ensuring an enabling environment for the non-profit sector, or strengthening community action and participation around rights to health. These wider platforms call for strong networking across sectors, with strong leadership and accountable, transparent, democratic governance. Civil society organisations (CSOs) agreed that this calls for partnerships to build knowledge and learning between civil society and other institutions. Hence civil society was encouraged to partner with the twelve Higher Education and Research Institutions in the country, particularly the five in the Western Cape Province.
As a result of the deliberations of the week, the CSOs involved developed a number of resolutions on joint action (see http://www.sangocowc.org for the full resolutions). For example, as one outcome, CSOs are now interrogating and making input to the African Peer Review Mechanism (APRM) Report from South Africa. These reports have been adopted at African Union level to report on developments in governance on the continent. The CSO contribution in South Africa will feed into the draft of the Second Report on the Implementation of South Africa’s APRM Programme of Action, and through this into the wider continental discussion. Civil society resolved on a range of platforms to strengthen their role as a watchdog, to widen networks, to include champions from key stakeholder groups and to support and monitor our own programmes of action. The week ended with a cultural festival on the final day to commemorate ‘Community House’, which has a rich history as a hub of radical civil society organisations and trade unions.
The South African Non-Governmental Organisation Coalition (SANGOCO) was tasked to co-ordinate and monitor the implementation of the resolutions. SANGOCO is a coalition of civil society networks and organisations. It originated in 1997 to re-build civil society and the society at large within the context of a world where social justice and civil liberties are under attack. It aims to establish a strong and vibrant civil society that has capabilities and policy influence in the interests of people, especially poor people. SANGOCO seeks to hold government programmes and policies accountable for the extent to which they effectively serve the needs and interests of poor people. SANGOCO was mandated by the CSOs to coordinate sectoral and cross-sectoral working groups to take forward the resolutions over the next two years 2012.
It was important for us that civil society representatives from other countries in east and southern Africa participated in the events of the week, including groups from Namibia, Mozambique, and Malawi, as well as people from civil society centres as far afield as Denmark, USA and India. The lunchtime cultural events provided an interactive marketplace where people from civil society from across different countries discussed and exchanged experiences on common struggles. The South African organisations urged their counterparts in other countries in the region to also strengthen their umbrella bodies and networking on common platforms.
Poverty has many dimensions and inequality exists across a range of social and economic factors. South African civil society has recognized that while issue specific platforms help to raise profile and draw attention to specific areas of deprivation, we need to bring civil society together around common agendas to address the many dimensions of poverty and causes of inequality. Even more so do we need to bring together civil society across East and Southern Africa to tackle the much deeper levels of poverty and inequality in the region, given the degree to which our economies, societies, labour markets and trade are interlinked. The policy dialogues and debates that were held during NGO Week 2010 in South Africa have helped strengthen these cross cutting coalitions in South Africa. We hope that they spread throughout the region.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For further information on SANGOCO or the NGO Week please contact sangocowesterncape@telkomsa.net or visit www.sangocowc.org
Last month, I spent two weeks touring four countries in Southern Africa: Lesotho, Zimbabwe, Malawi and Zambia. The primary purpose was to view the link between hunger and AIDS. I want to look back at that visit, because little will have changed between then and now (except, perhaps, that things will have deteriorated further), and then look forward to the prospects for addressing the pandemic in 2003.
At the outset, however, let me express, yet again, the fundamental conviction I have every time I visit Africa: there is no question that the pandemic can be defeated. No matter how terrible the scourge of AIDS, no matter how limited the capacity to respond, no matter how devastating the human toll, it is absolutely certain that the pandemic can be turned around with a joint and Herculean effort between the African countries themselves and the international community.
I am weary to the point of exasperated impatience at the endless expressions of doubt about Africa’s resolve and Africa’s intentions and Africa’s capacities. The truth is that all over the continent, even in the most extreme of circumstances, such as those which prevail today in the four nations I visited, Africans are engaged in endless numbers of initiatives and projects and programmes and models which, if taken to scale, if generalized throughout the country, would halt the pandemic, and prolong and save millions of lives.
What is required is a combination of political will and resources. The political will is increasingly there; the money is not. A major newspaper in the United States, reflecting on the paucity of resources, used the startling phrase “murder by complacency”. I differ in only one particular: it’s mass murder by complacency.
You will forgive me for the strong language. But as we enter the year 2003, the time for polite, even agitated entreaties is over. This pandemic cannot be allowed to continue, and those who watch it unfold with a kind of pathological equanimity must be held to account. There may yet come a day when we have peacetime tribunals to deal with this particular version of crimes against humanity.
As bad as things are in Southern Africa - and they are terrible - every country I visited exhibited particular strengths and hopes.
The little country of Lesotho has a most impressive political leadership, but is absolutely impoverished. If it had some significant additional resources, with which to build capacity, it could begin to rescue countless lives. I vividly remember the Prime Minister of Lesotho saying to me: “We’re told repeatedly by donors that we don’t have capacity. I know we have no capacity; give us some help and we’ll build the capacity.” It’s worth remembering that Lesotho has a population greater than that of Namibia and Botswana, but it has nowhere near the same pockets of wealth. It has, however, one of the highest prevalence rates for HIV on the continent, higher than Namibia; almost as high as Botswana, and is fatally compromised in its response by the lack of resources.
Zimbabwe, whatever the levels of political turbulence, has created a sturdy municipal infrastructure for the purpose of dealing with AIDS. You will know that for the last couple of years, Zimbabwe has had a 3% surtax on corporate and personal income, devoted to work on AIDS. A good part of that money has been channelled down to district and village level, through a complex array of committees and structures which actually get the money to the grassroots. It’s visible in the work of youth peer educators, outreach workers and home care through community-based and faith-based organisations. In other words, for all the convulsions to which Zimbabwe is subject, there remains an elaborate capacity to implement programmes, if only there were more programmes to implement.
In Malawi, we may be about to see the most interesting of experiments in the provision of anti-retroviral treatment in the public sector. The Government of Malawi had originally intended to treat 25,000 people based on receipt of monies from the Global Fund. They then realized that the calculation of 25,000 was based on the purchase of patent drugs, but now that it is possible to purchase generic drugs, the numbers eligible for treatment could rise to 50,000. There has been, predictably, a great deal of skepticism in the donor and other communities. However, while we were in Malawi, the country was visited by a WHO team which carefully examined the capacity and delivery issues, and came to the conclusion that treating 50,000 people, phased in of course, was entirely possible. This is an exciting prospect: the treatments are meant to be free of charge, and delivered through the public health sector.
Zambia, whatever the difficulties - and they are overwhelming - is emerging from the bleak and dark ages of denial into the light of recognition. The bitter truth is that in the regime of the previous President, nothing was done. He spent his time disavowing the reality of AIDS, and hurling obstacles in the way of those who were desperate to confront the pandemic. I can recall personally attending an annual OAU Summit on behalf of UNICEF, and sitting down with the then President Chiluba, and asking him what he intended to do about AIDS, and he simply wouldn’t talk to me about it. Well there’s a new President in Zambia. And although he’s been in place for only one year, everyone agrees that there’s a dramatic change in the voice of political leadership around the subject of AIDS.
The fact is that in every country, even under the most appalling of human circumstance, there are signs of determination and hope. Whether they can be harnessed in the name of social change will be known in the year 2003. God knows, there are incredible hurdles to leap.
The World Health Organisation Director General (D-G) Margaret Chan described the recent WHO Executive Board meeting on 21-26 January 2008 as ‘stimulating, constructive and instructive.’ Chan challenged member states’ to provide her with direction regarding the contentious issues facing the WHO but the meeting failed to break the deadlock on issues regarding the selection criteria of the D-G and on how to deal with the International Migration of Health Personnel.
Developed countries opposed the inclusion of regional rotation in the selection criteria for the D-G, alleging that this may undermine the selection of competent candidates. However, many developing countries supported regional rotation as a selection criterion in order to promote balance amongst the regions who have had candidates as Directors-General, while not compromising on competence. The current selection process includes expensive campaign programmes that poor countries cannot afford to mount. Inclusion of the principle of rotation will go a long way to levelling the playing field.
The options presented in the Executive Board report on what the options were for addressing the proposed selection criteria changes were: (1) maintaining the status quo; (2) special consideration to candidates from certain regions; (3) and (4), two related options, considering geographical representation as the criterion for the establishment of the shortlist; (5) considering geographical representation as the criterion for the eligibility of candidates; and (6) using the same system of regional rotation as that applied to candidatures for elective office.
Board members supporting regional rotation of the post of D-G emphasised the need to ensure an equitable selection process and a level playing field among regions. They noted that no D-G had been appointed from three of the six WHO regions, even though qualified candidates from those regions had been proposed in past elections. Board members in favour of maintaining the current system said a pattern of regional rotation would necessarily restrict the choice of candidates, and would not therefore ensure that the most qualified person was elected.
One proposal was that the D-G be elected for 5 years with contribution until all the regions have contributed a D-G. Then it will start again, with the exclusion of the region of the outgoing D-G. While some supported this proposal, others, particularly from high income countries did not. It was proposed that the matter be set aside for two years, to give regions a chance to discuss the issue and the board would decide on it in 2009.
Member states were similarly divided on largely North-South lines on the issue of the international migration of health personal. Issues related to a global strategy, a code of practice, compensation mechanisms, a look into the failing training practices in the developed countries and better data for managing international health worker migration were raised in the discussions.
The developed countries position on WHO’s role on international migration was mainly for collecting information and developing non-binding codes of practice. Many developing countries, on the other hand sought effective actions including a global strategy and compensation. Member states adopted polarised positions and decision making was again deferred, which effectively maintains the existing status quo. Countries in Europe and North America pointed out that migration can have positive effects, such as migrants returning home with useful experience. However it was noted by other states that only 23 percent of the 130,000 health worker personnel abroad came back.
Attention was given to WHO work on the global code of practice, a matter seen to be a high priority for Africa. Without health workers, the Millennium Development Goals in Africa could not be achieved, and it was felt by some that the D-G should work with member states to come up with mechanisms for receiving countries to invest in training health workers in originating countries and assist with incentives.
Particularly raised by low and middle income member states was the observation that developed countries have failed in their own training policies and are now armed with ways of getting health personal from lower income countries, handicapping national health plans and deeply weakening the health systems of these source countries . It was raised that financial, equipment and technical support should be given in compensation, that certain discriminatory policies should come to an end and migrant workers receive the same salaries and benefits as paid to nationals of host countries. Further, headway was urged in developing effective measures to manage migration.
However, it was also noted that migration was a personal choice and that countries dealing with the impact of migration should create ‘task shifting to broaden the types of health workers’ who can provide care. Some members felt that a code of practice would not carry the weight of a ‘soft law’ as it was non-binding and not any kind of law, whether soft or otherwise.
While the WHO Secretariat reported that it was now getting better data and dialogue in place on migration a consultative process should now take place at the Executive Board meeting in 2009.
The debate on these two widely different issues signal that there is yet weak consensus within the WHO Executive Board on key contentious issues facing the WHO. There appears to be agreement on the need to act on such issues, but not yet on the direction of action. A division on “north-south” lines has maintained a deadlock on issues regarding the selection criteria of the D-G and on how to deal with the migration of health personnel. Their deferral for further consultation and review in 2009 contradicts the need for clear leadership on action, with action on health worker migration and retention particularly essential and urgent for developing countries affected.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. EQUINET work on health worker migration is available at the EQUINET website at www.equinetafrica.org.
Are institutions that tap poor people’s desire for credit, shrinking Third World states’ already beleaguered welfare policies? The role of microfinance in poverty reduction, reducing risk environments for HIV and promoting private health insurance has attracted high profile interest since Muhammad Yunus won the Nobel Peace Prize last December.
Yunus’s Grameen Bank battled backward Bangladeshi patriarchal and religious attitudes to extend credit to millions of people. Poor women were typically arranged in groups of five: two got the first tranche of credit, leaving the other three as ‘chasers’ to pressure repayment, so they could in turn get the next loans. But a decade ago (at a time of lower foundation subsidies, new competitors, adverse weather conditions and a backlash by borrowers who used collective power of nonpayment), Grameen imposed dramatic price increases on loan repayments and resorted to extreme pressure techniques, including removing tin roofs from delinquent women’s houses. This reduced Grameen Bank’s main philosophical position - ‘We consider credit as a human right’ - to merely an argument for access, not affordability. This distinguishes Yunus from all rights-based social movements demanding ‘rights’ to free lifeline access to healthcare, AIDS medicines, education, housing, land, water, electricity, etc.
According to Munir Quddus, chair of the Department of Economics and Finance, University of Southern Indiana, the model needs more investigation: ‘The very nature of setting up groups leaves out the very poor who would be perceived by fellow members to have no ability to generate income and therefore high risk … microcredit simply deepens the exploitation of the women since the rates of interest charged by the bank in real [after inflation] terms are quite high; consequently, credit often worsens the debt situation and gives the husbands even more leverage.’
Evidence on South Asian microcredit and major credit programs suggest that credit does not necessarily have a positive impact on social relations. Many loans targeted at women are appropriated by male family members, leaving women as buffers between their spouses and lending institutions, with often stressful and violent results. Even where women’s incomes have increased, research found women’s work and debt loads also increased. Women’s access to credit does not guarantee improved confidence, mobility, control over assets, or freedom from violence. Therefore, microcredit must be interrogated to determine if it is really about poor people gaining control, or if it leaves structural and often global causes of poverty unaddressed.
For example, in 1998, when an emerging market crisis led to rising interest rates across the Third World, South African microlenders and borrowers were driven into bankruptcy by a 7% increase imposed over two weeks as the local currency crashed. In Zimbabwe, a 1980s US$66 million flood of World Bank financing revitalised the rural microfinance sector (initiated under 1940s Rhodesian rule) and reached 94,000 households. But within a decade, the peasant default rate was 80% - with repayment affordability being a huge factor (a typical lender’s overhead and collection costs on a small loan were 15-22% (including incorporation of a 4% default rate)). Michael Drinkwater’s (1991) detailed study of central Zimbabwe showed peasant farmers faced serious difficulties in servicing loans of just a few hundred US dollars, since average net crop profit was just $0.15/hour of labour, according to a 1989 Agriculture Ministry survey. This was compounded by ‘an overzealous launching of a group credit scheme’ and the ‘doubtful viability of high cost fertiliser packages’, inappropriate for the erratic climate. ‘The increase in credit use means farmers have to market more to stay solvent ... At the household level it is commonly debts not profits that are on the rise.’
This raises the question: ‘Is credit the most useful input for African peasants’ economic and social wellbeing, especially women?’ According to Mohindra and Haddad (2005), women’s health capabilities (opportunities to achieve good health) and health functionings (e.g. being healthy), ‘can be expanded via key determinants of population health, such as access to resources and autonomy’, with microcredit as a primary tool. But is microcredit really a tool for expanding access to health inputs when the structural disempowerment and malfunctioning markets that bedevil credit systems are added to the overall retreat of the Third World welfare state?
The question is important as Grameen-style microcredit is increasingly linked to health services ranging from education to insurance, including: the Niger CARE ‘Microcredit and Health Education for HIV/AIDS-Affected Women and Children in the Valley of the Widows’; the Philippine NGO Innovations for Poverty Action and the Green Bank marketing of health insurance and preventative care through 2000 microentrepreneurs; or
the International Medical Corps microcredit project to support local health programs in Eritrea. The Microcredit Campaign Summit pointed to many new opportunities to substitute microcredit for state or donor assistance in reproductive health education. But such schemes need to be questioned on: whether they deliver on resources and autonomy, how they change local power relations; and their record on arrears, social conflict and defaults.
Few rigorous studies document the relationships between financial vulnerability and health burdens. A study of a Dominican microcredit program, which made small loans to individuals to start or expand small businesses, included three communities: one with health promotion alone; one with microcredit alone; and one with both. The community with parallel microcredit and health promotion programs had the largest changes for ten of eleven health indicators. However, the study also traced health gains to improved ability to purchase commercial water supplies, making a link between microcredit and the demand on poor people to pay for commercial and privatised water. As the UNDP Human Development Report (2006) noted, microcredit is explicitly used to promote the market in essential services and enable poor households to meet the financing requirements.
While not denying the prospect that some microcredit schemes are worthy and effective, the criticisms raised offer warning. Claims made about microcredit as an overarching strategy to end poverty, change power relations, attack structures of inequality or improve vulnerable population’s health education should be treated with caution. Certainly, microcredit cannot stand in for decent social policy when it acts as a safety net, co-existing with and not transforming entrenched structures that generate poverty . In the worst case, microcredit can become an ideology explicitly hostile to state support for healthcare.
‘I believe that “government”, as we know it today, should pull out of most things except for law enforcement and justice, national defense and foreign policy, and let the private sector, a “Grameenized private sector”, a social-consciousness-driven private sector, take over their other functions.’
To illustrate the dangers ahead, those were words uttered in the 1998 autobiography of Nobel Peace Prize winner Yunus.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org. A more detailed analysis of the issues raised in this editorial can be found in Microcredit Evangelism, Health and Social Policy by Patrick Bond, Forthcoming in the International Journal of Health Services, June 2007.
In a 2015 report on the Representation and Participation of Key Populations on Country Coordinating Mechanisms (CCMs) in Swaziland, Lesotho, South Africa, Botswana, Zimbabwe and Zambia, (http://tinyurl.com/obuudjv) Aidspan noted that key population representatives (KPRs) “have often in the past been seen as somewhat token CCM members” and that “their ability to contribute, and the quality of their participation in the processes of these bodies [is] unclear”.
We believe indeed that building the capacity of KPRs to contribute their indispensable share to the governance of Global Fund-supported programs is a central condition for achieving the vision of ending HIV, tuberculosis and malaria as public health threats by 2030.
Women and girls, men who have sex with men, people who inject drugs, transgender people, sex workers, prisoners, refugees and migrants, people living with HIV, adolescents and young people, orphans and vulnerable children… Giving those groups a voice by opening the doors of CCMs to their representatives is a major step in the right direction. But to unleash their potential to be heard and become a trusted force for change, they need support to build essential skills and competencies.
The Global Fund and its success against AIDS, TB and malaria owe a lot to the extraordinary contributions of civil society representatives worldwide. With the new rules of engagement in the Global Fund governance systems, activists with high levels of formal education are now making room for a new generation of civil society representatives, whose level of preparedness varies considerably, as highlighted in the Aidspan report. These new arrivals must absorb a tremendous volume of information and data that is made available, at an increasing speed, about the Fund, its partners and health-related issues.
A variety of toolkits, manuals, guidelines, tutorials and training workshops has already been produced around Global Fund policies and processes. But these good initiatives are scattered, developed separately, written primarily in English, sometimes in French and Spanish, and generally not designed with a focus on the specific needs of less-educated or extremely marginalized groups. Let’s face it: how many KPRs have been efficiently trained through sporadic two or three-day workshops? How many have excelled basing their knowledge and understanding of program implementation through Global Fund orientation sessions? Self-education and workshops cannot by themselves be substitutes for a better structured and adapted training curriculum for KPRs.
In a 2014 study on the engagement in the funding model of key populations from 11 countries (at http://tinyurl.com/qxwuzd7), the Global Fund Board’s communities delegation observed: “In cases where community representatives had received capacity building over the longer term, KPs were empowered to engage, raise concerns, challenge existing power structures and decision making processes and influence final outcomes. In cases where capacity building was lacking, KP representatives were engaged only in a tokenistic way and faced stigma during the process, labelled as incompetent and seemingly reinforcing negative preconceptions about key affected communities”.
KPRs have access to extended networks and an intimate knowledge of the needs and priorities of some of the most hard-to-reach communities. They bring a unique expertise that other CCM members, be they doctors, academics, government representatives or other high-level officials don’t have. But to make the most of it, to enter CCM discussions confidently and influence public health decision-making in a credible way, they must learn to speak the language spoken at CCM meetings and in public health circles. They need to master the technical complexities of Global Fund procedures and be fully at ease with using the language of decision makers to represent the interests of their groups. This needs long-term capacity building.
We see four main components for such a curriculum, which could be conceived as a training-of-trainers program to reach out to members of marginalized communities in their own languages. Program management, from design to evaluation, is an area where KPRs and communities can bring true innovation, especially in monitoring and qualitative program evaluation. Good governance of their own community organizations is another essential component of their credibility. Advocacy is a third area that requires special skills, especially in the context of a complex international multistakeholder partnership. To develop and implement effective strategies that attract attention to their cause or to play constructive watchdog functions, KPRs must be able to conduct needs assessments and evaluations of service delivery systems, notably public ones.
Underlying those three areas, the importance of information literacy cannot be overstated. To keep learning, KPRs must develop essential skills to navigate their way through a vast and expanding array of information resources (websites, social media channels, mailing lists, databases, etc.). This is critical to building their networks, understanding where their priorities fit in the bigger picture, and keeping a strategic watch over the most relevant developments in their field of interest while avoiding information overload.
This may seem like a formidable challenge. The good news is that today’s internet offers cheap and reliable channels to deliver certified courses in multiple languages at no cost to participants, to connect to a global and diverse audience, reaching out to distant individuals at their own pace and offering a space for networking with their peers around the world. Although face to face training will remain indispensable to provide more targeted support, open online courses can offer an extraordinary channel to deliver training to very large groups, to monitor its results and to address concerns over fake, ineffective and costly training. The KPRs’ skills and knowledge gaps, as well as the technology to deliver a program that addresses them, can quite easily be figured out. For the Global Fund and its partners, it is mostly a matter of making this a priority and investing in the design and development of a curriculum for maximum impact, in a coordinated way.
Community leaders and KPRs represent the untapped ‘human resources’ of current and future public health efforts. By pooling together different capacity building initiatives and internet possibilities, public health training for KPRs is at our grasp. Let’s support their capacity to be heard, if we really hope to win the fight against disease.
A longer version of this post was published in Aidspan’s Global Fund Observer newsletter Issue 266 28 May 2015 http://tinyurl.com/pd7bhz3 and in R. Bourgoing’s Aid Transparency blog at http://tinyurl.com/owr4qb2 and it has been used with the authors permission. Hélène Rossert is a US-based Global Fund advocate and former Vice Chair of the Global Fund Board. Robert Bourgoing is an aid transparency advocate and trainer, and former Manager of Global Fund Online Communications.
The September 2011 UN High-Level Meeting on Non-Communicable Diseases (NCDs) has come and gone. The political declaration adopted by governments, is included in this newsletter. It points to the need for multi-sectoral public policies that create equitable health-promoting environments. It calls for action across government sectors and partnership across government, civil society and private sector to implement these policies. It mandates WHO to develop for consideration ‘voluntary global targets’ and indicators for monitoring by 2012, for accountability on the declaration. The Commonwealth issued a statement on 21st September welcoming the declaration as a commitment to deal with NCDs. Others, some included in this newsletter, raised concerns about the absence of clear commitments on funds or targets, such as on access to medicines or on regulations to curb trade in unhealthy products. Questions were raised on what can be achieved through a reliance on partnership and voluntary arrangements, with a call for stronger exercise of public health authority. The High level meeting on NCDs opened a window into the competing influences of politics, commerce, social movement and science on global health negotiations. While evidence of health need and feasible strategy is persuasive input to these competing influences, Thomas Gebauer asserts in this month’s editorial that ethical principles, such as solidarity, are fundamental to health, and must be applied in global negotiations that affect the human right to health.
A recent conference hosted by the Municipal Services Project in Johannesburg highlighted a growing tide of defiance from people around South Africa over privatisation and its impact on access to basic services. People travelled from all parts of South Africa to testify in the workshop on their experiences of hardship as a result of privatisation and unaffordable service costs, noting stories of evictions, and water and electricity cut offs. Most of these testimonies articulated the view that basic needs, such as water and electricity, are basic rights. Many highlighted the negative impact of reduced access to basic services such as water supplies on health and quality of life.
Among the delegates were representatives of non government organisations (NGO’s), academics, community based organisations (CBOs), and unionists. They consistently raised the constraints to service delivery under globalisation, privatisation and cost recovery measures, and their negative health impacts. Eddie Cottle of the Rural Services Development Network reported, for example, on the link between the cholera outbreak in South Africa and the introduction of user fees for water.
During the workshops, delegates discussed strategies to address the issue. Would a rights based approach or one centred on claiming legal redress for deprivation of basic rights be successful? Glen Farred from the Community Legal Centre noted that while the establishment of a constitution and a bill of rights provided certain opportunities, They were difficult to apply in the case of access to safe water. The meeting identified the need for a new wave of social mobilisation as being more important than legal battles in achieving constitutional rights around basic services.
The impact of foreign intervention in basic services was also explored. It was noted that the world’s water management continues to be taken up by foreign companies. Large dam projects funded by international finance institutions were also reported to undermine service access in poor communities. Medha Patkar from the Narmada valley India reported at the meeting on the struggle of people in the catchment area of one such large dam to stop the dam from being built. This dam was reported to be threatening 40 000 families, with thousands more homes reported to have been submerged since construction began. She described passionately the irreversible loss of a way of life, livelihood and wellbeing for indigent people and said globalisation, privatisation, and centralised management of the world’s natural resources made humanity itself one of the greatest threats to itself.
Patkar and others noted that the response to such challenges called for a social movement, able to strategise, resisting co-option by international agencies and able to resist neoliberal policies. Some role models were presented of health systems arising out of social movements, such as Daniel Chavez’s description of Porto Allegro, where strong mechanisms exist for citizen participation in municipal affairs.
The conference explored how such social forces for health are organised – and growing. Community struggles around access to basic services were seen to be snowballing, particularly when they have support from social movements around the world. More well established movements, like the youth activists and organised labour all noted their roles internationally in targeting access to serves and in building alliances with other community based organisations.
A growing social movement to pressure for basic services was thus seen as the greatest predictor of service cover. This was particularly the case as neoliberal forces have grown. As Yash Tandon noted:
“At Doha first world countries recaptured the gains won in Seattle through pressure and manipulation and aggressive tactics. The outcome was the pursuit of neoliberalism such that the markets must be opened to international competitors even for public goods. “
Market policies and inequitable development were viewed as primary threats to increasing cover of basic services. This drew attention to the potential impact of the proposed new African recovery plan - NEPAD - on access to basic services. Delegates observed features within NEPAD, including its commitment to deepen neoliberal market policies, that are likely to have negative effects for basic service access and generate increased social conflict over access to water, electricity and other basic rights. Whether poor communities obtain or lose access to safe water and electricity will certainly be one litmus test of whether NEPAD brings real recovery for African households.