There is longstanding stated policy support for health equity in East and Southern Africa. Social protest over inequality and pressure around delivery on these policies is equally longstanding, from struggles for political and economic rights to recent struggles over constitutional rights to food, water, shelter, healthy environments and health care, to hold the state and corporates accountable in relation to these entitlements, or to negotiate fairer benefit for Africa from use of its resources in the global economy.
So it confronts widely held social values when inequalities in health persist or widen, notwithstanding aggregate progress and economic growth. Why should women in Africa have 39 times the risk of dying in pregnancy and childbirth than those in high-income countries? Why, across the countries of East and Southern Africa should there be seven-fold differences in under five year mortality and 22-fold differences in the rate of women dying due to pregnancy and childbirth? Within some countries of the region nearly one in five children under five years die in the poorest households. Children of mothers with lowest education are five times more likely to be under-nourished than those with highest education.
People ask: Why shouldn’t all children, adolescents, mothers or households expect the nutrition, health and mortality outcomes of the most educated, wealthiest households or best performing geographical region of their country?
We live in an integrated regional community and global economy. Money, trade, raw materials and goods cross porous national borders. How then can such enormous differences between communities and countries be acceptable, particularly for conditions that can be prevented through technologies that have been known for over a century, including safe water, toilets, adequate food, decent shelter, access to midwives and so on? Why should huge numbers of people continue to suffer diseases of injustice?
In a 2007 Regional Equity analysis (http://tinyurl.com/9lrpl4e) , the EQUINET steering committee analysed the inequalities in health in East and Southern Africa and identified the policies and measures that could close them. The steering committee resolved to track what progress was being made in these areas, in a process called the Equity Watch. In 2012, EQUINET has produced a Regional Equity Watch that updates the 2007 analysis, drawing on a framework developed with review input from the East, Central and Southern African Health Community, WHO and UNICEF. The book is now available on the EQUINET website (www.equinetafrica.org) and acknowledges the many people and institutional contributors and processes that made input to it.
The 2012 Regional Equity Watch is essentially a watch on progress of what we know works to close gaps in health. It provides evidence on numerous policies and interventions that are being applied in health systems, agriculture, safe water and sanitation, in relation to employment and urbanisation and other areas that have closed gaps in inequality within the region. For example, investments in smallholder food production, especially for women farmers, have reduced inequalities in nutrition. Many countries have successfully implemented measures to encourage female children to enrol and stay in primary education. There are examples of activities that reduce urban poverty by enhancing employment, improving living conditions and investing in participatory planning, particularly in unplanned urban settlements. There are initiatives that have aligned national and international resources to support community management of safe water or to fund and support primary health care services and community health. There is promising practice in overcoming geographical differentials in access to health care through investments at primary care and community level, including through community health workers, community outreach, social organisation and participation, moving away from fee payments at point of care and integrating specific programmes within comprehensive primary care services. These practices underway repeatedly point to the possible.
However the 2012 Regional Equity Watch also asks why we are not making more progress in implementing the possible. It highlights that while there has been positive economic growth across most countries of the region in the whole of the 2000s, in many countries growth is occurring with increasing poverty and inequality, generating social disadvantage. Rapid, unserviced urbanisation, inadequate investment of profits and surpluses in new jobs, and significant disparities in access to agricultural resources, are common pathways found for growth with inequity. The Regional Equity Watch reports unacceptably slow progress in improving coverage of safe water and sanitation, low and unequal coverage of early childhood education and care and secondary education; inadequate public investment in improving access to land and other inputs for female smallholder food producers and inadequate resources - people, medicines and money- reaching and being absorbed by the community and primary care level of health systems. It raises concern about inadequate progress in formalising and resourcing mechanisms and capacities for participatory democracy and social power in health systems, particularly when observing the growing power that transnational corporates have in areas fundamental to health, such as in social determinants like food security or health service inputs like medicines.
Inequality within the region is overshadowed and underpinned by the scale of inequality globally. It points to a scale of inequality that needs to be more centrally and explicitly addressed in global dialogue, including on global development goals. At current rates of progress in narrowing the global gap in incomes, it would take more than 800 years for the bottom billion people – many of whom live in east and southern Africa – to achieve even 10 per cent of global income. The Watch points to the continuing net outflow of resources for health from the region, including through debt servicing, skilled worker out-migration, unfavourable terms of trade and extraction of unprocessed minerals and biodiversity. It questions the pro-cyclical, deflationary macroeconomic model that has dominated economic policy globally, given its failure to yield the sustained, inclusive or equitable growth needed to achieve social goals, and the unacceptable depths of deprivation and unacceptably wide and avoidable gaps in health and survival, and in coverage of services in our region. It raises frustration that slow progress in the strength, power and effectiveness of African voice in global decision making is being outstripped by a rapid pace of global extraction of African resources.
Many of the policy choices for a cohesive healthy society in East and Southern Africa raised in the 2012 Watch appear to be a matter of common sense. Beyond technical knowledge, therefore, their implementation depends on leadership and social action. In analysing progress and highlighting both the gaps and the possible, the 2012 Equity Watch aims to nurture and inform both the social intolerance for injustice and the affirmative leadership and demand for just alternatives.
Please send feedback or queries on the issues raised in this briefing or requests and comments in relation to the Regional Equity Watch 2012 to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org or download the 2012 Regional Equity Watch at http://tinyurl.com/8t2fqqf and http://tinyurl.com/8g6obf9.
Editorial
In March 2018, when African Union leaders in Rwanda signed the African Continental Free Trade Agreement (AfCFTA), there was much talk about it being a new chapter for the continent in furthering the socio-economic integration enshrined in the 1991 Abuja Treaty. It’s important therefore to ask- what implications does it have for health equity?
The agreement establishes a free trade area between African countries, liberalising 90% of trade in goods between countries, removing import duties on goods originating from African countries to enhance trade between them. On the one hand this can potentially promote sustained economic progress, with potential health gains if it offers benefits to all local producers, including small scale producers, and if the economic benefits are equitably distributed. On the other hand it can lead to risks to health if the laws and institutional mechanisms protecting health in cross border trade are not adequate.
One way to predict what the impacts of the AfCFTA may be on health is to examine what happened in previous trade liberalization experiences, specifically those in the International Monetary Fund and World Bank led Structural Adjustment Programmes. These trade liberalisation policies were implemented across Africa in a context of weak safety nets and protection of public sector services, including in health, education and agriculture. The decline of these services and economic inequality that arose after that experience raise questions on how the AfCFTA will be implemented.
Supporting a health sector calls for a range of areas of value-added production, such as for medicines and technologies. Our economies have still weak development of these areas of production and tend to import them, while exporting more or less the same products. So will the AfCFTA be accompanied by measures to promote investment for value added production in an organised collaborative manner, such as for infrastructures, equipment, technology and medicines for the health sector? Given that prior liberalisation policies have been accompanied by cost escalation for the ordinary person, will it assess and take as a measure of its progress a fall for the population in the price of essential medicines, commodities and services for health?
Most African countries have porous borders and many have weak capacities to check the quality and safety of goods crossing borders. When unsafe food products, chemicals, alcohol and other products that could harm health are poorly checked at borders there is a risk to public health. So too is the risk to health of cross border movement of substandard medicines. There are already reports by WHO of such medicines appearing in markets in some of our countries. Competition and wider markets provide a potentially health incentive for reducing prices of goods, so the AfCFTA could enhance access to low cost generic drugs from efficient producers within the continent. This benefit and the control of public health risk from harmful products and unsafe foods calls, however for significantly improved port health capacities in all our countries to accompany the flow of goods. Will the AfCFTA thus include specific measures to enhance these capacities in line with the International Health Regulations, and apply them at all the various points where goods cross borders?
If the AfCFTA promotes the freer movement of personnel, it could enhance availability and possibly accessibility of skilled personnel, including health workers, especially for countries experiencing acute shortages. But it could also do the opposite, as we have already experienced in our countries, where skilled health professionals are pushed or pulled to higher income areas and services, further deepening existing inequalities in their distribution. And the movement of people itself has the potential to spread disease across countries. So will the AfCFTA be introduced together with measures for training and resourcing personnel to manage the cross border spread of infection and to enhance equity within the continental access to skilled health workers?
The liberalisation of trade holds the promise of wider access to new goods and services, and to the spread of innovation across the continent. This can be very positive for health. At the same time changes in dietary patterns, employment conditions, physical environments and lifestyles can change consumption patterns in ways that are not always healthy. We have seen the consequences of this in the negative effect of consumption of processed foods and sweetened products in levels of obesity and diabetes for example. Our countries need strong public health laws and capacities and good communication capacities to manage such issues and avoid the epidemic of non-communicable diseases that has been witnessed in other regions.
The AfCFTA will certainly lead to changes in production and industries with implications for incomes and public revenues. As tariffs that protect domestic industries are removed, they are exposed to competition. If they have the capital and capacity to manage the change they may succeed, but if not they may close. For the public the question may thus be “what will happen to my job and my income?” Without adequate social security schemes in the continent, any significant negative shifts in jobs and incomes for countries who become net importers rather than net producers could be very harmful for health.
Given that import duties will be eliminated on 90% of goods traded between countries the public sector will lose the revenues generated from these import duties. Countries will thus need to diversify their sources of revenue. For some the growth in production may generate new tax revenue, for others that do not see the same production growth, their tax revenues may fall. As we have seen in the structural adjustment programmes, when this happens public health budgets are cut, with increasing dependency on external funders for the right to health care. As our countries intend to mobilise domestic financing for universal health coverage, what plans are there associated with the AfCFTA to make sure that it doesn’t lead to widening inequality in achieving this across the continent?
The AfCFTA could be a tool for fostering south-south cooperation on the continent, with a range of potential benefits for health. Countries could provide mutual support to strengthen areas of inadequacies and reduce inequalities across the continent. However, the issues raised above indicate that trade alone cannot achieve this without complementary measures to ensure wider benefits within and between countries, cooperation on production of health commodities and technologies, and strengthened capacities and measures to protect public health. As the negotiations to finalise the texts and implementation continue, it is imperative that the health sector takes an active role, not only to understand the implications of the AfCFTA, but to negotiate for measures in it that will safeguard the health of the people.
Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the AfCFTA text see https://www.tralac.org/documents/resources/african-union/1964-agreement-establishing-the-afcfta-consolidated-text-signed-21-march-2018-1/file.html
On 28 May 2008, the Institute of Tropical Medicine (ITM, Antwerp) hosted a workshop at the World Health Organization (WHO, Geneva) to review the evidence on positive and negative impacts of the global AIDS response in low-income countries in sub-Saharan Africa on general health systems and services. The workshop involved people working in AIDS and health services, in civil society and in academia with and from Sub-Saharan Africa.
The original question was simple and straightforward: what is the evidence to support or refute recent claims that global resources allocated to fight AIDS are over inflated and do little to support, and may even undermine, health systems?
Discussions quickly moved beyond this original question. The Alma Ata concept of Primary Health Care (PHC) – comprehensive PHC rather than selective PHC – proved to be a uniting concept. The real question became: how can the global AIDS response best contribute to the realisation of Comprehensive PHC? Most participants agreed that there are lessons to be learned – good and bad – from the global AIDS response, that will help us move closer towards Comprehensive PHC for all.
There is evidence of the global AIDS response strengthening general health systems and services, and there is also evidence of the global AIDS response weakening general health systems and services.
The most important point of stress identified related to the overall shortage of health workers. In some countries, the AIDS response was reported to have led to an ‘internal brain drain’, with health workers abandoning their previous occupations to work on AIDS programmes. In other countries, the AIDS response enabled improved working conditions of health workers across the board, helping to attract and or retain more health workers.
Without systematic reviews, or an agreed score card allowing us to add up the strengthening effects and to subtract the weakening, we cannot conclude if the overall result is predominantly negative or positive. However, the positive effects of strengthening general health systems and services seem be more likely where national public sector led strategies explicitly aimed for these positive synergies. This finding suggests that if recipient countries want AIDS funding to strengthen general health systems and services, they need to negotiate the needed flexibility from donors for this.
Therefore, we felt it would be more productive to focus on what measures promote positive synergies and avoid negative synergies - to support this, rather than trying to make a conclusive statement on whether the balance is currently positive or negative.
One key issue is the under-funding of health care in developing countries. Whether the objective is Comprehensive PHC for all, fulfilling the Right to Health obligation, or achieving the health-related Millennium Development Goals (MDGs), neither national nor international funding of health care measures up.
Scarcity of human and financial resources was observed to drive competition and rivalry. At the same time, health funding should not only increase, but also become more reliable in the long run. For ministries of health to embark to an ambitious health workforce programme, for example, a long term financing perspective is needed. It doesn’t make sense to increase training capacity today, if 10 years from now the additional health workers’ salaries cannot be secured to employ trained personnel. A new concept of sustainability adopted for AIDS treatment – where sustainability is based on domestic resources and sustained international funding – should be expanded to health systems and services, including salaries of health workers.
Most participants to the meeting acknowledged that AIDS activists have been more successful than the proponents of PHC at getting their priority high on the political and funding agendas. However, within the spirit of Comprehensive PHC, they saw this could be an opportunity rather than a threat, if this is used to equally raise the profile on general health systems and services, not to depress the profile given to AIDS responses.
Delegates felt the means to this was through renewed impetus for what is fundamentally a shared and uniting paradigm of Comprehensive PHC, including AIDS prevention and treatment, where:
• Health (and health care) is a human right, and an entitlement
• Programming and financing is adapted to needs and not to scarcity of human and financial resources
• Macroeconomic policies are adjusted to vital needs and not the other way around
• Concerns about the sustainability of health care is addressed as a shared global responsibility, depending as much on sustained national funding as on sustained international funding
• The people whose health is at stake are involved in the decision-making process
Where the global AIDS response has made significant progress on these issues, the benefits of this progress must be extended to general health systems and services.
Therefore:
• Governments must live up to their promises: governments of low-income countries must allocate 15% of their domestic government revenue to health while governments of high-income countries must allocate the equivalent of 0.7% of their Gross Domestic Product (GDP) to global solidarity, and 15% of that (0.1% of GDP) to health.
• These commitments should be open-ended (as long as needed), without aiming for national financial resources to replace international financial resources as soon as possible, as this would undermine the crafting of ambitious health plans, including workforce plans.
• Ceilings on health expenditure (included in policies imposed by the International Monetary Fund) must not hamper the realisation of the right to health or Comprehensive PHC for all.
• The people whose right to Comprehensive PHC is at stake have the right and the duty to be involved in critical decisions that affect their health.
• The global aid architecture must be reorganised in such a manner that it supports Comprehensive PHC for all, not one part of Comprehensive PHC at the expense of another; andGeneral health systems and services not only need strengthening, but also transforming: involving and working with communities as participants of health systems and services, rather than merely ‘clients’ or passive recipients of health services.
We found that the global AIDS response created real challenges for health systems and services, but also that there are ways to tackle and minimise them. The global AIDS response also created real opportunities, which should be maximized.
Comprehensive PHC is a uniting goal for all constituencies. It demands a significant mobilisation of knowledge, experience and additional funding. We cannot afford to repeat the mistake of three decades ago, when the ideal of Comprehensive PHC was abandoned as unaffordable, leaving us with the present health and health systems deficit.
This oped is not intended to be an accurate record of the meeting referred to which can be obtained from the authors located at Institute of Tropical Medicine, Antwerp [http://www.itg.be/itg/GeneralSite/Generalpage.asp]. EQUINET welcomes further opeds on the issues raised in this oped and on Comprehensive PHC, particularly from an equity perspective. Please send debate, comment or queries on the issues raised, or communications for oped authors to the EQUINET secretariat, email admin@equinetafrica.org.
The Global Ministerial Forum on Research for Health was held In Bamako, Mali From 17-19 November 2008, significantly the first time in Africa. The 'Bamako Call to Action' declared at the end of the meeting is the outcome of four years of meetings, dialogue and survey of key stakeholders the three days of the conference. As many researchers from the region would not have been present in these processes, this editorial, drawn from various public sources, captures some key features of the Call to Action, and provides a “fly on the wall” snapshot of some of the comments and reflections around it. The call and editorials cited are provided in more detail in this newsletter.
In the opening statement to conference delivered by the WHO Regional Director for Africa, Dr Luis Sambo, WHO Director General Dr Chan underlined the key role of research in keeping health high on the political agenda saying: ”We must have evidence and we need the right kind of evidence … because in most countries, an appeal to health equity will not be sufficient to gain high-level political commitment. It will not be enough to persuade other sectors to take health impacts into account in all policies.”
The Call to Action recognises that “Research and innovation have been and will be increasingly essential to find solutions to health problems, address predictable and unpredictable threats to human security, alleviate poverty, and accelerate development;” As one focus the call proposes establishing November 18 each year as a World Day of Research for Health.
National governments are called on to
• give priority to the development of policies for research and innovation for health, especially related to primary health care, in order to secure ownership and control of their research for health agendas;
• allocate at least 2% of budgets of ministries of health to research;
• improve capacity in institutions, ministries, and throughout systems for the implementation of research policies; and to
• develop, set, and enforce standards, regulations, and best practices for fair, accountable, and transparent research processes.
Further recommendations are made to promote the translation and exchange of knowledge and the build research capacities, including in young researchers.
Institutions at the regional level are encouraged to assist countries through international collaboration, where needed, to build and strengthen research for health capacity and to network researchers to promote the quality, ethics and sustainability of research. Meanwhile all stakeholders are called on to implement the recommendations from the WHO Commission on the Social Determinants of Health, especially those related to health equity, including to promote research on technologies addressing neglected and emerging diseases which disproportionately affect low- and middle-income countries and to ensure civil society and community participation in the entire research process.
To support this, funders and international development agencies are called on to better align and harmonize their funding and programmes to country research and innovation for health plans and strategies, and the global health research architecture and its governance to improve coherence and impact, and to increase efficiencies and equity in research. At least 5% of development assistance funds it was felt should be earmarked for the health sector in research, including for support to knowledge translation and evaluation and for national research institutions, especially in low- and middle-income countries.
From many quarters there has been a positive response to the call as a relevant step forward. The Lancet in its 29 November editorial declares that substantial advances have been made at Bamako on previous discussions, and the journal calls for 2009 to be “the year when the promises of Bamako are acted upon”. According to the Science and Development Network of 20 November 2008, the WHO has said that the Call to Action would be "used as a blueprint for research development approaches, with commitments made to submit the communiqué to the 2009 World Health Assembly and to the UNESCO General Conference. Ok Pannenborg, a senior health advisor at the World Bank, said: "The World Bank Group is extremely happy with the outcome, with its focus on research and innovation and research for health. This call will play a huge role in World Bank workings in the next four years".
The process itself was already reported by some to have had an impact. Aissatou Touré from the Institute Pasteur Dakar in Senegal reported in the conference, for example, that after the Algiers meeting, a decision was made to create a commission for research in the country’s health ministry, incorporating all the different actors involved in research for health to define the national research agenda for years to come.
But others were more critical: On SciDev.Net's blog on the conference one delegate asked ““We’re not saying anything new – what is the progress we’ve made?”
"There are no mechanisms in the call," said Damson Kathyola, director of research at the Malawian Ministry of Health, cited in the Science and Development Network review. "The WHO should [now] create innovation mechanisms for the monitoring and evaluation of the implementation of the strategies in the call. "We know that we need research to improve the health situation of our people in our countries. But there is a disconnect between policy and the implementers. Who's going to implement this?"
The World Bank, WHO, UNESCO, the Council on Health Research for Development (COHRED) and the Global Forum for Health Research have committed to set up a multi-stakeholder governance mechanism for research for health, including civil society, as a platform to take Bamako beyond 2008. The intention is to better network and support existing organisations. Will this work, or will it add another player to the increasingly populated work of initiatives and alliances? And how long will this take to be felt by researchers, health workers and communities in the lowest income countries?
The need to move more rapidly to action was perhaps the most common of the frustrations voiced. On the blog site for “Tropical Diseases Research to foster innovation and knowledge application (TropIKA ) “, Chris Bateman, News Editor of the South African Medical Journal is quoted as saying “Lots of fine words have come out. But, as a wild thought, how would it be if each of the 42 ministers were to tell the conference what they intended to do in the next year in terms of applying research to service delivery and filling the gaps where the needs are? That to me would give the conference real bite.” Dr Lindiwe Makubalo, Ministry of Health, South Africa, added further that “…..it’s really time to look at where the blockages are and try to move them”.
One blockage observed was the relative inequality in power in research– between international funders and countries and between researchers and communities, affecting how time and resources are applied. “Could there have been more representation from the groups we (researchers + communicators about health research) claim to represent? It would have been good to know the views of such groups as well,” asked one delegate.
Unless these blockages to implementing practices that are increasingly called for in documents and conference rooms are honestly identified and addressed, then perhaps BMJ Editor-in-Chief, Fiona Godlee, has basis for her more skeptical fears that in four years time, delegates will be having the same conversations at the next conference. Indeed, perhaps this caution, and concerns that resources now be directed to action, often at more local levels, lay behind the clause in the Bamako call to “evaluate the effectiveness and value of the four-yearly ministerial fora prior to convening a further high-level inter-sectoral forum to discuss global research for health priorities”.
Without any doubt, it is a success for South Africa, India and other co-sponsors of the TRIPS Waiver proposal, along with progressive political, professional and civil society voices, that the United States of America changed its position on the TRIPS Waiver. The waiver proposes a time-limited waive of patents and other rights related to essential health products for COVID-19 in the World Trade Organisation (WTO) TRIPS agreement.
The TRIPS Waiver proposals are now moving to text-based negotiations. If historical experience on access to medicines and the current power relations are anything to go by, the waiver proposers have grabbed the tail of the proverbial tiger in pushing for more distributed production of vaccines, diagnostics and therapeutics. What is to be done now that the US has agreed to talks?
It is important to understand that this stage does not represent agreement on the waiver. It has now merely advanced as an agenda item for discussion. The terms of the waiver have yet to be worked out. Even once agreed, implementation demands rapid support to increase production capacities for the range of products and systems that are able to distribute them, particularly in resource constrained settings. For all products covered, and particularly for vaccines and therapeutics, the waiver time frame and production capacities would need to be able to deal with current and emergent viral mutations and the updates required for a potentially endemic situation of an evolving virus.
Much remains to be done and the convergence of progressive forces that have pushed the waiver to this point need to robustly take on these remaining challenges to realise equitable access to vaccines, diagnostics and therapeutics.
The text-based negotiations and counter-lobbying by big pharma and others pose a risk of the proposals being diluted. As faced by HIV treatment activists in struggles over access to medicines, the proposals will face an incremental detraction from the largely wealthy countries seeking to preserve economic interests. Germany, the influential European power, remains opposed to the waiver, notwithstanding the US change in position. The tables seem to have turned on this. In the HIV-related Doha negotiations in 2001, the US played the ‘bad cop’ and the Europeans the ‘good cop’. While the European Parliament is largely supportive of the waiver it has limited legislative power, as intellectual property is in the European Commission’s domain. Further, the US trade representative to the WTO has said these negotiations will take time, as if they and not they virus are setting the timeline.
Already, the revisions that South Africa and India have made point to some of the areas that may be weakened: The duration of the waiver, with proposals for 3 years subject to renewal, must be adequate for the distributed transfer of capacities in an evolving situation. The necessary scope of technologies -vaccines, diagnostics, medical devices and therapeutics – is in the revised text and should not be whittled down. It is unclear if it will apply to patents only, or as in the current waiver proposal, to other key elements of intellectual property such as trade secrets, industrial designs and copyright.
The struggle for access to HIV-related medicines has much to teach. Two agreements were reached at the WTO, the 2001 Doha Declaration on Public Health, and the 2003 ‘August 30th Decision’. Both were victories to build on, but proved to fall short in meaningfully addressing access. They allowed rich countries that could not be seen to deny access to HIV treatments to virtue signal, but sustained hurdles for countries in applying the flexibilities they provided. This largely sustained dependency on imports for the lower income countries most affected by HIV.
The Doha declaration did establish the important principle of trade agreements being “interpreted and implemented in a manner supportive of WTO members' right to protect public health”, and levered improved, albeit not universal, access to HIV-related medicines. But, as the current pandemic has shown, they do not provide adequate measures for vaccines, diagnostics and other technologies essential for a public health response, and did not adequately shift priorities, power or production capacities to address unfair barriers in global trade rules to meeting public health challenges.
While the World Health Organisation (WHO) Director General has stood fast in articulating support for the waiver and called the inequity in vaccine access ‘vaccine apartheid’, WHO has less power in this debate and lacks the enforcement mechanism that the WTO has for its rules. WHO was out-manoeuvred by the Gates Foundation and rich countries’ preference for the ACT-Accelerator and COVAX at a time when the deeper proposals for patent pooling and technology transfer were made through the COVID-19 Technology Access Pool (C-TAP). The delay in enabling distributed production and weakness of COVAX is already evident in the shortfalls in supplies reaching low and middle income countries through COVAX, more sharply now with the pandemic demand in India restricting vaccine exports. The African Union recently warned African countries that delays in supplies may mean that they will need to restart their two dose vaccine programmes, or complete them with one dose vaccines that may not be distributed until late 2021. This global failure to meet health need makes virtue signalling on solidarity at the same time as self-protecting a profitable system reliant on patents and other monopoly rights particularly hollow. This is especially so in the context of the massive amounts of public funding that enabled innovations and the public support in opposing high income western countries for the waiver.
It can of course be argued that diplomacy involves compromise and that radical change demands sustained struggle. But the process is itself taking place in a space that is biased towards existing wealth. Negotiations at the WTO run on arcane principles and are largely not transparent. The rich countries hold much sway, including through supportive WTO officials. Important negotiations take place in so-called ‘green rooms,’ where experience indicates that consensus is achieved largely by excluding dissenters from the table. A current proposal by some high income countries to prioritise voluntary licensing arrangements as a solution is a symptomatic treatment, still under the control of big pharma, fails to address the causes of import dependency in Africa and other low and middle income countries and should not be used as a lever to delay or focus attention away from the waiver.
Proposers and supporters of the Waiver have grabbed the tail of the tiger. If the proposals are to avoid a death by a thousand cuts, this is the time to intensify focus. The transparency of these negotiations at the WTO and active vigilance, support and sustained activism will be essential to ensure that the outcomes achieved protect the public health rights and aspirations that have been behind the TRIPS Waiver to date.
“We demand the inclusion of the Right to Health in the new Zimbabwe constitution!”
This was the slogan at the Community Working Group on Health 15th national conference. The conference was held in October 2008 in Harare and coincided with the organisation’s 10th anniversary celebrations.
The CWGH was born in early 1998, to lead and give visibility to community processes in health. Ten years later over ninety participants attended the conference, including CWGH national members, partners, activists, health cadres and Health Literacy facilitators from 21 of the 25 CWGH districts. The conference reviewed the path that the CWGH has walked through the past ten years. We noted that as much as the CWGH has over the years positioned itself as a voice in the health sector and built community power, still the health sector has continued to deteriorate. The current socio-economic and political environment has not only perpetuated the deterioration, but has also made it increasingly difficult for civil society to offer alternatives for health problems. It was thus noted that the network needed to not only strengthen the existing structures and processes in the network, but also to re-strategise on how best to use these to engage on and advance health under the prevailing harsh environment.
At the conference our health literacy facilitators from 21 districts reviewed the work they were doing to widen social awareness and action on health. Despite the political volatility, we heard from district after district that of actions being taken, including in engaging with the political leadership on health issues. The work of the facilitators has increased the involvement of communities in health actions within communities and around Primary Health care, whether within the community on environmental health, or mobilising resources to support health centres. These are being done through community level initiative with limited external support. It was clear to us that we need to strengthen the programme and these cadres, to cement the work we are doing at community level and translate information into action.
One of the clearest messages was to revive the Primary Health Centre (PHC) concept and comprehensive PHC , if there is hope for change in the health sector. Mary Sandasi, a CWGH national member pointed to the relevance of PHC even 30 years after the Alma Ata declaration to re-build the declining health sector, particularly as it puts the people at the centre of the health system. The CWGH will consistently engage with stakeholders and government to make PHC a more central policy principle, and we will strengthen community structures such as health centre committees and boards and committees at district and national level to organise public efforts to achieve this principle.
As the health sector deteriorates, the gap between rich and poor has continued to widen. Poor people struggle to access health, and higher income groups claim a larger share of public health sector resources. We see EQUINET’s ‘Reclaiming Resources for Health’ book as a resource to inform how we can address unfair, avoidable differences in health. For example, the CWGH has over the past decade taken up equity issues with the Parliamentary Portfolio Committee on Health (PPCH), the Ministry of Health and Child Welfare (MoHCW) and other stakeholders to push for resources to go to services that support poor communities. We have for many years raised attention to the need for more resources to go to disease prevention, for example, and continue to see this as an issue, to ensure that we have safe living environments and communities.
While we commemorated our tenth anniversary, it was difficult to call it a celebration given the collapse of our health care delivery system. What we did celebrate was the dedication and commitment that people have put into the organisation and the struggle for health in the past ten years. The CWGH has grown to be a prominent voice in health, has won the hearts of many to champion peoples health issues and has given greater profile to the positive force that people provide in dealing with health problems. We have grown from strength to strength, but so too have the challenges we face!
To back our efforts to address these, the CWGH membership unanimously endorsed that the network champion the right to health, and push its inclusion in the production of a new Zimbabwe constitution. Taking the theme for the year; ‘CWGH @ 10: In Pursuit of Equity in Health through People Centred Health Systems’ we see that embedding the right to health in our constitution will give us the bottom line we need to make it clear that everyone has a claim to health and health care, no matter what the economic, socio-political, race, creed, gender or other feature. It will be a right that we will fight to include, through social action, and that we will ensure is not left on paper, but protected and promoted, through social action.
Further information on Community Working Group on Health can be found at www.cwgh.org.zw. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org.
Earlier this week, the Clinton Foundation announced the dramatic reduction of AIDS drug prices after its negotiations with several "generic" pharmaceutical manufacturers; the result was a cutting in half of the price of antiretroviral treatment for AIDS patients in several poor countries. While the news was welcome to most persons working on the issue, and while indeed many groups eagerly await specific details that might reveal problems or wonders in this deal, there is an underlying question that will remain unaddressed by technical evaluations of the new drug price reduction: what does it mean when a foundation headed by a person who--years ago--placed trade sanctions on countries attempting to import low-cost medicines now helps to procure such drugs and enters the spotlight of praise in the "AIDS community"?
The issue is not merely one of hypocrisy or even of repentant revelation and progressive reform. At issue, more generally, is the question of what the meaning of AIDS has become as it has travelled through so many powerful institutions and been altered by so many professional "institutionalists", and what the implications of this are for those people genuinely concerned about human well-being. The answer might be found in the frequently-expressed bitter remark from young public health students who now say that AIDS is getting "too much attention." Those who disagree with this perspective will, quite rightly, point to the disease's devastating toll and suggest that such attention is certainly justified and perhaps not even provided in adequate magnitude or appropriate programs. But, perhaps just as importantly, a second rebuttal is needed: that criticisms about one disease becoming too mainstream or too attractive for the institutional crowd assume that public health advocates are not fighting for general well-being, but rather battling against each other to steal the most funds from one another, like slaves competing for maximum output at the mill. If there is one thing that the AIDS activist movement has taught us over the last several years, it is this: that rather than fighting amongst ourselves over a fixed pot of money, those of us who stop thinking through the "cost-effective" framework and think through politically strategic paradigms can make the overall pot of money significantly larger, and can make our set of available options much wider. The funding provision may involve chaining ourselves to things, but the campaigns do in fact work, and few who review the history of AIDS activism can argue otherwise. To expand our paradigms simultaneously has also meant addressing the plain fact that diseases are not isolated and singular entities, but agents with reciprocal effects--that HIV rates affect TB rates, which affect community well-being and family stability (and vice versa), which in turn affect vulnerability to other diseases and social stresses and nearly everything else that matters to living a decent life.
Years ago, the paradigms used to address AIDS were focused on identifying specific "risk groups" and "targeting" them for interventions. These interventions were almost exclusively constructed though a "rational choice" framework (or what I've called "public health behaviourism")--a framework that wrongly assumes that poor women in economically-dependent relationships can negotiate sex, or that assumes that depressed men in the all-male barracks of South African mines (with a 42% injury rate) will care more about a disease that can kill them 10 years down the line than about finding some minor satisfaction through alcohol or sex. The paradigm even promotes "models" like Uganda, failing to account for the fact that much of the data coming out of such countries indicates that "prevention-only" measures were working only among the wealthier sectors, while the poor continue to suffer the greatest burden of disease. I have compared the realities of poverty and the rhetoric of public health behaviourism elsewhere (1); my task here is to argue that something very strange is going on if this behaviouristic paradigm has finally shifted to a new paradigm that addresses the issue of resource (mal)distribution and inequality--in particular, "access to antiretrovirals"--but in the midst of this, the Clinton Foundation, of all groups, has emerged as a central hero.
What is odd about this event is captured by the very framework of the Clinton initiative. I am not, here, referring to the extensive patent law strengthening done under the Clinton administration, which now ironically undermines in some ways the Clinton Foundation's own initiative; this set of issues around hypocrisy is obvious enough. What I am referring to is that the deal made by the Foundation was narrowed to one about AIDS, and more specifically, antiretroviral drugs. This seems appropriate, but I will argue that while it may be technically competent, it is not politically so, and the press releases and narrowing of scope of the negotiations to just antiretroviral drugs avoided the core of the problem. Not only was the scope merely "narrowed", but it was done in a way to suggest that such price negotiations could not lead to questioning of intellectual property issues, and more importantly, could not be used for diseases besides AIDS. This was merely an "AIDS drug access agreement". And AIDS will supposedly be solved through existing behaviouristic prevention measures and a few of these new types of drug negotiations. In essence, the deal moves us back towards the days when AIDS was treated as a singular entity, a problem to be addressed without asking questions of why it has appeared the way it has, and why it continues to sustain itself in the way it does (that is, why it remains a disease of the poor).
The Foundation focused on the drug price reduction as an AIDS issue, and AIDS as now primarily an "access to antiretrovirals" issue. If there is any sure indication that "access to antiretrovirals" has become a mainstream concern, this is it. And yet, as someone who has advocated for such access for nearly 7 years, this is a frightening phenomenon.
My concern is that lack of access to antiretrovirals is an indicator of something much broader, and AIDS is also a symptom of much more nested problems. If AIDS is appearing so often in the context of trade agreements, where the crash of primary commodity prices leads farmers to migrate to industrial centres and break off their marriages, making "monogamy" a nonsensical idea (2); if inequalities in access to jobs and education force women into prostitution as the means to survive (3); if the terms of inequitable worker contracts mean that depression and drug abuse are the two primary options for workers in the lowest income sectors (4, 5), then AIDS is not just a "syndrome", but an end-stage "symptom" of a much larger disease.
What is problematic, then, is that as "access to antiretrovirals" has become part of the centre of AIDS discourse, two camps have appeared to negotiate the phrase's meaning. On one side we have the Clinton Foundation, who through technical interventions and isolated negotiations will attempt to disguise its past and avoid coming to terms with patenting and other structural problems as it "solves" the pandemic through the most elite forms of politics: closed-door negotiations. On the other hand, there are those that recognize that "access to antiretrovirals" is merely a group of code words that indicate, most broadly, "the right to resources needed for a decent life." The lack of antiretrovirals in poor countries is part of a broader problem of lack of medicines; this, in turn, is symptomatic of a broader problem of inappropriate resource distribution, which in turn indicates dramatic power inequalities. That form of thinking is precisely what the Clinton Foundation's press releases seem to try to hinder, arguing that this selective price reduction was AIDS-specific, and something that the elites can take care of.
The distinction is not minor, for it brings us to bear upon our role as self-described "activists"--a term that, all too often, carries with it the most extreme forms of self-promotion and self-righteousness, and often a vulnerability to injure those who we claim to advocate for. The problem with treating AIDS as just a disease, and not a symptom of broader inequalities, is that this prescription is more frequently coming from "activists" who have lost touch with the context of the statements they receive from those they claim to represent. In the letters and editorials of papers in neighbourhoods and cities most affected by AIDS, the disease is not merely a concern about drugs. Drugs are crucial; but talk about inequality in access to drugs are also representative--they are indicators, social markers (like conspiracy theories or public protest) that something much deeper is going wrong. And the hegemony exerted by activists who lose this sense is a hegemony that is indeed very dangerous, because it inflates a desire for personal heroism and self-promotion and neglects the structural inequalities few are willing to approach for fear of being left out of elite conversation. The new public health advocates struggle with the task of understanding medicine distribution technicalities and little else; they do not ask if there are other avenues to approach, or even if this is merely one recipe torn apart and read in isolation, because they have forgotten (or have never learned) that this recipe was part of a much larger cookbook. AIDS is reduced to an issue of "access to antiretrovirals", rather than having "access to antiretrovirals" be a representative AIDS issue that serves to hint at the direction of the fuel tanks supplying the biggest fire in human history.
All too often, the "structural problems" fuelling the fire are declared impossible for public campaigning; too difficult for effective activism, or--worse yet--the domain of lunatics and extremists. Once again, the common, day-to-day forces in AIDS activism prove such contentions wrong. At universities across the U.S., U.K., and Canada, students are engaging with activist groups in "the South" to alter university drug development policies in line with the community needs of those who have been excluded from research benefits (www.essentialmedicines.org); in other parts of the U.S., even as federal funds get shredded under neo-conservative fiscal policies, activists have kept pressure on local governments to preserve key social services by promoting ballot initiatives among the poor; elsewhere, labour policies are becoming central parts of AIDS activism movements, which are winning battles to improve housing and terms of contracts after involving mine workers and other affected persons more centrally in the campaigning process. The key, then, to maintaining a representative discourse on AIDS is to diffuse power in this manner and consistently expand the meaning of AIDS to its structural causes rather than its most visible and easily acceptable end-points; the commonality between all of these effective "structural interventions" is that they are operated with a sense of caution, and a fear of exerting dangerous hegemony that forces those involved to re-think what it at stake. Rather than taking a mainstream issue and carving out a field of power within it, these campaigns are directing themselves in the opposite direction: taking an issue that is already mainstream ("access to antiretrovirals") and asking what is unrepresentative about it, what is missing from its ranks ("access to general resources needed for decent life"). And who better to ask than those who are most affected; those who do not gain entrance into the drug price negotiations of the Clinton Foundation (but, importantly, have gained access to the core of South African AIDS activism, 6)?
This article may be written as a formulaic prescription, and the more educated groups will criticize my simplicity and extravagance even as I discuss hegemony and preach humility. Their criticisms may be warranted; but in spite of that, a healthy warning should remain: that the fear of hegemony, the fear of being unrepresentative, can drive us much farther towards improving each others' livelihoods than any attempt to force our issues to be arbitrated by the mainstream sources of power in isolation from the core of active suffering, or to force social space into our preconceived visions by selectively filtering the voices and livelihood realities of those we claim to defend.
References:
(1) AIDS, Empire and Public Health Behaviorism:
http://zmag.org/content/showarticle.cfm?SectionID=2&ItemID=3988
(2) Bello, W., S. Cunningham, et al. (1998). A Siamese Tragedy: Development
and Disintegration in Modern Thailand. London, Zed Books.
(3) Farmer, P. E., M. Connors, et al., Eds. (1996). Women, Poverty and
AIDS: Sex, Drugs, and Structural Violence. Monroe, Common Courage Press.
(4) Campbell, C. and B. Williams (1999). "Beyond the biomedical and
behavioural: towards an integrated approach to HIV prevention in the
Southern African mining industry." Social Science and Medicine 48: 1625-39.
(5) Connors, M. M. (1994). "Stories of Pain and the Problem of AIDS
Prevention: Injection Drug Withdrawal and Its Effect on Risk Behavior."
Medical Anthropology Quarterly 8(1): 47-68.
(6) www.tac.org.za
The 18 to 23 July International AIDS Conference held in Vienna this year, subtitled “Rights Here, Right Now” was a platform to raise, yet again, the values based universal and indivisible human rights and the political commitments that inform our response, globally, to the unacceptable level of new HIV infection and mortality from AIDS. At the same time the shrinking provision of aid to low income countries and persistence of avoidable inequities globally in the progressive realisation of these rights starkly raises the reality of the competition between social rights to health, and private rights to intellectual property.
International aid to developing countries has declined in the past two years, with a fall of $1.1 billion in high income country support for developing country AIDS programmes between 2008 and 2009, according to UNAIDS and Kaiser Foundation. At the same time rich countries continue to pursue with vigour stronger protections for intellectual property rights (IPR) – in what is now known as the ‘IP Enforcement Agenda”. The effects of strong IPR protection may have been abated in earlier years by aid support for purchase of patented medicines, but low income countries seeking to meet needs in the current financial squeeze by procuring cheaper options or initiating their own local production of medicines, including of anti-retrovirals, face an unabated challenge to their implementing even those measures that are legal under the World Trade Organisation's (WTO's) Trade-Related Intellectual Property Rights (TRIPs) agreement.
The fall in funding to AIDS has itself been challenged by many, including the President of the International AIDS Society, Dr. Julio Montaner, and Stephen Lewis (former UN special envoy for HIV/Aids in Africa). As Dr Montaner said: “International governments say we face a crisis of resources, but that is simply not true: The challenge is not finding money, but changing priorities. When there is a Wall Street emergency or an energy crisis, billions upon billions of dollars are quickly mobilized. People’s health deserves a similar financial response and much higher priority.”
At the same time the fall in funding has made very clear the need to implement long-standing calls by progressive civil society to put in place more predictable means of global financing, and for African countries to maximise use of TRIPS flexibilities and to advance local production of pharmaceuticals. Yet is it precisely in this arena that measures are being taken to strengthen and enforce intellectual property rights and reduce the flexibilities needed by developing countries. There have been numerous examples of this, included those reported in prior issues of the EQUINET newsletter.
Measures to reinforce IPRs include in regional and bilateral agreements provisions that exceed TRIPs requirements and reduce the flexibilities provided by TRIPS (TRIPS plus); and also pressures on African countries not to exercise rights to compulsory licensing or parallel importation. The EU, which stated its commitment to access to medicines, has pursued measures that exceed TRIPs obligations in its trade agreements with developing countries including with India, in spite of an EU Parliamentary resolution on 12 July 2007 (P6_TA(2007)0353) urging it not to do so. There have been seizures in the EU of generic medicines in transit, not destined for Europe, performed at the insistence of EU pharmaceutical companies for allegedly being counterfeit. The EU has contributed to work on anti-counterfeiting legislation in East African countries that has raised new IPR restrictions on legitimate generic medicines, defining them within the scope of counterfeits (see EQUINET Newsletter 111). Similar seizure laws are being supported through a global initiative called IMPACT.
Significantly at the July AIDS conference, attention was also drawn to the use by the USA of its ‘Special 301’ law which it uses to list and “shame” countries for violating US commercial interests by not providing sufficient protection to IPRs. Health Gap, the Foundation for AIDS Rights and the Thai Network of People Living with HIV/AIDS with others have filed a complaint with the UN's Special Rapporteur on the Right to Health, Anand Grover, alleging that use of this law reduces access to medicines in low and middle income nations and violates international human rights obligations.
Global institutions appear to be offering weak protection to developing countries in their efforts to assert their rights, and the rights and flexibilities provided for in global treaties. In the 2006/7, during the WHO's negotiations on Public Health, Innovation and Intellectual Property (for so-called “neglected diseases”) efforts were made to contain the challenge to IPRs from neglected diseases by including a proposal to limit the scope of the discussion to only 14 diseases, a due process violation as no country proposed this for inclusion in the negotiating text. The IMPACT programme referred to earlier has had an association with WHO that was heavily criticised at the 2010 World Health Assembly. The WTO Dispute Settlement Body (DSB), instead of the defending the flexibilities provided in its own instruments through multilateral measures, has allowed the US room for unilateralism on its Special 301 law in a January 1999 dispute raised by the European Community. This was a decision that Chakravarthi Raghavan of the South-North Development Monitor termed as blatantly based on politics, rather than legal interpretation.
Almost a decade since the 2001 Doha Declaration on TRIPS and Public Health made the important step of asserting more clearly the rights countries already enjoyed to promote access to medicines, few countries have been able to use the rights enshrined in it. The Declaration was needed then because poor countries were precluded from using these rights by the rich countries. The cases cited in this editorial suggest that the last decade has been one of countless efforts to restrict and reverse those rights.
This is in a context where the latest WHO treatment guidelines recommend that people with HIV should start treatment earlier, bringing treatment for people in developing countries in line with treatment in wealthy nations, to help prevent transmission of HIV. Of the 14 million people needing treatment, only 4 million currently receive it. While private rights to IPRs are being vigorously enforced, who is vigorously enforcing the rights to life and health of these 10 million people, or the millions more who need medicines for other common diseases, including chronic conditions like diabetes and hypertension?
And where will we be ten years from now, with an unabated and expanding IP enforcement agenda?. The evidence from recent years outlined here suggests that basing future access to medicines on a benevolent global market, or even one that prioritises human rights in one region over commercial rights in another may be wishful thinking. There seems to be no alternative but for African countries to set a vision, and to develop, negotiate, build space for and implement strategies for their own local production of medicines, to meet their own market and population needs, while simultaneously fending off an IP enforcement agenda that does not meet their interests, in all its guises.
The EQUINET newsletter intends to raise the visibility and accessibility of evidence about and from east and southern Africa on different aspects of equity in health. Now in its 197th issue, it has since its inception shared a total of nearly 12 000 papers, articles, resources and other information on and from the region on areas related to health equity.
Launched in May 2001 by EQUINET from within the region and appearing monthly for the sixteen years since then, it has included new knowledge and evidence on a range of areas, from values, policies and rights, financing, health worker issues, clinical and health service practices through to health determinants and governance that have a bearing on improved delivery on policy commitments to equity in health. Thank you to the many people generating evidence and debate on these areas and to those who have helped the newsletter to be a consistent vehicle for sharing this information.
While it appears monthly in members’ email boxes, what may be less well known is that the current database of 11 500 articles compiled over the years on the EQUINET website is a resource that can be searched by themes and by title, author or text key words, to support research and evidence for social and policy dialogue.
This database may itself be an interesting source of evidence for those reviewing policy trends in the region. While it provides an accessible source of specific information for people working on equity in health and its determinants, it may also provide an interesting insight into the rise and fall of attention to specific issues in the region, from HIV and the retention of health workers, to emergencies, chronic conditions and universal coverage. Some areas, such as gender equity, poverty and social participation in health, have also had persistent presence since the first newsletter in 2001, albeit with less visible focus and with different lenses and perspectives. For others, such as privatisation and the public-private mix of health services, there appears to have been a deficit in attention, with far less open access publication, despite their importance for health equity in the region.
The sixteen years of the newsletter also provide an insight into the changing nature of evidence. In 2001 there was a predominance of formal publications in journals, reports and print media. This continues, with a slow improvement in journal papers being led by authors from within the region. Today, however, there is a more diverse mix in the forms of evidence, adding an increasing presence of blogs, videos, talks, photojournalism and art forms. This has brought new voice to the evidence and analyses on health equity, although many still face barriers in access to digital media.
We’d like to hear your voice.
As we head towards the 200th issue, let us know where the newsletter has been useful to you and what improvements you would want to see.
For our 200th issue, we invite you to send us in August and September editorials written by you, and any links to videos, blogs, papers or other online resources you want to share on your perspective on the opportunities that we should be tapping in east and southern Africa for making immediate or longer term advances in equity in health (whether generally, or on a specific aspect), and how and by whom they could be taken forward.
Please send feedback or queries or editorial or url links to information to the EQUINET secretariat: admin@equinetafrica.org
Introduction
The Global Forum’s annual conference was held in Mumbai, India from 12-16 September 2005, and focused on “poverty, equity and health research”. EQUINET was extremely well represented, with four papers presented, three in full plenary sessions, on EQUINET research in the area of: participation and health, ART, fair financing and policy analysis. The papers presented by the EQUINET conference participants can be found on the Equinet website.
Forum 9 was attended by delegates from around the globe; one of the great attractions of the Global Forum conferences is that it includes participants from a wide range of research disciplines, policy-makers and civil society organisations. The conference had seven main themes: poverty; equity; innovation; neglected diseases and conditions; policies, systems and priorities; research capacity strengthening; and reproduction and human development. Some of the issues discussed and conclusions arising from the two core themes of poverty and equity are summarised below.
Poverty theme
The key role of poverty in contributing to ill health, and the lack of access to health services for the poorest were highlighted in a number of presentations. There was also an emphasis on how out-of-pocket payments for health care leads to further impoverishment for vulnerable households.
One of the most interesting ‘debates’ at the conference related to whether or not the Mexican PROGRESA (now called Opportunades) program has been successful or not. This program involves monthly payments to poor households on condition that the household attempts to improve their education, health and nutritional status.
For example, a household will receive up to US$28 per month per child if the child attends 85% or more of classes, and up to US$12 per month per family in ‘food transfers’ if each child receives 2-4 health checkups per year, each adult receives one health checkup per year and pregnant women receive seven pre-and post-natal checkups.
Findings from evaluations of this program, undertaken in two different sets of villages, were presented in two different sessions and contained divergent results. The one study, undertaken by the World Bank and IMF, claimed very positive results of the program with a very high proportion of beneficiaries being in the poorest section of the population and improvements in health status and educational enrolment, as well as poverty reduction, being attributed to the program.
The other study, undertaken by a team of local researchers in one of the poorest areas of Mexico, found less positive outcomes. In particular, they highlighted that although the program was targeted at the poor, many poor households were not being reached. Very importantly, the program appears to be creating conflicts and “destroying the social fabric” of communities. There appear to be conflicts between those who are benefiting from the program and those who are not, despite being “equally poor”, and there is resentment at the paternalistic monitoring of family education and health choices. Unfortunately, no opportunity was presented to debate these studies or the PROGRESA program in detail. Nevertheless, these presentations highlighted the need to carefully monitor poverty reduction programs and to identify unexpected negative impacts.
One of the key recommendations arising from this theme was that mechanisms of accurately and comprehensively identifying and protecting the poor are urgently needed.
Equity theme
Much of the research presented at the conference again highlighted the extent of inequities at household, community, national and global levels and the effects of inequities on vulnerability and risk of infection, disease and injury; access to care, treatment interventions and health outcomes. Unlike many other conferences which focus almost exclusively on inequities on the basis of socio-economic status, considerable emphasis was placed on gender inequities and inequities related to disability at Forum 9. While this was very positive, it was noticeable that the gender and disability sessions were more poorly attended and it was noted that inequities related to ‘race’, ethnicity, age, language and cultural affiliation received very little attention. There was also quite limited discussion on how to successfully address inequities.
One of the particularly interesting series of papers presented at the conference, which might provide insights on fair financing approaches to be considered in the African context, related to the EQUITAP project. This project has undertaken an extensive analysis of equity in health care financing in a large number of Asian countries. The results very clearly demonstrate that countries, such as Hong Kong, Malaysia and Sri Lanka, which have strong public health systems with general tax revenue being the major source of finance in the health sector are the most equitable. Health systems that have universal health insurance systems, such as Thailand, also fare quite well. The EQUITAP project has also analysed the level of catastrophic out-of-pocket payments in Asian countries. The findings from the EQUITAP and other research projects all highlighted the need to move away from out-of-pocket payments as a health care financing mechanism and to increase tax and insurance funding for health services.
Other observations
In the closing plenary, there was a general sense that many interesting issues had been raised and that there had been valuable engagements between participants. A number of suggestions were made on how to improve on these engagements in future, including:
- Greater care should be taken in the language that we use, to enable communication between different researchers and between researchers and policy-makers. Sometimes unnecessary jargon is used, but more concerning is that certain terms (e.g. equity) are commonly used but may have a number of different interpretations depending on the underlying ideological perspective. In order to ensure effective communication, it is important that everyone clarify their specific definition or interpretation of key terms.
- It is critical to pay greater attention to the context within which particular research has been undertaken, both in interpreting the findings but also in assessing the generalisability of findings.
- Forums such as this should create opportunities for more deliberately structured and challenging debate. Many participants regarded the lack of explicit debate on contradictory research findings, as highlighted above in the case of the PROGRESA program, in order to better understand what works and what does not, and why, as a missed opportunity.
- There was a perceived need to invest more energy in trying to consolidate and synthesise existing knowledge to a greater extent. In particular, there is a need to disseminate information on positive experiences and success stories.
The next Global Forum conference will be held in Cairo, Egypt from 29 October to 2 November 2006 and will focus on “Combating disease and promoting health”.
* Di McIntyre is with the Health Economics Unit, University of Cape Town.
* Please send comments to admin@equinetafrica.org