Editorial

Health systems throughout sub-Saharan Africa have been in a state of decline since the debt crisis of the 1980s and the subsequent effects of structural adjustment, chronic public under-investment and health sector reform. In this context, with the fragile health systems resulting, the proliferation of global health actors and initiatives (GHIs), that we have witnessed over the past decade, presents a risky strategy for catalyzing sustained and equitable improvements in health.

Vertical, selective GHIs could either establish a ‘virtuous cycle’ of positive synergies with health systems strengthening, or enter a ‘vicious cycle’, where they perpetuate or accentuate existing health system deficiencies, creating a greater dependence on vertical programmes for the rapid delivery of life-saving interventions. The publication in the Lancet this year (2009; (Vol 373 pages 2137 – 2169) of a review of the impact of GHIs on health systems by the World Health Organization’s Maximizing Positive Synergies (WHO MPS) initiative has therefore attracted attention and controversy.

The review noted the positive association between GHIs and improved outcomes, particularly in terms of HIV/AIDS, TB, Malaria and vaccine-preventable child deaths. However, it did not adequately answer the question of whether vertical and selective disease-based GHIs have had a positive or negative effect on health systems more broadly, nor whether they could have been better designed or implemented to optimize across-the-board health improvements.

This is because the review faced many methodological limitations. The first was a lack of good quality studies and evidence on the issue. This is a consequence of the minimal resources invested in establishing the monitoring systems needed to assess the effects of GHIs on health systems. Further, there is limited appreciation in the health community of the kinds of methods needed to study complex and large socially-mediated systems.

A second limitation was the lack of quality control of the data used by the WHO MPS collaborative group. Good, moderate and poor quality data appear to have been treated equally, including potentially biased information provided by GHIs themselves. On top of this, most members of the writing group had a direct conflict of interest with the subject matter, so the conclusions and recommendations read as a result of political negotiation, rather than an independent synthesis of the available evidence.

As a third limitation, the review only examined four actors: the Global Fund to Fight Against AIDS, TB and Malaria, GAVI, the World Bank’s Multi-Country AIDS Programme (MAP), and the US President’s Emergency Plan for AIDS Relief (PEPFAR). It therefore didn’t capture the effects of more than a hundred other global health actors and initiatives, despite the fact that one of the biggest problems for countries is the cumulative effect of numerous GHIs.

Finally, the conceptual framework of the review was designed to examine the effect of GHIs on health systems, but the conclusions of the review muddled the assessment of the impact of GHIs on health systems with impacts on health outcomes and outputs. Clearly, the Global Fund, GAVI, PEPFAR and MAP have had a positive impact on health outputs and outcomes. It would have been hard to avoid doing so considering the billions of dollars spent by these four GHIs, and the general four-fold increase in development assistance witnessed since 1990, described by Ravishankar and others in the same issue of the Lancet (2009, Vol 373, pages 2113 – 2124).

The question of whether vertical and selective disease and vaccine-based GHIs have had a positive or negative effect on health systems is perhaps academic. What is more important is that GHIs are henceforth able to maximize their positive synergies with broader health systems needs.

In this regard, in spite of its limitations, the WHO MPS initiative has been an important and valuable exercise. It has drawn attention to the need for further monitoring and assessment of the relationship between GHIs and health systems strengthening. This should include paying greater attention to the global health architecture as a whole, and efforts such as the International Health Partnership launched by some bilateral and multilateral health funding agencies to reduce the wasteful fragmentation, duplication, competition and conflicts amongst different actors and initiatives. Secondly, it has highlighted the need for GHIs to ensure that external development assistance for health is invested in a more coherent, equitable and comprehensive manner.

However, for GHIs, health sector and civil society actors, including those in east and southern Africa, the challenge is in knowing how to move forward. For example, if GHIs are to pay more attention to health systems strengthening, who will coordinate this? As a follow-up to the work and deliberations of the High Level Taskforce on Innovative Financing for Health, the World Bank, the Global Fund and GAVI are now discussing how they can create a shared platform for financing and supporting health systems strengthening.

But what will this mean? Will the World Bank take the lead in defining the policy agenda, and if so, will it promote a conservative and neoliberal policy agenda? Or will an expanded and modified version of the Global Fund and GAVI take charge? What of the role of the WHO, the International Health Partnership and countries themselves? With a global health architecture that remains over-populated, disorganized and competitive, there is a danger that countries may experience a series of uncoordinated and selective health systems strengthening initiatives. Agreeing to the fact that GHIs must pay more attention to health systems strengthening is only the start of a process.

While there is welcome attention to how official aid can be better managed to support health systems strengthening, there has been little discussion about how private finance will be harnessed to support equitable health systems development. The Gates Foundation, working with the International Finance Corporation, the African Development Bank and a German development finance institution have recently created a new private equity fund that will invest in small- and medium-sized private health companies in sub-Saharan Africa. Such an initiative runs contrary to the evidence that expanding commercialized health care will be harmful to equity and health systems strengthening.

Furthermore, the attention placed on health systems strengthening does nothing to plug the existing resource gaps of many countries. How do we campaign for a comprehensive Primary Health Care agenda when there is are still too few health workers, or inadequate funds for medicines? With the economic recession and signs of some donors cutting back on development aid, the competition for scarce resources may get worse.

This situation calls for the global health community to develop a set of positions and campaign on three distinct, but inter-related issues: The first is the architecture of development assistance for health, to work towards a coherent system for funding equitable health systems development and on-going improvements in access to effective health care. The second is that of health systems policy itself, particularly in relation to the appropriateness and fairness of different health financing strategies, as well as the role of markets and the private sector. Finally, the third, resonating with the call to meet the full content of the 2001 Abuja commitment at national and international level, is that of expanding both domestic and international resources for health in Africa.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For papers on health systems (fair financing, health worker retention) effects of GHIs visit the EQUINET website and the Economic Governance for Health network website at www.eg4health.org

A high level WHO commission has warned the rich world that unless there is a dramatic increase in development assistance for health the legitimacy and stability of the current regime of global economic governance may be seriously threatened.

The WHO Commission on Macroeconomics and Health (CMH) was established by the Director-General of WHO in January 2000. The Commission was chaired by Professor Jeffrey Sachs of Harvard. It members and helpers included former ministers of finance, people from the World Bank, the International Monetary Fund, the World Trade Organisation, the United Nations Development Program, the Economic Commission on Africa and the Organisation for Economic Cooperation and Development. The Commission was financially supported by the Bill and Melinda Gates Foundation, the Rockefeller Foundation and the UN Foundation and by the governments of the UK, Luxembourg, Ireland, Norway and Sweden. The CMH presented its final report to Dr Bruntland in December 2001.

The Commission set up six working groups, on: health, economic growth, and poverty reduction; international public goods for health; mobilisation of domestic resources for health; health and the international economy; improving health outcomes of the poor; development assistance and health.

WHO Director-General Dr Gro Harlem Brundtland welcomed the report of the WHO Commission on Macroeconomics and Health on December 20th 2001: "This report is a turning point," she said. "It will influence how development assistance is prioritized and coordinated in the years to come."

The Commission’s report is an important health policy statement. It may prove to be as significant as the 1993 World Bank Report, Investing in Health , in providing a ‘credible’ policy narrative proclaiming concern about the health of the poor while reconciling health development objectives with the continuing operation of a brutal and unfair global economic regime.

It is a difficult report to analyse. The argument is tortuous and selective in its use of evidence. For example, despite its commission about the relations between macro economics and health, there is no reference in the whole report to the population health progress of Cuba which has not been as closely integrated into the global economy as most developing countries (see Lobe, 2001). There is one reference only to Kerala where it is suggested that the excellent health outcomes achieved there may have been due to the adequacy of the water supply (page 122).

In places it stretches fact, logic and credulity to the point of combustion. More challenging is the task of interpreting the strategic purpose of the DG in commissioning the report and that of the members of the Commission in framing their presentation. It is clear that the report is meant to be read at several different levels.

It is a big report and is accompanied by dozens of working group reports. There is a lot of material to absorb and consider. This raises questions about how Third World governments, health activists, NGOs and academics might respond to the report.

This commentary is prepared as an initial contribution to (what I hope might develop as) a collaborative process of analysis involving health activists, practitioners and academics associated with the struggle for health in the Third World. We may not be able to match the resources available to the Commission but through an internet collaboration we can draw upon a wide range of expertise and experience in considering the Commission’s report and participating in the wider discussion which will unfold. (See accompanying notes about how this internet collaboration might operate.)

This commentary has three parts. In the first part I summarise the broad argument presented in the report. In the second part I discuss this argument exploring some of their assumptions of fact and movements of logic. Finally I explore the politics of the report; what is the subtext; what are the hidden messages; what were the strategic purposes and expectations of the DG and of the Commission?

This is a preliminary commentary, explicitly designed to stimulate a wider discussion and more broadly based analysis of the report. I am looking forward to hearing what other critics think about the report. I have not read all of the working papers and my judgements should be understood as tentative at this stage.

Ann-Louise Colgan, Research Associate, Africa Action April, 2002.
Health is a fundamental human right, recognized in the Universal Declaration of Human Rights (1948), and the Constitution of the World Health Organization (1946). Health is also an essential component of development, vital to a nation's growth and internal stability. Over the past two decades, the World Bank and International Monetary Fund (IMF) have undermined Africa's health through the policies they have imposed. The dependence of poor and highly indebted African countries on World Bank and IMF loans has given these institutions leverage to control economic policy-making in these countries. The policies mandated by the World Bank and IMF have forced African governments to orient their economies towards greater integration in international markets at the expense of social services and long-term development priorities. They have reduced the role of the state and cut back government expenditure.

While many African countries succeeded in improving their health care systems in the first decades after independence, the intervention of the World Bank and IMF reversed this progress. Investments in health care by African governments in the 1970s achieved improvements in key health indicators. In Kenya, for example, child mortality was reduced by almost 50% in the first two decades after independence in 1963 [1]. Across sub-Saharan Africa, the first decades after independence saw significant increases in life expectancy, from an average of 44 years to more than 50 years [2].

In the 1980s and 1990s, however, African governments had to cede control over their economic decision-making in order to qualify for World Bank and IMF loans. The conditions attached to these loans undid much of the progress achieved in public health. The policies dictated by the World Bank and IMF exacerbated poverty, providing fertile ground for the spread of HIV/AIDS and other infectious diseases. Cutbacks in health budgets and privatization of health services eroded previous advances in health care and weakened the capacity of African governments to cope with the growing health crisis. Consequently, during the past two decades the life expectancy of Africans has dropped by 15 years [3].

Africa Action calls for an end to World Bank and IMF policies that undermine health. This requires canceling the debts that prevent African governments from making their full contribution to addressing the health crisis. It also requires ending the imposition of harmful economic policies as conditions for future loans or grants. This position paper provides a brief background overview of World Bank and IMF policies. It focuses particularly on their impact on health.

1. The World Bank and IMF in Africa The World Bank and IMF were created at the Bretton Woods Conference in New Hampshire, U.S.A., in 1944. They were designed as pillars of the post-war global economic order. The World Bank's focus is the provision of long-term loans to support development projects and programs. The IMF concentrates on providing loans to stabilize countries with short-term financial crises. The World Bank and IMF became increasingly powerful in Africa with the economic crisis of the early 1980s. In the late 1970s, rising oil prices, rising interest rates, and falling prices for other primary commodities left many poor African countries unable to repay mounting foreign debts. In the early 1980s, Africa's debt crisis worsened. The ratio of its foreign debt to its export income grew to 500% [4]. African countries needed increasing amounts of "hard currency" to repay their external debts (i.e.
convertible foreign currencies such as dollars and deutschmarks). But their share of world trade was decreasing and their export earnings dropped as global prices for primary commodities fell. The reliance of many African countries on imports of manufactured goods, which they themselves did not produce, left them importing more while they exported less. Their balance of payments problems worsened and their foreign debt burdens became unsustainable.

African governments needed new loans to pay their outstanding debts and to meet critical domestic needs. The World Bank and IMF became key providers of loans to countries that were unable to borrow elsewhere. They took over from wealthy governments and private banks as the main source of loans for poor countries. These institutions provided "hard currency" loans to African countries to insure repayment of their external debts and to restore economic stability. The World Bank and IMF were important instruments of Western powers during the Cold War in both economic and political terms. They performed a political function by subordinating development objectives to geostrategic interests. They also promoted an economic agenda that sought to preserve Western dominance in the global economy. Not surprisingly, the World Bank and IMF are directed by the governments of the world's richest countries. Combined, the "Group of 7" (U.S., Britain, Canada, France, Germany, Italy and Japan)
hold more than 40% of the votes on the Boards of Directors of these institutions. The U.S. alone accounts for almost 20% [5]. It was U.S. policy during the Reagan Administration in the early
1980s, to expand the role of the World Bank and IMF in managing developing economies [6]. The dependence of African countries on new loans gave the World Bank and IMF great leverage. The conditions attached to these loans required African countries to submit to economic changes that favored "free markets." This standard policy package imposed by the World Bank and IMF was termed "structural adjustment." This referred to the purpose of correcting trade imbalances and government deficits. It involved cutting back the role of the state and promoting the role of the private sector. The ideology behind these policies is often labeled "neo-liberalism," "free market fundamentalism,"or the "Washington Consensus." From the 1970s on, this orientation became the dominant economic paradigm for rich country governments and for the international financial institutions. The basic assumption behind structural adjustment was that an increased role for the market would bring benefits to both poor and rich. In the Darwinian world of international markets, the strongest would win out. This would encourage others to follow their example. The development of a market economy with a greater role for the private sector was therefore seen as the key to stimulating economic growth. The crisis experienced by African countries in the early 1980s did expose the need for economic adjustments. With declining incomes and rising expenses, African economies were becoming badly distorted. Corrective reforms became increasingly necessary. The key issue with adjustments of this kind, however, is whether they build the capacity to recover and whether they promote long-term development. The adjustments dictated by the World Bank and IMF did neither.

African countries require essential investments in health, education and infrastructure before they can compete internationally. The World Bank and IMF instead required countries to reduce state support and protection for social and economic sectors. They insisted on pushing weak African economies into markets where they were unable to compete with the might of the international private sector. These policies further undermined the economic development of African countries.
2. What is Structural Adjustment? Structural adjustment refers to a package of economic policy changes designed to fix imbalances in trade and government budgets.
In trade, the objective is to improve a country's balance of payments, by increasing exports and reducing imports. For budgets, the objective is to increase government income and to reduce expenses. In theory, achieving these goals will enable a country to recover macroeconomic stability in the short-term. It will also set the stage for long-term growth and development. The structural adjustment programs of the early 1980s were meant to provide temporary financing to borrowing countries to stabilize their economies. These loans were intended to enable governments to repay their debts, reduce deficits in spending, and close the gap between imports and exports. Gradually, these loans evolved into a core set of economic policy changes required by the World Bank and IMF. They were designed to further integrate African countries into the global economy, to strengthen the role of the international private sector, and to encourage growth through trade. Typical components of adjustment programs included cutbacks in government spending, privatization of government-held enterprises and services, and reduced protection for domestic industry. Other types of adjustment involved currency devaluation, increased interest rates, and the elimination of food subsidies. The underlying intention was to minimize the role of the state.

World Bank and IMF adjustment programs differ according to the role of each institution. In general, IMF loan conditions focus on monetary and fiscal issues. They emphasize programs to address inflation and balance of payments problems, often requiring specific levels of cutbacks in total government spending. The adjustment programs of the World Bank are wider in scope, with a more long-term development focus. They highlight market liberalization and public sector reforms, seen as promoting growth through expanding exports, particularly of cash crops. Despite these differences, World Bank and IMF adjustment programs reinforce each other. One way is called "cross-conditionality." This means that a government generally must first be approved by the IMF, before qualifying for an adjustment loan from the World Bank. Their agendas also overlap in the financial sector in particular. Both work to impose fiscal austerity and to eliminate subsidies for workers, for example. The market-oriented perspective of both institutions makes their policy prescriptions complementary.

Adjustment lending constitutes 100% of IMF loans. In 2001, approximately 27% of World Bank lending to African countries was for "adjustment." In the World Bank's total loan portfolio, adjustment lending generally accounts for between one-third and one-half [7]. The remainder of World Bank loans are disbursed for development projects and programs. The project portfolio of the Bank covers such areas as infrastructure, agricultural and environmental development, and human resource development. In some cases, the projects supported by World Bank loans do make useful contributions to development. But these occasional successes must be weighed against the negative effects of increasing debt, imposed economic policies and their consequences. The past two decades of World Bank and IMF structural adjustment in Africa have led to greater social and economic deprivation, and an increased dependence of African countries on external loans. The failure of structural adjustment has been so dramatic that some critics of the World Bank and IMF argue that the policies imposed on African countries were never intended to promote development. On the contrary, they claim that their intention was to keep these countries economically weak and dependent. The most industrialized countries in the world have actually developed under conditions opposite to those imposed by the World Bank and IMF on African governments. The U.S. and the countries of Western Europe accorded a central role to the state in economic activity, and practiced strong protectionism, with subsidies for domestic industries. Under World Bank and IMF programs, African countries have been forced to cut back or abandon the very provisions which helped rich countries to grow and prosper in the past. Even more significantly, the policies of the World Bank and IMF have impeded Africa's development by undermining Africa's health. Their free market perspective has failed to consider health an integral component of an economic growth and human development strategy. Instead, the policies of these institutions have caused a deterioration in health and in health care services across the African continent.

3. Poverty and Health Care Cuts Health status is influenced by socioeconomic factors as well as by the state of health care delivery systems. The policies prescribed by the World Bank and IMF have increased poverty in African countries and mandated cutbacks in the health sector. Combined, this has caused a massive deterioration in the continent's health status.

The health care systems inherited by most African states after the colonial era were unevenly weighted toward privileged elites and urban centers. In the 1960s and 1970s, substantial progress was made in improving the reach of health care services in many African countries. Most African governments increased spending on the health sector during this period. They endeavored to extend primary health care and to emphasize the development of a public health system to redress the inequalities of the colonial era. The World Health Organization (WHO) emphasized the importance of primary healthcare at the historic Alma Ata Conference in 1978. The Declaration of Alma Ata focused on a community-based approach to health care and resolved that comprehensive health care was a basic right and a responsibility of government. These efforts undertaken by African governments after independence were quite successful. There were increases in the numbers of health professionals employed in the public sector, and improvements in health care infrastructure in many countries. There was also some success in extending care to formerly unserved areas and populations. Across the continent, there were improvements in key health care indicators, such as infant mortality rates and life expectancy. In Zambia, the post-independence government expanded public health care services throughout the country. The number of doctors and nurses was also significantly increased during this time. Infant mortality was reduced from 123 per 1,000 live births in 1965, to 85 in 1984 [8]. In Tanzania, during the first two decades of independence, the government succeeded in expanding access to health care nationwide. By 1977, more than three-quarters of Tanzania's population lived within 5 km of a health care facility [9]. While the progress across the African continent was uneven, it was significant, not only because of its positive effects on the health of African populations. It also illustrated a commitment by African leaders to the principle of building and developing their health care systems.

With the economic crisis of the 1980s, much of Africa's economic and social progress over the previous two decades began to come undone. As African governments became clients of the World Bank and IMF, they forfeited control over their domestic spending priorities. The loan conditions of these institutions forced contraction in government spending on health and other social services. Poverty and Health The relationship between poverty and ill-health is well established. The economic austerity policies attached to World Bank and IMF loans led to intensified poverty in many African countries in the 1980s and 1990s. This increased the vulnerability of African populations to the spread of diseases and to other health problems. The public sector job losses and wage cuts associated with World Bank and IMF programs increased hardship in many African countries. During the 1980s, when most African countries came under World Bank and IMF tutelage, per capita income declined by 25% in most of sub-
Saharan Africa [10]. The removal of food and agricultural subsidies caused prices to rise and created increased food insecurity. This led to a marked deterioration in nutritional status, especially among women and children. In Zambia, for instance, following the elimination of food subsidies, many poor families had to reduce the number of meals per day from two to one [11]. Malnutrition resulted in low birth weights among infants and stunted growth among children in many countries. It is currently estimated that one in every three children in Africa is underweight [12]. In general, between one-quarter and one-third of the population of sub-Saharan Africa is chronically malnourished. The deepening poverty across the continent has created fertile ground for the spread of infectious diseases. Declining living conditions and reduced access to basic services have led to decreased health status. In Africa today, almost half of the population lacks access to safe water and adequate sanitation services [13]. As immune systems have become weakened, the susceptibility of Africa's people to infectious diseases has greatly increased. A joint release issued by the WHO and the Joint UN Programme on HIV/AIDS (UNAIDS) in April 2001 reports that the number of cases of tuberculosis in Africa will reach 3.3 million per year by 2005 [14]. The WHO reported in 2001 that almost 3,000 Africans die each day of malaria. Each year in Africa, the disease takes the lives of more than 500,000 children below the age of five [15]. Most devastating of all has been the impact of the HIV/AIDS pandemic. The spread of HIV/AIDS in Africa has been facilitated by worsening poverty and by the conditions of inequality intensified by World Bank and IMF policies. Economic insecurity has reinforced migrant labor patterns, which in turn have increased the risk of infection. Reduced access to health care services has increased the spread of sexually transmitted diseases and the vulnerability to HIV infection.

A concern for health equity is not new in global health. Equity was central to the World Health Organization (WHO) 1946 constitution, and to the work that culminated in the Declaration of Alma Ata in 1978. Despite this, the health agenda has mostly focused on securing progress on priority challenges. This has contributed to substantial advances in average life expectancy in most parts of the world. Yet the global health community has often seemed unable to counter the widening inequities brought by uneven progress.

The recently completed World Health Assembly has the potential to be a turning point in addressing health inequities. Two resolutions were passed, fundamentally grounded in a concern for equity and social justice - one on 'primary health care, including health systems strengthening' (available at http://apps.who.int/gb/ebwha/pdf_files/A62/A62_R12-en.pdf) , and another on 'reducing health inequities through action on the social determinants of health' (available at http://apps.who.int/gb/ebwha/pdf_files/A62/A62_R14-en.pdf).

Around 50 countries spoke in strong support of the resolution on primary health care, and almost 40 countries intervened in support of acting on the social determinants. There was a constructive consensus in favour of both texts, with discussion centred on the strength and tone of the resolutions. Throughout the Assembly, multiple references were made to the importance of social justice and fairness in the plenary and across the agenda items.

The events that sparked these resolutions from WHO - the convening of the Commission on Social Determinants of Health in 2005 and the groundswell of support from countries for the renewal of primary health care, leading to the 2008 World Health Report - reflect an increasing understanding and intolerance for widening health inequities in the modern era. There is increasing support for the idea that health equity should be seen as a key development goal and as a measure of the progress of the global community.

Such consensual support would have been unthinkable until relatively recently and has strongly built on the explosion in knowledge of health inequities, both within and between countries, in the last twenty years. The broad range of civil society and academia have made important contributions in terms of advocacy, the generation of knowledge and the demonstration of innovative strategies to address the social determinants. The Commission's damning diagnosis - 'social injustice is killing people on a grand scale' - owes much to this work.

So what now? The twin resolutions call for a broad range of actions based on the values of Alma Ata from the international community, member states and the WHO secretariat. The Assembly's understanding of both primary health care and addressing the social determinants of health emphasises the key role of multi-sectoral action, beyond the necessary but insufficient functioning of health systems, if health inequities are to be reduced. Achieving such action issues a difficult challenge to health leaders at global, national and local levels.

Anyone who believes in health equity should be encouraged by these developments. Of course, the resolutions by themselves will not achieve health for all. But they provide a powerful endorsement of the report of the Commission and of the need for renewal of primary health care. The challenge in implementing these resolutions, to contribute towards improved health equity, is one to which civil society can continue to make a vital and essential contribution.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue please visit http://www.who.int/topics/primary_health_care/en/ for PHC and http://www.who.int/social_determinants/en/index.html for SDH.