Alternative world health report articles
----------------------------------------
Two articles from the latest electronic newsletter of the Net-
work on Equity in Health in Southern Africa.
See http://www.equinetafrica.org for more details.
ALTERNATIVE WORLD HEALTH REPORT LAUNCHED IN CUENCA AND LONDON
by David McCoy and Mike Rowson
The conception and birth of the Global Health Watch
Five years ago, about 1500 people from 80 countries met in Bang-
ladesh at the first Peoples Health Assembly. The Assembly was
organised as a counter-balance to the official World Health As-
sembly convened every year by World Health Organisation, and
represented a protest against the failure to achieve health for
all by the year 2000.
The Assembly gave renewed expression to social objectives such
as fairness and the universal right to health care, as well as
to the public health principle that in addition to providing
health care, health systems and health professionals must act to
abolish poverty and work towards people having access to educa-
tion, nutrition, water, sanitation and peace.
It also gave birth to the Peoples Health Movement a network of
individuals and organisations from all regions of the world,
formed with the understanding that the principles of the Charter
would only be achieved through social mobilisation and political
engagement. The Global Health Watch, an alternative world health
report from the perspective of civil society, was designed as an
instrument to support advocacy and mobilisation. Amongst its
aims is to provide a platform that will embrace the science and
politics of development, and thereby, simultaneously involve
academics, health practitioners, parliamentarians, journalists
and civil society in improving health and equity.
More than 120 people researchers, health workers, non-
government policy analysts and campaigners - and 70 non-
government organisations contributed to the report. The connec-
tion of the Watch to the Peoples Health Movement and a wide
range of NGOs will hopefully ensure that it doesnt end up as
another report gathering dust disengaged from the vehicles
that can help translate analysis and recommendations into actual
action. Already a number of NGOs have volunteered to host
launches of the Watch in other countries, including Malaysia,
South Africa, Ireland, Egypt, Germany, Holland, and the US.
Watching
The Watch is not designed to report on the state of health and
poverty it is not about the size of the HIV pandemic, or the
number of children who die every second; or the declining life
expectancy in Africa. The aim is to provide a report on what is
being done about improving health by reporting on the actions,
policies and programmes of organisations charged with improving
health. This idea of watching the performance of key institu-
tions can also be viewed as a contribution to democratic defi-
cits that exist at many levels of decision-making and the ero-
sion of public accountability that has accompanied globalisation
and the concentration of wealth and power.
Global political and economic institutions
According to the Universal Declaration on Human Rights, people
do not just have a right to an adequate standard of living and
medical care they also have a right to live in a social and
international order in which the rights to medical care can be
realised. However, this right is continually violated. According
to the World Commission on the Social Dimension of Globalisa-
tion, none of the existing global institutions provide adequate
democratic oversight of global markets, or redress basic ine-
qualities between countries.
The Watch questions the success story painted by proponents of
the current form of globalization, pointing to increases in pov-
erty in Africa, eastern Europe, central Asia and Latin America.
Producers in developing countries have often been undermined by
increased global competition from powerful nations after trade
liberalisation. In Mexico, for example, the liberalisation of
the corn sector under the North American Free Trade Agreement,
led to a flood of imports from the United States, where agri-
business is massively subsidised. Mexican corn production stag-
nated whilst prices declined. Small farmers became much poorer
and some 700,000 agricultural jobs disappeared over the same pe-
riod. Rural poverty rates rose to over 70%, the minimum wage
lost over 75% of its purchasing power, and infant mortality
rates amongst the poor increased.
To change this will require a shift away from the dominant human
rights discourse which focuses on the obligations of national
governments towards their own citizens, towards more of a focus
on a) the obligations of governments to the citizens of other
countries; and b) the obligations of non-government actors, as
well as the rules by which the world economy is controlled and
governed. Furthermore, whilst some countries have social con-
tracts, progressive taxation systems and laws and regulations to
manage the human consequences of market failures at the national
level, there is no global social contract to manage the fail-
ures of globalization.
World Health Organisation (WHO)
A key chapter in the report is dedicated to WHO. The report ar-
gues that WHO is insufficiently resourced, inadequately empow-
ered, undermined by national political agendas and handicapped
by internal management problems. WHO does many things well and
repeatedly demonstrates the need for a multilateral agency
charged with protecting and promoting health, but the Watch
calls for better funding and improvements in WHOs operating en-
vironment. The report also notes that the proliferation of pub-
lic private initiatives, vertical programmes and the insidious
influence of the World Bank has resulted in WHO being further
undermined as the leading global health agency.
But we need, for example, a WHO that can challenge and aspire to
block trade and economic agreements that threaten to harm health
and human rights. As a starting point, the Watch calls upon WHO
to convene a delegation of public health and trade experts to
attend the trade talks in Hong Kong this year, mandated with the
role of providing public health advice to Ministries of trade
and finance. But this simple request is unlikely to be granted
without public lobbying. At the most recent Executive Board
meeting of WHO, a mild resolution put forward by developing
countries requesting WHO to conduct a more active analysis on
the impact of trade on health was blocked by the US and other
countries illustrating the impotence of WHO in tackling the
more fundamental determinants of health.
Other recommendations aimed at WHO include:
Steering the global health ship
- Substantially increase funding for WHO with more proportion-
ately devoted to its core budget with fewer strings attached; -
Open a debate on WHOs key roles to avoid mission-creep and to
develop consensus within and beyond the organization; -
Strengthen WHOs role at country level and give it a mandate to
help governments co-ordinate global, bilateral and international
NGO initiatives to improve health.
An organization of the people not just of governments - Expand
current efforts to reach out to civil society, especially in the
developing world; - Ensure that public-interest civil society
organizations are differentiated from those acting as a front
for commercial interests; - Improve the nature of the WHO lead-
ership elections possible solutions include a wider franchise,
perhaps of international public health experts and civil society
organizations. Candidates should be required to publish a mani-
festo and debate their vision for the organization publicly.
Improve the management of the organization - Improve the mix of
the professional staff, ensuring that there are more social sci-
entists, economists, public policy specialists, lawyers and
pharmacists. More representation from developing countries
should be coupled with stronger regional offices run by experi-
enced professionals.
The corporate sector
Of the 100 largest economic entities in the world, 51 are busi-
nesses; and the combined sales of the top 20 businesses are 18
times the combined income of the poorest 25% of the worlds
population. Transnational corporations wield immense power
through their wealth, control of resources and influence on gov-
ernments and key decision-making bodies, with profound conse-
quences for health and development.
The price of medicines and the radical changes to the way we
construct patents; the resistance to making the required changes
to address climate change; widespread labour exploitation and
occupational health hazards; the dumping of cheap, subsidised
food in Africa; the corrupt trade in weapons; the unchecked pol-
lution of many extractive industries; and the unhealthy changes
in food eating practices are just some examples described in the
report, of the causal relationships that exist between profit-
seeking corporate activity and the state of global health.
While commercial activity and free enterprise in themselves
should not come under attack, the deterioration of democratic
control and oversight over corporate actions and power must be
highlighted. The imbalance between corporate freedom and social
obligations is unhealthy, and health professionals need to as-
sert their public health authority to limit the negative conse-
quences of corporate actions, and ensure proper regulatory
frameworks.
The attention paid to the corporate sector also leads us to
shift thinking away from an exclusive focus on poverty towards
an equally necessary focus on wealth, and in particular one what
many would call obscene wealth. One of the demands we make is
for the establishment of an international tax authority to help
recover the conservatively estimated US$255 billion that is lost
annually through tax avoidance.
This is an amount of money, in spite of the low tax rates, that
would fund comprehensive and functional health care systems in
every poor country. Public-private partnerships and corporate
social responsibility programmes are great, but the Watch calls
for the greater use of legitimate, fair and non-punitive instru-
ments of public policy to ensure the universal provision of
health care and social security, and the redistribution that is
required to reverse the politically unsustainable deepening of
global disparities.
Health systems
The chapter on health systems sets a very different agenda from
the one currently popular with donors, where the emphasis is on
fragmented, vertical health programmes usually focussed on one
or two diseases, or on particular selected interventions. The
Watch describes how Ministries of Health in poor countries oper-
ate in a policy circus, pulled in a hundred different directions
by different programmes, donors and agencies, undermining coher-
ent and integrated health systems development. In many in-
stances, these agencies also contribute to an internal brain
drain sucking many of the most skilled professionals out of
public health care systems.
In the poorer countries, this has come on top of economic cri-
ses, structural adjustment programmes and neoliberal reforms
that have decimated public health care systems and extended the
commercialisation of health care to the detriment of equity, ac-
cessibility and efficiency.
The Watch presents new evidence which suggests that higher lev-
els of private finance and provision lead to worse health out-
comes, and explains how private financing and provision leads to
a commercialisation of health care systems which widens health
care inequities, lowers access to care for the poor, causes in-
efficiencies and deteriorates levels of trust and ethics.
Unless a common vision of health care systems development is es-
tablished, we will not achieve the health-related Millennium De-
velopment Goals. The Watch therefore calls for the adoption of a
10-point agenda to repair and develop health care systems (more
detail on the recommendations is available from both the Watch
itself and the accompanying advocacy document, Global Health Ac-
tion):
1. Provide adequate funding for health care systems; 2. Take
better care of public sector workers; 3. Ensure that public fi-
nancing and provision underpin health care systems; 4. Abolish
user fees that push people into poverty; 5. Adopt new health
systems indicators and targets that incentivize countries to im-
prove the health system rather than simply tackle specific dis-
eases; 6. Reverse the commercialization of health care systems
by using regulatory and legislative instruments; and search for
ways in which the private sectors resources can be harnessed
for the public good; 7. Strengthen health management and adopt
the District Health System as the model for organising health
care systems; 8. Improve donor assistance within the health sec-
tor; 9. Promote community empowerment to improve the account-
ability of the health system; 10. Promote trust and ethical be-
haviour to combat the corrosive effects of commercialization.
At the moment international health agencies consistently stress
the importance of strengthening health care systems but with
little debate or discussion as to what this actually means. This
is one area where WHO can really play a positive role and demon-
strate health sector leadership.
Global Health Watch 2
Planning for the second edition of the Watch has begun. But be-
tween now and then, the challenge will be to actively mobilise
the broader health community around the Watch and the advocacy
agenda that accompanies it.
At the launch of the report in London, NHS organisations and
professional associations were asked to think of institutional
responses to the global health crises by: - Developing long-term
partnerships with counterparts in poor countries - involving
support, the transfer of material resources, skills and technol-
ogy and also providing a mechanism by which health workers in
the NHS can learn and understand the impact of UK actions and
policies on global health); - Daring to put aside a proportion
of money to promote global health until such time that we have a
mechanism to recompense poor countries for training so many of
our health workers; - Implementing fair trade and ethical pur-
chasing policies within our own organizations; and - Campaigning
for change. Medact, which was established specifically as a mem-
bership organization for health workers to promote global
health, provide one concrete vehicle by which individual health
workers can work together to lever change.
In southern Africa, the health and development community should
consider ways in which the Watch can be used as a tool to
strengthen and develop a progressive global public health move-
ment and greater public accountability.
* David McCoy and Mike Rowson are managing editors of GHW
* Please send comments to mailto:admin@equinetafrica.org
--
IMPACT OF ADJUSTMENT POLICIES ON VULNERABILITY OF WOMEN AND
CHILDREN TO HIV/AIDS IN SUB-SAHARAN AFRICA
by Roberto De Vogli and Gretchen L. Birbeck
The social and economic impact of the adjustment programmes of
the International Monetary Fund (IMF) and the World Bank in de-
veloping countries has been a source of heated debate over the
last two decades. Research on the effects of these policies has
led to contradictory conclusions.
A number of World Bank evaluations indicate that 'adjuster coun-
tries' generally succeed in improving health, education, and so-
cial welfare programmes compared to 'non adjusters' (1-3). Based
on such studies, the World Bank concludes that adjustment pro-
grammes do not necessarily adversely affect vulnerable popula-
tions. Furthermore, the World Bank believes that reforms that
include these reforms are necessary for poverty eradication in
developing countries.
On the other hand, publications from UNICEF and from representa-
tives of academic institutions and non-governmental organiza-
tions (NGOs) indicate that adjustment policies may be particu-
larly harmful for the most vulnerable populations. In "Adjust-
ment with a human face", UNICEF reports studies from several de-
veloping countries which indicate that adjustment policies have
negatively affected the health status of women and children (4).
Evidence suggests that the adjustment programmes may also create
conditions favouring societal vulnerability to HIV/AIDS (5). Un-
fortunately, no study, to date, has systematically evaluated the
relationship between IMF/World Bank economic reforms and the
vulnerability of women and children to HIV/AIDS.
This paper reviews what is known regarding the social and eco-
nomic consequences of adjustment policies on maternal and child
welfare and explores the potential impact such consequences may
have on the vulnerability of women and children to HIV/AIDS. We
approach the impact of macroeconomic adjustment policies from a
conceptual perspective. Our theoretical framework illustrates
how adjustment policies may influence the predisposing factors
for impoverishment of women and exposure of children to HIV/AIDS
in sub-Saharan Africa.
The underlying assumption is not that adjustment is the only
cause of vulnerability of women and children to HIV/AIDS. Ante-
cedent predisposing factors, such as poverty and inequality, are
responsible for the vulnerability of women and children to
HIV/AIDS in the first place. However, adjustment policies may
further contribute to a socioeconomic environment that facili-
tates the exposure of women and children to HIV/AIDS, especially
when their implementation is not accompanied by specific meas-
ures protecting the most vulnerable populations.
AIDS in sub-Saharan Africa directly and indirectly devastates
the lives of millions of women and children. According to the
joint United Nations Programme on HIV/AIDS (UNAIDS) and the
World Health Organization, 19.2 million women and 3.2 million
children aged less than 15 years are living with HIV/AIDS in the
world. Almost two-thirds of them reside in sub-Saharan Africa.
In 2003, over one million women and approximately 610,000 chil-
dren died from AIDS.
Socioeconomic conditions of women and children are determined by
a series of hierarchical factors that interact with one another
at different levels of their ecosystem. These factors correspond
to the household level (i.e. income of the family), the meso
level (i.e. food prices, real wages, employment opportunities),
and the macro level (i.e. economic policies, health policies,
social welfare systems). The latter level is particularly impor-
tant: macroeconomic changes modify the meso-economic conditions
that, in turn, are transmitted down to the household level. Mac-
roeconomic measures, such as adjustment policies, may have an
impact not only on macroeconomic indicators, such as gross do-
mestic product (GDP) growth and the external debt rate, but also
on social indicators, such as access of women and children to
shelter, food, healthcare, and education. Since poor access to
basic human needs may facilitate the exposure of children to
HIV/AIDS, economic policies at the macro level may ultimately be
related to the socioeconomic conditions that reduce or facili-
tate the spread of HIV/ AIDS among infants and youths.
Economic reforms that decrease access to basic needs for poor
households will eventually result in increased exposure of women
and children to HIV/AIDS. Conversely, economic growth that leads
to increased access to basic goods and services for the most
vulnerable families may significantly reduce their exposure to
the infection.
Since 1980, most sub-Saharan African countries entered into one
or more adjustment programme(s) of the IMF/ World Bank. Many of
these programmes have not been implemented as prescribed by the
World Bank and IMF, but as implemented, these policies have not
produced the expected results in terms of economic growth and
reduction of unsustainable debt. A World Bank study of 26 Afri-
can countries that implemented adjustment policies concluded
that six countries had a large improvement in macroeconomic in-
dicators, nine had a small improvement, and 11 had a deteriora-
tion (3). Moreover, Africa's external debt increased from US$
120 billion in 1980 to US$ 340 billion in 1995 (14).
Adjustment policies mainly consist of currency devaluation and
financial liberalization; privatization of government corpora-
tions; trade liberalization (including import liberalization and
export promotion); elimination or reduction of subsidies for ag-
riculture and food staples; and reductions in government spend-
ing (including expenditure for health, education, and social
services).
Analyses of the effects of currency devaluation on prices for
basic items, such as food, housing, and transportation, lead to
controversial conclusions. Prices for basic commodities rise af-
ter the adoption of the adjustment policies because currency de-
valuation increases the cost of imports. In Zambia, devaluation
increased the cost of bread from 12 kwacha a loaf in 1990 to 350
kwacha in 1993 (21). In Senegal, after currency devaluation, in-
flation rates dramatically increased especially for daily food
and health products (22). In Kenya, the real price for maize
rose by 29% between 1982 and 1983 (23). In Tanzania, commodity
prices skyrocketed as a result of devaluation (24).
Despite these results, there is also evidence that currency de-
valuation may be an appropriate solution to prevent a further
collapse of a failing economy (13). A study conducted in cocoa-
growing areas of Ghana concluded that even the poorest small-
holders benefited from the improved producer prices resulting
from devaluation (25).
If currency devaluation produces mixed effects, removal of food
subsidies has a more direct impact on access to food and basic
commodities, especially among low income groups. In Zambia, af-
ter the removal of subsidies in 1985, the price of maize meal
rose by 50% (26). In Zimbabwe, after eliminating food subsidies,
the cost of living for lower-income urban families rose by 45%
between mid-1991 and mid-1992. The increased cost of food items
results in a sharp reduction of low-income household expenditure
on other basic commodities.
Sharp increases in the cost of living and impoverishment of
women not only increase the vulnerability of infants to
HIV/AIDS, but also have a negative impact on vulnerable young
people. Children of poor mothers are more likely to be exposed
to predisposing factors for HIV (10). Socioeconomic constraints
force these children to leave school and search work to support
their families. Children may also be abandoned. Youths and chil-
dren living in impoverished families are more likely to live and
work on the street, where they may be forced into prostitution
to exchange sex for money, goods, food, or shelter (31).
Privatization results in significant job losses in the public
sector without necessarily increasing employment in the private
sector (34-36). To improve efficiency and keep production costs
low, public enterprises reduce costs of labour by freezing wages
and reducing employment.
This results in a decline of real wages or an increase in unem-
ployment, especially among low-income workers. During the 1980s,
average real wages declined in 26 of 28 African countries (34).
In Ghana, between 1984 and 1991, after privatization of the 42
largest state enterprises, more than 150,000 workers lost their
jobs (31).
These cutbacks in public-sector employment disproportionately
affect women (4,37,38) who traditionally hold positions, such as
clerical workers, cleaners, nurses, or teachers. In Ghana, the
least skilled women working in the public sector lost job pro-
tection, security, and benefits as a consequence of policies
aimed at increasing efficiency, while others lost employment al-
together (39). Privatization not only affects women in urban ar-
eas, but also impacts those in rural areas since informal land
privatization is linked to a reduction in access of women to
subsistence food production (40).
Unemployment, low wages, and job insecurity caused by privatiza-
tion not only increase women's adoption of survival strategies,
including prostitution, but also modify existing gender-related
relationships. Employed women tend to be more empowered by hav-
ing more opportunities for education, more experience in public
life, more self-confidence and self-esteem, all basic prerequi-
sites for negotiating safe sex with male partners (41). Con-
versely, unemployment, job insecurity, and reduced purchasing
power increase the exposure of women to sexual harassment and
sexual abuse, especially among those working in low-earning jobs
(42).
Reduced employment opportunities resulting from privatization
may also increase the proportion of African children forced to
live on the street or work to support their families (43). In
Zambia, due to privatization and retrenchment of government em-
ployees, 72,000 people lost their jobs and child labour in-
creased nine folds among females aged 12-14-years (44).
In regions where a significant proportion of population live in
miserable conditions, indiscriminate cost-recovery measures dis-
proportionately affect those who cannot afford to pay user-
charges. The World Bank and other organizations which support
the implementation of user-fees for health services insist that
even poor households are willing to pay for higher quality, more
reliable health services. In a household survey conducted in
Rwanda, most respondents, regardless of income, indicated a
preference for higher fees to assure the availability of medica-
tions (59).
However, populations living on less than a dollar per day can
rarely afford to pay user-fees and their inability to pay may
negate their 'willingness' to pay (60). The literature repeat-
edly shows that introducing user-charges at STI clinics result
in a dramatic drop in women's use of services (61-64). Access to
free STI treatment and condoms increase their use (65-66), and
the introduction of user-charges creates an obstacle to HIV-
preventive behavioural practices among women. Women and youth
without access to AIDS education, HIV screening, STI treatment,
and reproductive health services have little control over their
AIDS-related risk factors. Untreated STIs increase the risks of
HIV transmission (67) as shown in Uganda where over 90% of new
HIV infections were attributable to other STIs (68). The intro-
duction of user fees for health clinics is likely to increase
the number of untreated STIs consequently producing high HIV
susceptibility in women (66). These HIV-infected women infect
their children through vertical transmission of the virus.
Following the prescriptions for structural adjustment and stabi-
lization policies, many sub-Saharan African countries reduced
public expenditure on education and introduced school fees lim-
iting access to education, especially among those children who
cannot afford to pay such charges (4,36). The introduction of
school fees causes a dramatic fall in primary school enrollment
rates and increases the number of children who drop out of
school. Sub-Saharan Africa has the lowest primary school enroll-
ment ratio in the world. This ratio fell from 77.1% in 1980 to
an estimated 66.7% in 1990 (69).
Certain components of adjustment reforms, such as currency de-
valuation and trade liberalization, may produce mixed effects on
the vulnerability of women and children to HIV/AIDS. Other re-
forms, such as financial liberalization, removal of food subsi-
dies, and introduction of user fees for healthcare and education
have a negative impact on the spread of the epidemic among poor
women and children. In most cases, adjustment policies create
synergies making it extremely difficult to identify their net
social effects. Clearly, there is, currently, no single study
capable of demonstrating a causal link between adjustment poli-
cies and the exposure of women and children to HIV/AIDS. How-
ever, this analysis provides some evidence that adjustment poli-
cies may inadvertently facilitate societal conditions that in-
crease the vulnerability of women and children to HIV/AIDS in
sub-Saharan Africa.
It must also be acknowledged that the World Bank is, at present,
the largest single investor in health in sub- Saharan Africa.
Such investment may reduce the HIV epidemic through some mecha-
nisms. However, the unintended consequences of adjustment poli-
cies may have greater negative effects on the same health out-
come.
Given the potential for adjustment policies to exacerbate the
AIDS pandemic among women and children, there is an urgent need
to either demonstrate that such measures are not harmful to ma-
ternal and child welfare or to modify policies. The present
buffering mechanisms designed to protect the most vulnerable
segments of the population during macroeconomic stabilization
and structural adjustment are not sufficient. The IMF and the
World Bank need to provide adequate scientific evidence demon-
strating the effectiveness of their policies. Failure to do so
may undermine their international credibility and further exac-
erbate the already tragic social conditions of marginalized
women and children at risk of HIV/AIDS in the developing world.
* This article is composed of extracts from the original review
paper, done with permission of the author. For the full paper
and list of references visit
http://www.phishare.org/documents/icddrb/3205/
* Roberto De Vogli is with the Department of Epidemiology and
Public Health, University College of London. Gretchen L. Birbeck
is with the African Studies Center and Departments of Neurology
and Epidemiology, Michigan State University.
* Please send comments to mailto:admin@equinetafrica.org