What can Africans expect from the World Health Assembly (WHA) on 14 May 2007? Judging from past experience, the Assembly will be a forum where African countries will find issues critical to public health being raised, but not resolved without a struggle.
Kenya, supported by other African countries, proposed in a resolution on Malaria that, countries’ provide legislation to use “to the full” the flexibilities allowed under World Trade Organisation (WTO) agreements to increase access to anti-malarial medicines, diagnostics and technologies for prevention. The US has strongly opposed this. The WHO Executive Board therefore decided in January 2007 to send the draft resolution to the WHA with both the alternate US and Kenya proposals in bracketed text, indicating a lack of consensus. Inexplicably, the draft resolution posted on the WHO website did not reflect the Kenyan proposal and it took many days before it reflected the decision of the Board. The Kenya proposal needs to be supported to protect the legitimate legal rights that countries have under WTO.
Despite the negative US position, at the 2006 WHA many countries recognised that the current intellectual property rights system does not adequately provide for research and innovation on treatments for diseases that disproportionately affect developing countries. To address this, an Inter-Governmental Working Group on Public Health, Innovation and Intellectual Property was established to prepare a global strategy and plan of action. This Working Group will table a report at the WHA.
A resolution will also be tabled on the rational use of medicines, in light of a finding of irrational drug use in over 50% of medicines in developing countries, with weak application of essential medicines, particularly in the private sector. African countries could potentially treat double the number of people within the same budget if this were addressed. The issue of rational use of medicines has been discussed at the WHA since 1985, and countries have urged greater leadership, evidence based advocacy and support from WHO to advance implementation of rational drug use.
While these issues are on the WHA agenda, there is concern about what is happening in practice on intellectual property rights and health. In research on the small pox vaccine, WHO’s relatively open approach to ownership of the research outcomes has enabled private companies to derive exclusive patent rights from such research, such as the US patents have been registered on treatments by the University of California in April 2004 and April 2006. Such patenting could hamper access to vaccines for many countries in the future.
While small pox was eradicated in 1977, many countries still hold unofficial stockpiles of the small pox virus, with only the US and Russia holding official stockpiles. Backed by recommendations of the Committee on Orthopoxvirus Infections, in 1996 African countries pushed strongly for the destruction of the remaining stocks of the virus, given that the risk posed by deliberate or accidental release outweighed any benefits from retention. In a counter initiative, several developed countries including the US and Canada, drawing on recommendations from a new and differently constituted Advisory Committee on Variola Virus Research, are seeking to block the destruction dates so as to retain the right to seek approval for "scientifically interesting" research, including genetic modification of small pox.
WHO is now applying the same open approach to the Avian Flu virus, i.e. sharing specimens without ensuring provider and other countries have adequate access to treatments and vaccines. Countries like Indonesia, who share viruses, have found that they either cannot afford or cannot secure access to the vaccines because of limited production capacity, leaving their citizens vulnerable to infection. The WHO Guidelines (March 2005, listed but not available on the website) state that WHO Collaborating or Reference laboratories will neither share viruses or specimens, nor publish research results without permission from the originating country. Yet the sharing of specimens has not followed these guidelines, allowing private appropriation of the research outcomes.
Indonesia stopped sharing its viruses with WHO in 2007 even though sharing facilitates research into treatments and vaccines. Indonesia took action, not for commercial interest, but because it could not secure adequate access to vaccines for its people, who were offered vaccines at a prohibitively expensive US$20 per dose. Indonesia did say it was willing to share the viruses on more equitable terms, but WHO has thus far not been able to create equitable conditions for either virus sharing or access to Avian Flu treatments for countries in need (in Africa, Nigeria, Djibouti and Egypt have reportedly experienced Avian Flu). These cost barriers to access vaccines or treatment carry massive risk for the countries concerned: according to the US Centre for Disease Control (http://www.cdc.gov/flu/avian/gen-info/facts.htm) the Avian Flu mortality rate can reach 90 to 100% in 48 hours. In 2005, Indonesia experienced this problem when Roche refused to supply Tamiflu because of advance orders from other countries intent on stockpiling, even while Asian countries were experiencing an outbreak. Roche has sought to remain the sole producer of Tamiflu, despite donating some medicine to WHO.
Access to vaccines by developing countries may be further compromised by the limited global vaccine production capacity. Vaccine producers have taken advance purchase orders for vaccines. The resolution on Avian Flu to be considered by the WHA provides an opportunity for countries in Africa and elsewhere to ensure that access to vaccines is not a privilege primarily for wealthy countries, and that WHO facilitates wide access in response to need.
These upcoming issues at the WHA signal both the continued importance of international collaboration on health issues, as signified in the WHO constitution, as well as the need for constant pressure for and vigilance over its practice.
This editorial reflects the author's individual views. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at admin@equinetafrica.org.
Editorial
There is a dire shortage of professional health care workers to deliver essential health services in sub-Saharan Africa, including life-saving antiretrovirals (ARVs) for people living with HIV and AIDS. Donor support for disease-specific interventions for AIDS, tuberculosis, and malaria has increased markedly in recent years. However, funding for recurrent costs for these interventions, such as increasing salaries and creating new posts, has remained taboo.
The Global Fund to Fight AIDS, TB and Malaria (GFATM) was created largely due to pressure from activists and non-governmental organisations (NGOs) who fought to have a global financing facility that would pay for ARVs – something that was considered off-limits to donors before 2002. In 2005, a specific "window" of funding was created to support health systems, including human resource costs. Since then the option has been integrated within specific disease components.
Although there is some degree of uncertainty about the scope of GFATM support for human resource costs in future rounds, country applicants have an opportunity to request such support in Round 7. The GFATM should provide unambiguous and continued support for funding salaries and other "recurrent" human resource costs. Bilateral donors should follow suit.
Lesotho is a case in point. The country has the third highest HIV prevalence in the world after Swaziland and Botswana – and is the poorest of the three. It is struggling with a catastrophic health worker situation that threatens to make it impossible for the country to scale-up and sustain HIV care and treatment for the more than 270 000 Basotho presently living with HIV and AIDS.
In January 2006, Doctors Without Borders/Médecins Sans Frontières (MSF), an international medical humanitarian organisation, launched a programme in Lesotho in Scott Hospital Health Service Area (HSA), a rural health district with a catchment population of 220 000. The programme provides decentralised HIV care and treatment, including ART, integrated into existing primary health care services. In the first year, more than 3 500 people were enrolled in HIV care and over 1 000 had initiated ART at Scott Hospital and 14 rural health centres.
Scott Hospital HSA has a higher than average health worker coverage rate. Still, according to an assessment of workloads in Scott Hospital HSA carried out by MSF in August 2006, there are up to 45 consultations per nurse per day not including HIV-related consultations. With the introduction of dedicated HIV services, the workload in the past year has increased dramatically. The World Health Organisation recommends that nurses should conduct no more than 20 consultations per day.
Between January and July 2006, at least 18 nurses left the HSA for "greener pastures". Ten new nurses were hired after July 2006, but six additional nurses left, leaving more than a quarter of nursing posts vacant.
With more than 35 000 people estimated to be living with HIV and AIDS in Scott Hospital HSA alone, at least 5 000 of whom are in urgent clinical need of ART, the needs far outstrip the capacity of health facilities and health workers. MSF has employed several strategies to cope with these shortages – from providing mobile MSF medical teams to bring "in-service" support to nurses to task-shifting to new cadres of community health workers to introducing measures to improve staff retention.
Ultimately, however, immediate measures will need to be put in place at the national level to recruit and retain skilled nurses and other professional health care workers, including as a necessary first step, increasing their salaries. Without major investments in retention of skilled staff, ART programmes – including the MSF-supported programme – are vulnerable to collapse.
The GFATM, bilateral donors, and all other relevant actors, must clearly state, with money on the table, their support for funding salaries and other interventions to support human resources for health. Affected-country governments must then meet this commitment with emergency plans to address the human resource crisis.
As for Lesotho, an emergency human resource plan needs to be developed and donors need to step up to the plate. The US Millennium Challenge Account is committing an unprecedented US $140 million for health infrastructure. "Brick and mortar" projects are welcome, but without support for health care workers, this construction/renovation programme will be tantamount to supplying computer hardware without software to run programmes.
Funding salaries on a recurrent basis and supporting other initiatives to stem the loss of health workers and bring relief to overburdened staff and the thousands of patients they serve is a critical requirement in order to expand and sustain HIV/AIDS care and treatment.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, admin@equinetafrica.org. Further information on MSF and its programmes can be found at www.msf.org and on EQUINET work on AIDS and health systems www.equinetafrica.org.
In February this year the WHO Director General, Margaret Chan caused a storm when she was quoted in Thailand saying that the country should negotiate with pharmaceutical companies before issuing a compulsory license. She encouraged the nation’s public health ministry to improve its relationship with drug companies to strike the right balance in accessing drugs. Chan’s statement created the impression that there was something wrong with compulsory licensing that needed to be corrected through negotiating with pharmaceutical companies.
If the comments were meant to shock and awe, they achieved exactly that! Shocked treatment access advocates sought clarification from the DG herself on the alleged statements. Five days after the comments appeared in the Bangkok Post of February 2, civil society received information that a letter was dispatched to Thai’s Minister of Health, Mongkol Na Songkhla. There had been a misunderstanding, the Director General said. She regretted that her comments “were misrepresented in the media, and may have caused embarrassment to the government of Thailand. They should not be taken as criticism of the decision of the Royal Thai government to issue compulsory licences which is entirely the prerogative of the government, fully in line with the TRIPS agreement.”
For the avoidance of doubt, the Director General went on to say the following:
"WHO unequivocally supports the use by developing countries of the flexibilities within the TRIPS agreement that ensure access to affordable, high quality drugs. This includes the use of compulsory licensing, as described in paragraph 6 of the Doha Declaration on the TRIPS Agreement and Public Health. The decision whether to issue a compulsory license for a pharmaceutical product is a national one. There is no requirement for countries to negotiate with patent holders before issuing a compulsory licence."
This statement helped to clarify an impression that pharmaceutical companies have higher priority than people’s lives. For Africa this is particularly important, with Southern Africa the epicentre of the global HIV epidemic with 34 % of global AIDS deaths occurring in the region. While AIDS places a heavy burden on households and health systems generally, the cost of treatment for AIDS continues to be disproportionate to the incomes of affected families and of governments.
According to Oxfam reports, prices of some treatment regimens for AIDS are on the rise. This is saddening evidence coming six years after the historic signing of the Doha Declaration on TRIPS and Public Health in 2001. Fierce generic competition has helped prices for first-line AIDS drug regimen to fall by 99% from $10,000 to roughly $130 per patient per year since 2000. However prices for second-line drugs remain high due to increased patent barriers in key generics producing countries like India. Patients who develop resistance to first line regimens need these second line drugs, and the number is likely to grow over time, as will the unaffordable cost to health systems.
As outlined in the EQUINET / SEATINI leaflet on using TRIPS flexibilities (at www.equinetafrica.org) countries have full authority under TRIPS to use compulsory licensing or parallel importation of drugs if their laws provide for this and they need them for public health., Most (but not all) countries in the region have now passed the relevant laws for this. But the political and diplomatic pressure to dissuade governments from using these TRIPS flexibilities keeps mounting. A case in point is the legal action against the Indian government by a pharmaceutical company, Novartis. Novartis is challenging a section of India's Patents Act that aims to restrict certain kinds of patents. Novartis brought a civil lawsuit against the Indian government after the country rejected in January 2006 the company's attempt to patent a new version of its leukaemia drug, Gleevec, on the basis that the drug is a new formulation of an existing drug. If Novartis wins the case it could potentially set a precedent for other pharmaceutical companies seeking patent protection for formulations of drugs made before 1995, including antiretrovirals.
As institutions involved in health in Africa, we expect no ambiguity on this from WHO. Governments should be encouraged to use the flexibilities provided to them in the WTO TRIPS Agreement, including issuing compulsory licenses, to access generic drugs. With the Global Fund for AIDS, TB and Malaria and UNAIDS, still more needs to be done to bring down the cost of these drugs, particularly of the second line regimens, and to make them affordable on a long term basis.
For our part, we expect our governments and parliaments to ensure that our national laws incorporate TRIPs flexibilities, that our authorities are organised to implement them and that our populations are organised to protect their use. We expect our governments to reject clauses in bilateral trade agreements that attempt to remove authority to use these flexibilities. We have regional intergovernmental organisations such as COMESA and SADC to share information, resources and expertise and to harmonise legislation.
We can also stimulate the production and marketing of generic drugs, increasing returns to producers and access for people who need them. We can work through these same regional organisations to collectively issue compulsory licenses for common public health problems. In Latin America, for example, ten countries joined efforts to get agreements from generic manufacturers and originators on generic drug production. If ESA countries use regional frameworks to collectively issue compulsory licenses for the same drug, this builds a large enough market to encourage producers to invest in producing cheaper, generic versions of these drugs.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org and please visit the SEATINI website at www.seatini.org. EQUINET work on health equity in economic and trade policy and further information on TRIPS flexibilities is available at the EQUINET website at www.equinetafrica.org.
Are institutions that tap poor people’s desire for credit, shrinking Third World states’ already beleaguered welfare policies? The role of microfinance in poverty reduction, reducing risk environments for HIV and promoting private health insurance has attracted high profile interest since Muhammad Yunus won the Nobel Peace Prize last December.
Yunus’s Grameen Bank battled backward Bangladeshi patriarchal and religious attitudes to extend credit to millions of people. Poor women were typically arranged in groups of five: two got the first tranche of credit, leaving the other three as ‘chasers’ to pressure repayment, so they could in turn get the next loans. But a decade ago (at a time of lower foundation subsidies, new competitors, adverse weather conditions and a backlash by borrowers who used collective power of nonpayment), Grameen imposed dramatic price increases on loan repayments and resorted to extreme pressure techniques, including removing tin roofs from delinquent women’s houses. This reduced Grameen Bank’s main philosophical position - ‘We consider credit as a human right’ - to merely an argument for access, not affordability. This distinguishes Yunus from all rights-based social movements demanding ‘rights’ to free lifeline access to healthcare, AIDS medicines, education, housing, land, water, electricity, etc.
According to Munir Quddus, chair of the Department of Economics and Finance, University of Southern Indiana, the model needs more investigation: ‘The very nature of setting up groups leaves out the very poor who would be perceived by fellow members to have no ability to generate income and therefore high risk … microcredit simply deepens the exploitation of the women since the rates of interest charged by the bank in real [after inflation] terms are quite high; consequently, credit often worsens the debt situation and gives the husbands even more leverage.’
Evidence on South Asian microcredit and major credit programs suggest that credit does not necessarily have a positive impact on social relations. Many loans targeted at women are appropriated by male family members, leaving women as buffers between their spouses and lending institutions, with often stressful and violent results. Even where women’s incomes have increased, research found women’s work and debt loads also increased. Women’s access to credit does not guarantee improved confidence, mobility, control over assets, or freedom from violence. Therefore, microcredit must be interrogated to determine if it is really about poor people gaining control, or if it leaves structural and often global causes of poverty unaddressed.
For example, in 1998, when an emerging market crisis led to rising interest rates across the Third World, South African microlenders and borrowers were driven into bankruptcy by a 7% increase imposed over two weeks as the local currency crashed. In Zimbabwe, a 1980s US$66 million flood of World Bank financing revitalised the rural microfinance sector (initiated under 1940s Rhodesian rule) and reached 94,000 households. But within a decade, the peasant default rate was 80% - with repayment affordability being a huge factor (a typical lender’s overhead and collection costs on a small loan were 15-22% (including incorporation of a 4% default rate)). Michael Drinkwater’s (1991) detailed study of central Zimbabwe showed peasant farmers faced serious difficulties in servicing loans of just a few hundred US dollars, since average net crop profit was just $0.15/hour of labour, according to a 1989 Agriculture Ministry survey. This was compounded by ‘an overzealous launching of a group credit scheme’ and the ‘doubtful viability of high cost fertiliser packages’, inappropriate for the erratic climate. ‘The increase in credit use means farmers have to market more to stay solvent ... At the household level it is commonly debts not profits that are on the rise.’
This raises the question: ‘Is credit the most useful input for African peasants’ economic and social wellbeing, especially women?’ According to Mohindra and Haddad (2005), women’s health capabilities (opportunities to achieve good health) and health functionings (e.g. being healthy), ‘can be expanded via key determinants of population health, such as access to resources and autonomy’, with microcredit as a primary tool. But is microcredit really a tool for expanding access to health inputs when the structural disempowerment and malfunctioning markets that bedevil credit systems are added to the overall retreat of the Third World welfare state?
The question is important as Grameen-style microcredit is increasingly linked to health services ranging from education to insurance, including: the Niger CARE ‘Microcredit and Health Education for HIV/AIDS-Affected Women and Children in the Valley of the Widows’; the Philippine NGO Innovations for Poverty Action and the Green Bank marketing of health insurance and preventative care through 2000 microentrepreneurs; or
the International Medical Corps microcredit project to support local health programs in Eritrea. The Microcredit Campaign Summit pointed to many new opportunities to substitute microcredit for state or donor assistance in reproductive health education. But such schemes need to be questioned on: whether they deliver on resources and autonomy, how they change local power relations; and their record on arrears, social conflict and defaults.
Few rigorous studies document the relationships between financial vulnerability and health burdens. A study of a Dominican microcredit program, which made small loans to individuals to start or expand small businesses, included three communities: one with health promotion alone; one with microcredit alone; and one with both. The community with parallel microcredit and health promotion programs had the largest changes for ten of eleven health indicators. However, the study also traced health gains to improved ability to purchase commercial water supplies, making a link between microcredit and the demand on poor people to pay for commercial and privatised water. As the UNDP Human Development Report (2006) noted, microcredit is explicitly used to promote the market in essential services and enable poor households to meet the financing requirements.
While not denying the prospect that some microcredit schemes are worthy and effective, the criticisms raised offer warning. Claims made about microcredit as an overarching strategy to end poverty, change power relations, attack structures of inequality or improve vulnerable population’s health education should be treated with caution. Certainly, microcredit cannot stand in for decent social policy when it acts as a safety net, co-existing with and not transforming entrenched structures that generate poverty . In the worst case, microcredit can become an ideology explicitly hostile to state support for healthcare.
‘I believe that “government”, as we know it today, should pull out of most things except for law enforcement and justice, national defense and foreign policy, and let the private sector, a “Grameenized private sector”, a social-consciousness-driven private sector, take over their other functions.’
To illustrate the dangers ahead, those were words uttered in the 1998 autobiography of Nobel Peace Prize winner Yunus.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org. A more detailed analysis of the issues raised in this editorial can be found in Microcredit Evangelism, Health and Social Policy by Patrick Bond, Forthcoming in the International Journal of Health Services, June 2007.
On December 10 the Africa Public Health Rights Alliance launched an important “15% now!” campaign. We carry information on the campaign in this newsletter, and its call for African heads of state to allocate 15% on government spending to health, as promised at the African Union (AU) summit in Abuja, in 2001.
There is clear evidence of the pressing demand for significantly improved resources for health in east and southern Africa (ESA): We see it in high levels of poverty and deprivation, persistently high HIV, AIDS and other preventable diseases, high rates of child and early adult mortality, inadequately staffed and resourced public health services and massive inequalities in health outcomes between sub-Saharan Africa and other regions. The EQUINET newsletters in 2006 have presented different facets of this evidence. Health is determined by the conditions in which people live, work and interact, and depends on policies and spending beyond the health sector. The investments in the health sector are, however, critical, especially in the context of high levels of inequality and poverty. These investments can prevent avoidable illness and mortality, redistribute social resources to deprived households, protect against the impoverishing effects of ill health and demonstrate our values and commitment as a society to human security. As our May newsletter editorial suggests, health sector investments have greatest impact on low income communities when they are made in public sector primary health care and district health systems.
The World Health Organisation estimated in 2000 that an expenditure of US$60 per capita is the minimum level of health expenditure needed for a health system to function well. The Macroeconomic Commission on Health estimated in 2003 that a minimally adequate set of interventions to meet the basic health needs of poor communities is between US$34 and US$38 per person per year, not including some of the wider systems demands for a functional health system. However African health systems and communities face challenges that call for additional resources: The World Bank estimated in 2002 that Africa would need an additional US$4.2 billion to meet the costs of HIV prevention and AIDS Care, given the scale of the epidemic. Meeting the Millennium Development Goals (MDGs) adds to this cost. This makes an expenditure of US$60 per person per year a not unreasonable estimate, and one that would need to be made largely in the public sector if the benefits are to reach poor households.
Yet many public health sectors in ESA are trying to deliver health systems, pay health workers and respond to health challenges on less than $15 per person per year, and some on less than US$10 per year. Overall per capita expenditures on health in the region, public and private combined, average less than US$30 per person per year, while government spending on health is less than 10% total government spending for the majority of countries in the region.
Increasing to 15% of Government spending on health is an important and necessary sign of government commitment to health, even while it would not on its own for most countries in ESA provide adequate per capita resources for health. The call for “15% now!” justifiably calls for implementation of this commitment. If the 15% target is met through increased donor resources and not through increased application of domestic revenue, it is not a clear test of that commitment and is vulnerable to donor withdrawal. The “15% now” should thus be understood to exclude donor resources.
However, many countries in the region need more than the 15% government spending. Additional resources must be applied.
One of the sources for this must be debt cancellation. With over US$ 100 billion external debt in ESA in 2003 and even more paid out over three decades to service the debt, current debt relief measures are inadequate to overcome “debt domination”. Applied over many decades, with relatively small reductions in annual debt, they still leave African countries with significant debt burdens and deplete domestic resources for heath. As in last year’s call by civil society organisations and governments in the South-North consultation on alternatives to debt domination, the a call for “15% now!” must go together with a call for “Debt cancellation now!”.
Debt servicing is only one of the many ways resources are flowing out of our region. As demonstrated in the April EQUINET newsletter editorial, unfair and unequal terms of trade, outflows of private finance, shifts to speculative foreign investment, phantom aid, a massive outflows of health workers and global exploitation of non renewable African resources represent some of the vast and ongoing outflows of the continent’s existing and potential wealth. A recently released UN WIDER report included in this newsletter observes that inequalities in wealth have widened, with the richest 2% of adults in the world owning more than half of global household wealth, while the bottom half of the world adult population –a large share in Africa - own barely 1% of global wealth. Net outflows of African wealth represent a perverse flow of resources for health from those with greatest health needs in the poorest regions, to those with least health needs in the wealthiest regions.
This calls for a global response. An increase in predictable long term overseas development aid would provide one means of addressing this situation, and could be applied to increase the per capita spending on health to more meaningful levels, over and above the “15% now”. Efforts by some G8 countries to explore new sources of tax funding for global transfers are important steps towards this. So while African governments must be accountable for their 15% to health, so too wealthy countries must honour their commitment to “0.7% GDP to ODA now!”
But achieving global commitments to health in ESA calls for more than increased aid. Global commitments to universal access to antiretroviral treatment discussed in our June newsletter editorial, or the social development goals set at the 1995 World Summit for Social Development (WSSD), discussed in our November editorial, call for enabling, accessible, responsive and accountable states committed to mobilize the resources for health (15% now!), unencumbered by excessive debt servicing (Debt cancellation now!) and supported by ODA (0.7% GDP to ODA now!) Yet this can leave governments and people in ESA heavily reliant on external aid for their health, while wealthy groups in high income countries and corporates continue to benefit from trade, finance and resource outflows from the region. Levering increased investments in heath must be backed by challenge to these resource outflows and to the trade and macroeconomic policies that intensify inequities in control over the resources for health. “Reclaim African wealth for African health...now!”.
Please send feedback or queries on the issues raised in this editorial to the EQUINET secretariat at TARSC, email admin@equinetafrica.org
There have been dramatic changes to municipal services such as water and electricity since the end of apartheid in South Africa, with considerable research having gone into the impacts of commercialisation and cost recovery on low-income households. The research has revealed a complex and often negative relationship between the marketisation of these services and access and affordability for the poor. It has also been shown to have direct and very negative public health implications, most acutely in low-income township and rural areas.
Less obvious, and much less researched, have been the impacts of changes in service delivery on the mental health of low-income residents and household members. The fact that there is a relationship between poor mental health and poverty in general has now been well established. Common mental disorders (notably, anxiety and depression), while once thought to be the preserve of the rich who could afford the ‘luxury’ of worrying about emotional issues, have in fact been shown to have higher prevalence in low-income households. It has also been suggested that there is a cycle of vulnerability between poverty and marginalization, physical ill health, emotional distress, and mental disorder.
What, then, might be the links between poverty, mental health and the shift towards market-oriented reforms in basic services? A preliminary detailed ethnographic study of ten low-income families coping with a serious mental disorder (schizophrenia) in Cape Town pointed to several problems including:
• Health and safety problems. Household members have difficulties in ensuring appropriate use of medication (due to lack of water), practicing adequate hygiene, growing their own food, and with general comfort (such as being warm and dry). There are also concerns about being forced to use open fires, candles and paraffin stoves for cooking and warmth, leading to additional health and safety worries such as poisoning, fires, and respiratory infections.
• Time and energy. Considerable time and energy are spent searching for alternative sources of water and electricity and having to live with limited supplies of both.
• Social tensions. Respondents expressed concern with having to borrow money or water from neighbours and family members, leading to additional stresses in the lives of
household members and often to tensions within families and neighbourhoods, exacerbating the stigmas typically attached to mental disorders.
• Social activities. Reducing service consumption has implications for people’s social lives and household entertainment. Most of the households interviewed owned a television or radio, for example, but were reluctant to use them due to electricity costs. One family member reported being bored at home and therefore spending time with peers who encouraged him to use drugs. This has important implications for health, as co-morbid substance abuse has been shown to play a role in relapse of schizophrenia as well as being implicated in the onset of psychosis.
• Relapse. The stress of not being able to afford adequate services, or having these services cut off or restricted, would appear to add considerable stress to the person with the mental disorder, possibly contributing to a worsening of the disorder and/or a relapse.
• Impact on care-giving environment. Inadequate services would appear to increase levels of stress and burden for the caregiver(s), with implications for their own mental health. This then impacts on the family member with the mental disorder as well as the household as a whole, as the caregiver’s ability to care for the family may be compromised. Women appear to be the most affected by this as the primary caregivers.
Households experienced considerable financial hardship as a result of cost recovery strategies on basic services, with 29% of household income being spent on water and electricity on average, and arrears on water and electricity bills as high as R18 200. This situation caused anxiety and added considerably to overall family stress.
While households used a range of strategies to minimise water usage, the need to save water was a further source of anxiety and conflict. Similarly, concerns were raised about electricity usage and cut-offs, with disability grants being used to pay for fuel and basic services in many households.
While direct links between experiences of service delivery difficulties and the onset or relapse of mental disorder cannot be drawn, but it is clear that uncertainty about services in the context of poverty add to overall stress levels. Much remains to be done in terms of realising the rights of people with mental disorders (and their families) in South Africa. Without considering the broader context of poverty and service delivery it will not be possible for them to adequately improve their lives.
Editors comment: This issue of the newsletter presents material on mental health and equity, and we note the limited publication found in this area. EQUINET invites further contributions on mental health in Africa, and particularly in relation to equity issues. Please send contributions, feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. Further information on issues raided in the briefing or the Municipal Services Project see http://www.queensu.ca/msp/ Greg Ruiters, Institute for Social and Economic Research, Rhodes University Grahamstown.
Editors Comment: In mid-December of 2005, the World Bank hosted a gathering of academics, policy analysts, policy makers and development practitioners at Arusha, Tanzania on the theme of New Frontiers of Social Policy. The meeting reviewed progress on commitments made at the 1995 World Summit for Social Development (WSSD). The Arusha meeting proposed a number of new frontiers for social policy: First the transformation of subjects and beneficiaries into citizens”, recognizing their rights and strengthening their capacity to claim these rights, including through alliances between the poor and other segments of society. The second new frontier of social policy was identified as fostering an enabling, accessible, responsive and accountable state, with institutional mechanisms that offer redress against power inequities. The third new frontier was identified as strengthening the capacity of states to mobilize revenue from their citizens, with enabling international support, diminishing reliance on external aid. The meeting called for greater emphasis on equity outcomes in social policy. Chan Chee Khoon, Professor of Health and Social Policy at Universiti Sains Malaysia comments on these meeting outcomes. An extended version of this paper has been accepted for publication in Global Social Policy and will be published by SAGE Publications in Global Social Policy 6(3) December 2006 - © SAGE Publications 2006. This shorter version has been produced for the EQUINET newsletter with permission from the author and Sage Publications
Notwithstanding the language and imagery of pioneering intellectual endeavor, my first (Anglophone) reaction to the Arusha statement was, déjà vu again? Just as Jeffrey Sachs and the WHO Commission on Macroeconomics and Health recycled human capital theory, so are we now revisiting Dudley Seers (The Meaning of Development), redistribution-with-growth, basic (human) needs, and other 1960s vintage wisdom recast in 21st century guise? What precisely is novel in the statement?
Novelty aside, three important points are noteworthy in the Arusha statement:
Firstly, it prominently endorsed a rights perspective, going beyond human needs. A rights perspective, it should be noted, can be accommodated or co-opted within a market-oriented approach. So for instance, Tony Blair and New Labor can declare that the de facto right-to-health of UK citizens is still intact even as German medical teams are brought in to attend to NHS patient backlogs, NHS patients are sent to France or India for treatment, NHS support services are outsourced to Kaiser Permanente, etc. In effect, this transforms the debate over state versus market, into a comparative assessment of the performance efficiencies of service providers, whether public, private, voluntary, for-profit, or some hybrid of these. Oddly, these debates often seem oblivious to parallel trends in fiscal reforms and the declining fiscal capacity of states, which the Arusha statement attempts to address through domestic mobilization of revenues.
Secondly, the Arusha statement endorsed a more embedded analysis of institutions, states, and other actors, in order to elucidate the success and failures of international development approaches to poverty reduction.
This is appropriate, indeed overdue. Going beyond states, it should also be extended to international organizations including the Bretton Woods institutions (BWIs). For instance, the World Bank has itself been subject to forces pushing for privatization (divesting its development lending role to private capital markets), much in the way that welfarist states are urged to selectively offload their more profitable (or commercially viable) social services to the private sector.
Challenged by the 2000 Meltzer Commission recommendations to cease lending to ‘credit worthy’ middle-income countries’(i.e. to stop competing with private lenders), the World Bank seems to have re-positioned itself as an even more influential promoter of the interests of private capital, even as it tries to harmonize this with “poverty reduction” (trickle down theory, a rising tide lifts all boats, what’s next? a sideways lurch towards horizontal equity?). We see, for instance, expanded roles for the International Finance Corporation (IFC) and the Multilateral Investment Guarantee Agency (MIGA) within the World Bank Group, with IFC and MIGA commitments to private sector borrowers rising from 3.3% of World Bank loans in 1980 to 25% in 2000. The World Bank Private Sector Development Strategy, 2002, (para. 87) emphasized the lead role of the Bank in insuring and catalyzing private investment in ‘more risky environments’ and in supporting ‘the development of cross-border private investment’ , crowding in (sic) ‘private investment rather than crowding it out’.
David de Ferranti, who retired in 2005 as World Bank vice-president for the Latin America and Caribbean department, found it necessary to reiterate that “much of what the World Bank actually does directly helps to improve the climate for private investment: implementing trade reforms and removing restrictive regulations on foreign direct investment; expanding private provision of utilities and infrastructure; strengthening essential legal and judicial infrastructure for private markets; freeing business from harmful and superfluous regulations” (cited in de Ferranti 2006. The World Bank and the Middle Income Countries, in Rescuing the World Bank ed. Nancy Birdsall Wash. DC,: Center for Global Development).
Thirdly, the Arusha statement quite rightly cautions against a targeted approach as an undiscriminating policy response to demonstrable social inequities in development. Thandika Mkandawire, UNRISD director, has recently authored an insightful review of universalism versus selectivity through targeting in social policy and development practice (Targeting and Universalism in Poverty Reduction. UNRISD Programme Paper Number 23. Geneva: 2005). He examines the circumstances and the forces behind the shift from universalism toward selectivity in social policy discourses addressing poverty in the developing countries. He then reviews the lessons learnt from such policy approaches and related practices: the administrative difficulties and transactional costs of targeting in the poor countries, the political economy bases of policy choices and program preferences, and the contingent and sometimes unpredictable effects of policy choices on individual incentive. In particular, he pays special attention to the cost-effectiveness argument which the advocates of selectivity deploy as a major consideration in its favour.
One aspect he does not dwell upon though is that targeting as a policy choice is eminently compatible with the concerns of influential sectors, including entrepreneurs and investors, seeking profitable opportunities in service sectors which thus far have been the domain of the public sector. The modern welfarist state acts importantly as a risk pooler in coping with uncertainty, whether arising from social, natural, or created environments. Publicly provided (or publicly financed) social services often entail cross-subsidies and risk pooling (in effect, an implicit social contract rooted in solidarity) to ensure a more equitable access to essential services than would be the case with purely market-driven production and distributional systems. With the devolution of social services to private enterprise, entrepreneurs in search of investment prospects would be primarily interested in the “market-capable” segments of society (if the state demurs from extending this effective demand, through public financing, to those without the disposable incomes).
Not surprisingly, as the flipside of privatization, voluntarism has emerged as a popular slogan, in rhetoric if not in substance, along with an ascendant neo-liberalism (George Bush Sr’s thousand points of lights, Mahathir’s caring society as counterpoint to Malaysia, Inc., etc). Social capital and civic society likewise are appealing to the World Bank as private capital proceeds to undermine a sense of community worldwide.
Seen in that light, targeting is also the persuasive face and generic template for the privatization of essential social services, persuasive because it draws upon considerable intuitive appeal. The intuitive appeal is not without reason, and targeting can in fact achieve quite positive results under certain favorable circumstances, e.g. when targeting is used to direct and to fine-tune extra benefits to low-income groups within the context of what are fundamentally universalist policies (targeting within universalism). As distinct from this however, targeting versus universalism has remained as the preferred policy axis for much of the international development establishment, prompting Thandika Mkandawire to observe that “one remarkable feature of the debate on universalism and targeting is the disjuncture between an unrelenting argumentation for targeting, and a stubborn slew of empirical evidence suggesting that targeting is not effective in addressing issues of poverty (as broadly understood)”.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org. Further information and publication on EQUINET work on public health policy is available at the EQUINET website at www.equinetafrica.org.
Recent media attention in South Africa has drawn attention to an outbreak of Extreme Drug Resistant (XDR) TB and the need to contain infectious diseases such as XDR TB by extraordinary methods such as quarantine. Such measures, typical of the public health approach to community health problems, involve the limitation of individual rights in the interests of the public good. In this case, the need to contain a costly, highly dangerous and virtually untreatable form of TB by forcibly quarantining patients with this form of TB, were said to outweigh the rights of the patient to autonomy and freedom of movement. Rightly, discussions in South Africa focused on whether the restrictions of the rights of the individual in the interests of the greater good could be justified.
At one level, this is an important debate because it is typical of many other public health conflicts (e.g. in relation to HIV or claims on scarce resources), where individual rights run into conflict with interests that represent a collective or social benefit. Resolving such conflicts in ways that retain respect for human rights whilst advancing public health is important for public health planners, and methods to do so have increasingly emerged in the human rights and public health literature that help public health practitioners negotiate these difficult trade-offs. Thus, in considering whether a limitation on individual autonomy could be justified in the public interest, one would expect that:
- the objective of the policy, such as quarantine, has an objective of legitimate interest and is provided for in terms of a due legal process;
- the policy will be effective in realising that objective;
- the policy is strictly necessary in a democratic society to achieve that objective;
- there are no less intrusive means available to achieve the same objective; and
- the policy’s application is not arbitrary, discriminatory or unreasonable.
Often many public health measures are applied routinely without careful reflection as to whether these criteria are met. Calls for HIV notification, for example, are often made without clear policy objectives, or, where objectives are intended, without any evidence that notification will meet these objectives better than any other methods that are less restrictive of individual autonomy.
However, it is the case that, under certain circumstances, and given certain requirements being met, limiting rights for the public interest can well be justified in terms of international human rights law. Indeed, the limitation of rights may well be viewed differently when one realises that states have obligations imposed by international human rights law to positively realise various obligations to control the spread of infectious diseases (ICESCR, article 12) and to meet requirements for general welfare (ICCPR, article 4).
However, on another level, the public health objective itself is often the expression of a rights obligation of government to realise, for example, an environment not harmful to health (Section 24 of South Africa’s Bill of Rights), or the right of access to health care. Such socio-economic rights obligations are themselves necessarily collective in nature, and the trade off is not so much between individual civil liberties and public health objectives, but between different kinds of rights, such as individualist rights to autonomy, and social rights such as the those relating to health care access or a safe environment, both of which are needed to realise health. Protecting individual autonomy is important for the effectiveness of treatment programmes to ensure patient adherence and build trust in the health service, as much as social measures being required to control the spread of infectious diseases.
Popular misconceptions of rights as being solely or predominantly about civil liberties and formal parliamentary democracy have been fostered by a combination of the ascendance of neo-liberal economic policies in international policy making, as well as the unopposed exercise of power by the USA and its allies in the post-Cold War period in ways that entrench narrow individualist views of rights. Indeed, recognition of the indivisibility of rights and the equal importance of socio-economic entitlements and equity run counter to market-oriented development policies fostered by international development agencies.
Thirdly, human rights are not just about limits to state power but also speak to realising human potential in ways that confer agency.
When faced with public outcry or a health emergency, public health responses frequently fall back on traditional population interventions that obviate any role for individual and community action. The resort to autocratic traditions of central command and control has a strong anti-democratic history in public health and is based on a deep suspicion that humans can be trusted to make decisions in their own collective interest. It is not surprising, therefore, that many of the pioneering anti-smoking public health measures originated in the health programmes of Germany’s Nazi government and were entirely compatible with the ferociously anti-democratic and inhumane ideology of the Nazi regime. What a human rights approach brings to public health, therefore, is to ensure that social justice is a counterbalance to unchallenged utilitarianism, and that checks on power serve to protect the vulnerable, in ways that confer agency on communities to determine the policies and programmes that affect their health.
Increasingly, human rights advocates are realising that the sources of power in society who must be held accountable are not just states, but non-state actors, including multilateral agencies and multinational corporations whose de facto control of resources determines access to the conditions required for health to a far greater extent than does that of many states. International human rights law is increasingly providing “soft” law guidance through issuing of codes of conduct, norms and standards to ensure non-state actor accountability for human rights. Given that human rights are a product of developmental struggles, these frameworks will only be translated into meaningful instruments for accountability through strong civil society pressure on governments to turn such codes and standards into law.
Rights are not just about empowering vulnerable groups, but are themselves the products of contestation of power, at local, national and international level. And where power is contested, we should expect that the products of this contestation will reflect the relative balance of forces of different actors. For this reason, the exclusive emphasis on good governance, parliamentary democracy and civil liberties that has emerged as the dominant paradigm in some development discourses driven by Western governments has ironically contributed to a depoliticisation of rights and of development, because it strips struggles for health of any dimensions that challenge power imbalances – at local, regional and international levels. Yet power imbalances are what underlie health inequalities. This has led many to question “Why rights, why rights now?” since when the language of rights becomes denuded of power, it is turned into a technical exercise of compliance with norms.
Unchallenged, therefore, we should not be so naïve as to imagine that human rights will of necessity benefit poor people, poor communities or poor countries. Rather, by using and shaping rights towards pro-poor choices, human rights become transformative rather than simply easing human suffering. When human rights discourses, for example, begin to challenge and overturn obstacles posed by trade commitments to the realisation of the right to health, then the transformative nature of human rights emerges.
In this paradigm, the role of civil society organisation (CSOs) is absolutely central to realizing the agency that makes human rights approaches transformative. Yet many CSOs undertaking work in the health sector may 'do' human rights work, but are often not aware of the rights implications of their work on the ground. Is 'doing' human rights enhanced by 'acting' (i.e. conscious awareness of) human rights as well? Pilot research in the Western Cape with three health CSOs points to the multiplicative effect that a rights paradigm adds to their impact. By framing (health) needs as rights to which duty-bearers can be held accountable, not only is the demand for pro-poor services strengthened but beneficiaries of these services are enabled to be active agents in securing the conditions for their health, rather than passive recipients of state or NGO services. Moreover, placing demands in a right framework challenges service providers to see their role as realising states’ human rights obligations rather than simply delivering services. It is particularly in the field of socio-economic rights that the duality of service provision as fulfillment of human rights is evident and where it is clearest that human rights are more than just civil liberties.
CSOs engaging with rights approaches can build much stronger advocacy through sharing experiences and learning best practice. EQUINET, through its health rights theme, plans to explore the establishment of a learning network for CSOs in the region using rights approaches as a mechanism for enhancing civil society participation in the development of national health systems that are comprehensive, people-led and people-centred. We invite participation from CSOs and activists throughout the region in developing this network and look forward to your input and contribution to this debate.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat, email admin@equinetafrica.org for attention to School of Public Health, University of Cape Town, Leslie London. Further information and publication on EQUINET work on health rights as a tool for health equity is available at the EQUINET website at www.equinetafrica.org.
In 2000/1 South Africa endured a cholera epidemic that spread throughout the eastern coastal region and to other provinces. It resulted in 265 deaths in five provinces and 117,147 people, mostly in the KwaZulu-Natal province, were infected. The epidemic was, according to the World Health Organization, the biggest such outbreak in Africa for the reporting period.
According to rural development researchers and the South African government, the policies of cost recovery had disadvantaged those for whom even a small charge of about R20 a month was too much. At its epicentre, those who could not afford new charges implemented in August 2000 were returning to traditional and untreated water sources and were falling victim to the disease.
The government declared the cholera epidemic an emergency and promised to provide a free six kilolitres of water to every household every month. A Municipal Services Project Occasional Paper 10, “Still Paying the Price: Revisiting the Cholera Epidemic of 2000–2001 in South Africa” examined the extent to which the response to the epidemic has led to sustained provision of safe water and improved sanitation to the poor. The evidence presented in the report suggests that there is a clear relationship between cost recovery for water, indifferent management leading to interruptions in supply, and vandalism.
In two communities - one at Nqutshini, a small settlement near the town of Empangeni on the banks of the Mhlatuzi River; and the other at Nkobongo, a developing low-cost housing area with continued informal settlements near Ballito, 40km north of Durban - there was some concealment and denial of the disease because of the stigma it carries.
In a number of cases where people fell ill, the family members were uncertain how to respond. Often the cholera victim tried to conceal and deny the disease, and this led to significant delays in seeking treatment. In one instance, a young girl died after hiding her symptoms for some time; in another, an older man had to be heavily persuaded before going to the hospital. The stigma associated with cholera complicated the acceptance of the need to avoid using river water, to treat this water, and, if sick, to seek medical assistance.
There were varying responses to the messages put out by the authorities on radio and television and carried by the Community Health Workers. Many in Nqutshini found it difficult to acknowledge that the river, from which they had always collected water, should be the carrier of disease. Some accepted that the water they were collecting from the river may be contaminated and need treatment, but others did not. Some saw the warnings against using river water as a way of forcing people to pay the monthly charges. It appears that for a period water was treated with Jik (bleach) by many, but this dropped off rapidly when the bleach was no longer available for free.
Scepticism about the official view was also associated with ideas reflecting a view of hostile external forces aiming to undermine the community, e.g. the belief by some that whites were spreading the disease through low-flying aeroplanes. In all cases, the MSP report on the epidemic presents vivid personal recollections of those who were afflicted, the dread it evoked, and the speed at which people’s health declined.
Comparisons between conditions during the epidemic in 2000/1 and at the time of fieldwork in 2003 revealed a number of improvements: Most people now accessed piped water closer to their residence or through yard connections and most used Ventilated Improved Privies (VIPs). Most people at the time of the survey felt their water to be safe to drink and did not treat the water.
However, there were ongoing complaints of frequent interruptions in the water supply through vandalism, burst pipes and for non-payment. In the two communities, the state was not providing Free Basic Water as promised, although the communities are both poor and thus generally vulnerable to cholera. At Nqutshini piped water was not flowing at all. Partly because of the dysfunctional water supplies, there was increased water storage by community members - an additional factor associated with cholera.
The incidence of diarrhoea among children in the household was found to be associated with extreme poverty, as were problems with accessing sufficient water, the ability to pay for water and the household having prior experience of cholera. All these factors - in particular the continued cycle of water-related disease in households over time - point to poor health conditions and continued vulnerability to disease among those living in extreme poverty.
The government’s policy of Free Basic Water has been unevenly implemented and greater attention needs to be given to meeting the needs of the rural poor and those in poor peri-urban communities who would most benefit from its provision. Poor communities need a reliable water service, which requires better municipal management. Interruptions lead to long storage of water, which poses a health risk to those who consume this water. Communities and households with a prior experience of water related diseases seem most vulnerable to recurrence. Health and municipal authorities should give priority to those communities with a history of water-related disease to end the cycle of disease.
The Municipal Services Project is a multipartner research, policy and educational initiative examining the restructuring of municipal sservices in southern Africa. See http://www.queensu.ca/msp/ to contact the project at Rhodes University South Africa to obtain copies of the full report.
Sub-Saharan Africa is the only region in the world where the absolute number and proportion of under-nourished children has increased in the last decade. East Africa is the sub-region experiencing the largest increases in numbers of underweight children –projected to increase by 36% from 1990 to 2005. Findings for stunting (chronic under-nutrition) and wasting (acute under-nutrition) are similar. Under-nutrition is the underlying cause of over half of child deaths. Even mild to moderate malnutrition can lead to significant deficits in cognitive and physical development.
One reason for the dismal nutritional status of children in Africa is the continual lack of food for many in the region. In less than four decades, Sub-Saharan Africa has been transformed from a continent that was a net exporter of food to one that is now heavily dependent on food imports. According to the Food and Agricultural Organisation, Africa’s food imports have risen from 8% in 1985 to 18% of world imports in 2001. A decline in agricultural and rural investment in Africa has led to a 12% decline in agricultural productivity for the workers in the region in the 1990s. Any growth in agricultural output has thus been achieved mostly from expanding the area under cultivation.
The United Nations Millenium Development Goals Hunger Task Team in 2004 summarised the consequences of this path to meeting food needs:
“Expanding the area under food production is inherently unsustainable, as the supply of new lands in densely populated areas of Africa is largely exhausted or must be maintained as natural systems for biodiversity conservation and other ecological services. The first effect in Africa and elsewhere in the tropics has been to expand into land that was previously available for fallows. Leaving land fallow allows land under cultivation the necessary time to recover from the effects of the crops taking nutrients from the soil. As a result of the reduction or elimination of fallows, soil fertility has fallen dramatically in many places, and yields are reducing with time. As the land becomes exhausted, there develops a serious tendency to continually sub-divide land among family members, which leads to smallholdings that are too small to produce a family’s food”.
Significantly, the yields of most important food grains, tubers and legumes (maize, millet, sorghum, yams, cassava and groundnuts) in most African countries are no higher today than in 1980. The environmental impacts of deforestation and drought, floods and the loss of topsoil are being compounded by the lack of investment. Only about 4% of land under cultivation in Africa is irrigated. This compares with 14% in Latin America and the Caribbean, a region with similar population densities and resource endowments. Fertilizer application is 15% lower today than in 1980. The number of tractors per worker is 25% lower than in 1980 and the lowest in the world. Africa’s share of total world agricultural trade fell from 8% in 1965 to 3% in 1996.
However, poor food security or poverty alone is not the whole story. Otherwise how does one explain the experience of many countries and populations that managed to achieve significant reductions in malnutrition before similar reductions in poverty? How does one explain the presence of malnutrition in situations where food is widely available? If one compares, for example, the experience in one region of Sri Lanka, Indonesia, the Philippines and Thailand, in the 1980s and 1990s, Sri Lanka and Thailand showed rapid improvement in nutrition, Indonesia showed slower but consistent improvement, and the Philippines little progress. Malnutrition in Latin America decreased from about 21% in 1970 to 7.2% in 1997, while income poverty decreased by only about 1% over the same time period.
Clearly reducing malnutrition is not solely dependent on increases in income. Gains in Latin America are attributed to good care practices (such as improved complementary feeding) access to basic health services, including family planning, safe water and sanitation and to women’s education and the cash resources they control.
Policies providing for female education, social safety nets, affordable food and public health services have contributed to improvements in nutrition even with minimal changes in poverty levels. In Sri Lanka, high levels of female education have been linked to improved child nutrition and child survival. Sri Lanka’s impressive performance in nutrition is also attributed to the establishment of social safety nets, especially the free or heavily subsidised distribution of rice, providing a minimum consumption floor. More recently, Save the Children UK in 2004 pointed to the universal, equitable and efficient public health system in Sri Lanka as an important reason for the low levels of maternal and child mortality in the country. Thailand incorporated nutrition as an important part of its National Economic and Social Development Plan (NESDP). This led to the establishment of an extensive community-based network of village health communicators and volunteers with existing village committees and leaders. These groups focus in communities on the fulfilment of basic needs such as optimal nutrition, provide education for this and monitor progress this through community-based growth monitoring.
A similar mobilisation of communities, health systems and national resources is required if we are to make a start in combating childhood malnutrition in Africa. This is an essential step if there is to be sustainable development in the region. Co-ordinated by the Health Science Research Council, EQUINET has embarked on a programme in east and southern Africa to collect and share information on case studies of how health systems address the wider social and economic factors affecting nutrition and lever action on these factors.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat email admin@equinetafrica.org. EQUINET work on food security and nutrition is available at the EQUINET website at www.equinetafrica.org. Work by the Medical Research Council of South Africa (MRC) is available at www.mrc.ac.za.