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«ANSA Alternatives to Neo-liberalism in Southern Africa The search for Sustainable human development in Southern Africa Editors: Godfrey Kanyenze, ...»

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In comparison with neo-liberal practices such as ring-fencing and business units, the declaration of some goods as "public" would be a clear-cut advance. Viewing services such as water and electricity as public goods is one way of situating a service in a broader developmental paradigm. In a market economy, this is directly connected to whether we regard such services as commodities or resources for development. Rejecting the perspective of commodification has important consequences for developing an alternative framework.

Viewing services as public goods presents considerable potential for addressing the needs of the population. While traditional economics defined public and merit goods quite narrowly, the analysis can be extended to include a number of other goods and services that relate to socio-economic rights and equitable sharing of the benefits of an industrialised economy. Ultimately, in an ethical developmental welfare state, clean air, recreational facilities and Internet access could be seen as public goods.

5.8 Programme agency Some of the key short and medium-term measures that would make progress towards an alternative have been outlined. Winning gains such as scrapping arrears or state-led job creation are crucial. However, the process for attaining such victories is also critical. If such gains are to be part of building an alternative, they must be the result of mobilisation at grassroots level. The precise form of an organisation or social movement that can successfully advance an alternative is difficult to delineate. Past formulations such as vanguard parties, national liberation movements or even traditional trade unions do not have a grand track record of success.

It is likely that new organisational forms will emerge from new struggles.

Nonetheless, such a political force requires at least the following four major features, which are rarely seen in community or labour

organisations today:

• A political force must bring together the interests of organised labour, the broader working class and poor rural communities.

The knowledge of workers needs to become a resource for transforming both service delivery and the relationships between labour and the community. For example, instead of hiring expensive consultants to design service delivery strategies that bring in the private sector, workers themselves can be used as researchers to define and analyse problems. In many communities, municipal workers who collect refuse or maintain facilities are the most direct interface between local government and the public yet there are few instances where these workers take part in a needs assessment of the community. At the same time, workers need to be educated in how to build such relationships. In many communities, the face of the municipality is a rude or uncaring clerk who ignores or abuses citizens who are carrying out a routine transaction. At times, even certain layers of the workforce have joined business and their employers in condemning those who are in arrears as "irresponsible" or perpetuators of a "culture of non-payment." Such a schism between labour and the community is further exacerbated by the notion that workers form an "elite" simply because they have a job. This absurdity has become a battle cry for employers who want to drive down wages and working conditions. That a Southern African worker earns perhaps 10% (in hard currency terms) of their US or German counterparts and that the vast majority of African workers have to support more than a handful of unemployed family members is somehow missed in the perpetuation of the "workers as elite" myth.

• A political force must find ways to extend women's participation in building an alternative. The majority of the services provided by municipality overlap with what is traditionally viewed as "women's work" in the household. When there is no money to load the prepaid electricity card, women's workload in cooking or accessing fuel increases. When local governments increase charges for services such as childcare or primary health provision, in most instances they are shifting work onto women and young girls. If a toddler cannot go to a crèche, most likely a woman or young girl will have the task of looking after him or her at home.

If there are no accessible healthcare facilities, most likely a woman will have to look after the sick family members at home.

When we look at the mobilisations around service delivery issues in social movements we find many women involved. But in most cases, when we look to the leadership of the organisations in these communities, men are in the majority. Similar genderbased problems also exist in the trade union movement. Even unions which have a majority of women members typically have male-dominated leadership. Until women's centrality in leading these struggles and their special skills and experience are recognised, a political force capable of contesting the neo-liberal local government agenda is unlikely to emerge.

• While service delivery and payment systems may seem like the most local of issues, there is an increasingly international dimension to what is taking place in local government.

Municipalities draw their models and their policies from "international best practice." When assets are sold off or services are contracted out, particularly in water and electricity, transnational corporations are often involved. Indeed there is a roll of international players in service delivery and companies like Vivendi and Suez Lyonnaise des Eaux and brokers such as PriceWaterhouse Coopers are on the list of usual suspects. The global character of these companies requires a global perspective to contest their cost recovery policies. Hence, at times, local movements fighting for an alternative will have to draw on the lessons from organisations in other parts of the world who have had direct experience with the particular corporation or issue which they are confronting. The local is global, just as the global is local.

Chapter 11 Prioritising public interests in health

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Southern Africa is a region of significant wealth and significant inequality in a world of even greater wealth and inequality. In a global environment where wealth has not, and is not being adequately harnessed for human development, Southern Africa has proposed positive policies for health and had periods of high health gain, but has been unable to sustain these in the face of neo-liberal economic policies. People have been impoverished by colonial, multinational and elite exploitation of African resources, falling terms of trade for African products, huge resource outflows due to debt, migration, war, displacement, persistent inequalities in access to wealth, poor access to public resources and other factors described further in this paper32.

2. Health and poverty

There is a significant body of evidence of the strong relationship between poor health status and material and social deprivation. Poverty is closely linked to ill health, but this is mediated by the quality of and access to housing, sanitation and clean water, literacy and educational levels, employment opportunities, income levels and social inclusion. People who lack these resources are those in insecure jobs, in rural areas and in groups that have been subject to past prejudice, such as racial discrimination.

While the majority of Southern Africans experience absolute poverty, it is the growing differentials between rich and poor, the inequity of those with This paper draws to a significant extent on the work of the progressive intellectuals, state and civil society health activists in the regional network for equity in health in east and Southern Africa (EQUINET). Direct references to source materials are given.

greatest health needs having worst healthcare access and the widening of global inequalities in health between Africa and OECD countries that signal the failure of an economic and social policy (see for example the widening disparities between OECD countries and SSA between 1970 and 2000 in Table 1).

Table 1. Comparison of child mortality rates over time

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A child born to a low income household in Mozambique has a ten times greater chance of dying before their first birthday than one born to a middle class family in neighbouring South Africa. The same poor child has a significantly lower chance of having safe water supplies, a healthy diet or access to health services for immunisation or treatment of basic diseases than her wealthier counterpart (EQUINET SC 2000, 2004).33.

The primary contradiction in this scenario is global. Certainly there are differences in health within Southern Africa, but the abusive primary and stark injustice in health is in the inequity between need and response North and South.

The table on the next page exemplifies this with data on the relationship between HIV, health and socio-economic development.

It demonstrates both absolute poverty (millions of people living below the poverty line) and relative poverty between rich and poor countries.

The per capita GDP of SSA is 16.5 times less than that of the high-income OECD countries, while its HIV prevalence is approximately 25 times higher.

The evidence for this is provided in ample detail in a number of background papers and not repeated here. Two EQUINET steering committee papers (2000 and 2004) summarise this evidence for Southern Africa.

Table 2. Selected socio-economic, health and HIV indicators

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Source: UNDP 2003 and UNAIDS 2002 Comparing some of the poorer countries of the SADC to the high-income OECD countries, the income and HIV prevalence differential from north to south grows to 53. While a woman in an OECD country has an 89% chance of reaching the age of 65 years, only two out of five women can expect to do so in Malawi. In Tanzania, every sixth child born alive will die before the age of five years compared to every 167th child in the OECD countries.

The differential of wealth and health creates secondary pressures on health systems. The global "brain drain" has seen thousands of skilled human resources flowing from Africa to richer countries, as health workers are pushed out by diminishing real incomes to meet a growing disease burden under worsening working conditions, and pulled by the growing demand of ageing populations in high income countries and the failure of systems in these countries to plan or invest in these public health needs.

A third (31%) of the UK healthcare workforce is from overseas and approximately 20% of the permanent medical workforce in Canada, Australia and United States is made up of foreign graduates. In the 1980s, for example, the doctor population ratio was 1:10,800 in sub-Saharan Africa compared to 1:1,400 in all developing countries and 1:300 in industrialised countries. Since then, the situation has deteriorated. In the 1990s the doctor population ratio in Malawi, Mozambique and Tanzania was 1:30,000 or more and in Angola, Lesotho, Zambia and the Democratic Republic of Congo this ratio stood at 1:20,000 (McCoy 2003).

Apart from the poor to rich subsidy that this represents, this level of human resource loss totally undermines Africa's health systems. (Padrath et al. 2003) Aids is intensifying these trends. The SADC countries, with a combined population of only 3.5% of the world's population, accounts for 35% of the people living with HIV/Aids globally. The current HIV and Aids situation is amply documented elsewhere. The epidemic has directly escalated mortality, reduced life expectancy (from figures in the 60's to figures in the 40's) and torn away at the social fabric of families and communities. A study in Zambia revealed that 65% of households in which the mother had died had dissolved and the region now has millions of orphans (470,000 in Malawi; 660,000 in South Africa; 810,000 in Tanzania; and 780,000 in Zimbabwe) (McCoy 2003). Aids is spread along the lines of and intensifies existing socio-economic and health inequities.

The pattern of HIV transmission indicates the common spread of HIV from more socially and economically powerful adult males to poor and economically insecure females, particularly female adolescents. HIV has Graphic source PHM spread rapidly where people move for trade, work, food, social support and where such mobility links people with some disposable income and those who live in poverty, particularly where the latter are women. Hence areas of migrant employment, transport routes and urban and peri-urban areas have been high-risk environments for HIV. The impact of Aids on the poorest groups has been to precipitate them deeper into poverty, and to facilitate the intergenerational transmission of poverty. The impacts have been found to be greatest at household level, where Aids can lead to chronic and potentially intergenerational poverty.

The business and finance sectors have swiftly taken measures to ring fence themselves from impacts of Aids. Death, disability and medical insurance schemes have excluded people with HIV or reduced benefits, reducing coverage and household savings and shifting the costs of unsecured risks to public and household budgets. Studies have found that households unsupported by social security spend four times the share of annual household income on Aids related health costs when compared with households covered by social security (Hanson 1992). In contrast, HIV levels have fallen where young people have been able to act to avoid infection and where prevention services are accessible. Access to treatment has started to improve as global resources have begun to respond to massive pressures from treatment activists and some southern governments to make treatment accessible. While HIV/Aids follow inequalities in power and wealth, social mobilisation, solidarity and state action is able to challenge these inequalities.

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