«ANSA Alternatives to Neo-liberalism in Southern Africa The search for Sustainable human development in Southern Africa Editors: Godfrey Kanyenze, ...»
These policy shifts, based on fundamental shifts in the paradigms and values governing health, had a profound impact on health systems in Southern Africa. Public spending on health, a major factor in improved household health, declined in the region under structural adjustment programmes and healthcare resource allocations were systematically biased against primary care. Health personnel attrition increased, quality of care fell, (particularly at primary care level) and health sectors became more dependent on external financing even though external financing itself fell.
Bond and Dor (2003) show that two decades of IMF, World Bank-led market-oriented, export-led state policies, characterised by the commercialisation/privatisation of the public sector functions in Africa, produced a number of negative effects on health systems. These included disincentives to health-seeking behaviour, witnessed by the lower utilisation rates and declines in the perceived cost and quality of services, falling household ability to meet major healthcare expenses, reduced size of and real incomes in the civil service, declining health worker morale and the increasing commodification of basic health-related goods and services such as food, water and energy that made many unaffordable. Over the period of structural adjustment the total debt stock in Africa rose from US$60.6 billion in 1980 to US$206.1 billion in 2000, while investment and saving rates declined. Debt servicing levels exceed expenditures on health in almost all countries in the region. As debt has consumed an increasing share of revenue, public health expenditure has fallen to well below the US$30-$40 needed to provide reasonable, quality basic healthcare.
Liberalisation enabled a wider spread of providers with an inadequate state infrastructure to regulate quality or ensure equity in the growth of private providers. The liberalised growth of private care under conditions of declining access to basic public services led to parallel worlds, where those with wealth and connections could access the highest technology while many poor people cannot get or afford secure access to tuberculosis (TB) drugs or to safe water supplies. Many of these changes not only changed the funding and affordability of services, but also meant that citizens, who once expected safe water or healthcare as a right delivered by the state, now had to negotiate as consumers with a plethora of providers and bureaucracies (Bond and Dor 2003, Loewenson 1993, Loewenson and Chisvo 1994) 37.
Globalisation, under the WTO post Uruguay, has deepened the liberalisation trends initiated by SAPs, including those of health. While SAPs provided various measures for the commercialisation of health services, these were under state authority and reversible. Trade liberalisation under the WTO has now been extended to significant new areas, including trade in services, trade-related investments and intellectual property rights, removing national and state authority over these areas once agreements are in force or commitments have been made. This drastically reduces the authority of national governments for making policy even where this is needed to protect public health. These
agreements cover a number of areas critical to health, including:
• Food sovereignty and market access in agricultural trade • Patenting of indigenous knowledge systems and biodiversity • Liberalisation and limits to regulation and cross subsidies in essential services (health, water, electricity) (GATS) • Patenting and licensing of drugs impacting on cheaper drug access (TRIPS).
While trade agreements do provide limited space for countries to act in the interests of sectors such as public health, they demand significant institutional resources and capabilities to take advantage of them. These resources are not always available to individual countries in the south.
When southern countries exercise these powers they often meet major challenges. In South Africa, for example, legal processes for the compulsory licensing and parallel importation of generic drugs met not only with legal challenges but also with threats of sanctions from northern countries. These challenges were raised even though the measures taken were compliant with the WTO TRIPS agreement.
The negative impact of SAPs on health and healthcare is outlined in a number of documents and so is not repeated here. The Muncipal Services Project (http://www.queensu.ca/msp/) has a range of publications on the negative impacts of privatisation and the commercialisation of essential services.
The control and regulation of trade through the WTO and various other bilateral trade agreements, underpin accentuating disparities between rich and poor. At the conclusion of the Uruguay round of trade talks in 1994, the UNDP and OECD calculated that, although global income would grow by US$200-500 billion, all these gains would go to the industrialised countries of the OECD and to the richer middle-income developing countries. SSA was predicted to lose US$1.2 billion a year. Although the Doha round of negotiations has been better for developing countries as a whole, it has been predicted that any gains for SSA and South Asia will be lower than the aggregate losses resulting from trade liberalisation.
While poor countries are expected to open up their markets and their natural resources to "fair and open" market competition, the richer countries are able to pick and choose where and when "protectionism" and public subsidies are acceptable. The agricultural subsidies of the European and North American farmers is one example of a sector in which poor countries are being forced to open up their economies to unfair competition. Even in those markets in which developing countries have a natural advantage, the last two decades have been bad for developing countries. In 2000, prices for 18 major export commodities were at least 25% lower in real terms than in 1980.i
Health systems in Southern Africa are thus, by 2004:
• Struggling against the policy erosion of fundamental values of universality, solidarity and equity that informed the liberation struggles and that built health systems in most wealthy economies • Struggling to deliver under conditions of severe domestic under funding of public health services and dependency on external funding and payments from poor households • Medicalised and less organised around acting on the major determinants of ill health • Segmented and subject to creeping commercialisation at lower levels and rampant commercialisation at higher levels • Under attack from global and bilateral trade agreements, challenging national authorities and public inputs and interests around health • Suffering significant losses of personnel from public to private systems and from Southern to northern health systems.
This globalisation process is accelerating at a pace that is not even able to adequately provide for a construction of limited "global welfarism". In the late 1990s the UNDP criticised the failure of the global economic and trade system to provide for human development and welfare needs (the most humble of demands of a capitalist economy). Since the 1990s while trade measures have escalated, global welfare measures have not.
Table 3. Comparison spending on health and on luxury items
Source: Human Development Report, 1998 Transfers from wealthy to low income countries for social development have not improved, nor have they matched commitments. Despite the fact that OECD countries are wealthier, the level of ODA to SSA has been falling. While the wealth per person in the OECD countries more than doubled between 1961 and 2000, the amount of aid that was given, dropped by four times over the same period. Between 1990 and 2001 ODA fell from about 0.33% to 0.22% of donor countries GNP, the lowest level ever. Furthermore, ODA has declined most in the regions and countries of greatest need. Of the 49 least-developed countries, 31 receive less aid today than in 1990 (McCoy 2003).
Meanwhile, the drain of resources from Africa to the north, dating back many centuries, through waves of slavery, colonialism and unfair terms of trade, is now intensifying under current forms of neo-liberal free market globalisation (Bond 2006). Resources flow out of Africa through debt, falling terms of trade, capital and financial market outflows, reduced foreign direct investment, human resource flows and depletion of natural resources. SADC governments as a whole spend more on debt servicing (an average of 4.1% of GDP in 2001) than they do on providing basic social services such as health (an average of 2.8% of GDP in 2000). In terms of the total debt stock of poor countries, the amount that has been written off to date is a mere $36.3 billion; less than one third of the $110 billion promised in 1999 and not much more than 10% of the conservatively estimated $300 billion of unpayable debt owed by a group of 53 countries that have been identified as very poor and indebted (McCoy 2003).
The weak inflow of ODA has not matched this outflow. The creation of new private financing initiatives has added little new funds for social development, especially for the public social services i.e. health and education. The current massive shortfall in public resources in Africa through this "dispossession of wealth" (Bond 2006) and collapse of public financing, has caused significant damage to the public health and social systems in the region.
The establishment of the Global Fund for Aids, TB and Malaria (GFATM) was based on the correct conclusion of the WHO Macroeconomic Commission on Health that little would be achieved in improvements to health in Southern Africa without significant increases in the resources for health, through substantial global transfers. While the GFATM has generated new resources for the fight against Aids, TB and malaria, it has not been able to raise the amount of money required from wealthy countries even for these three focused disease programmes, let alone to implement the strengthening of the health systems, health worker training and deployment needed to deliver on these programmes.
The GFATM relies on "goodwill": In November 2004, in the midst of a major global campaign to expand Aids treatment to three million people by 2005 and a clear need for increased investment to achieve this, the GFATM faced a challenge from the USA and European backfunders of not funding a fifth round. In an era where the risks to health cross national borders and spread globally, where global policies have a powerful influence on community health and where global inequalities threaten even the most basic public health measures, global social policy has not been able to establish a secure, long-term means of financing health, including even the fundamental primary healthcare systems. Global transfers for the most fundamental social rights, recognised globally through UN conventions and commitments, such as access to water, to immunisation, to basic healthcare and to education, thus remain matters of "charity"38.
There are options: The http://www.phmovement.org/pubs/articles/tobintax.html presents a discussion on the Tobin tax for example as a global mechanism to distribute wealth generated from the global economy and control currency speculation.
People in Southern Africa seek to have a health system that values and entitles all citizens, enables people to remain healthy and that provides effective support in times of sickness.
This paper argues that delivering on these aspirations can only be done through approaches that are based on values of solidarity, universality and equity. Healthcare cannot be organised as a commodity that is sold to the highest bidder and accessed by those who can afford it.
A social and health policy that delivers on these values thus provides for
institutions and measures that:
• Redistribute and direct resources towards those with the greatest health needs • Are led by an effective public sector that is able to exert leverage over the system as a whole • Are advanced and defended by a broad social mobilisation in the interests of poor and marginalised people and in the interests of the public as a whole.
Where are the specific sites of struggle around this in this decade? The following areas demand focus from workers, progressive intellectuals and public interest organisations if we are to realise our values and aspirations
6.1 Food sovereignty and nutrition Up to two-thirds of all Africans in Southern Africa live in rural areas trying to make a living from land that is often marginal with little opportunity to earn wages; three-quarters of those living in rural areas live below the poverty line. There is a growing crisis for both producers and consumers of food. While child nutrition has improved globally, in SSA the proportion and absolute number of malnourished children has increased. In food insecure environments, poor people spend a significant share of time securing food thus further increasing their economic insecurity.
Malnutrition among infant girls is one of the main routes for the intergenerational transmission of poverty.
Food security is determined by the worsening macroeconomic context in most Southern African countries. Food production is undermined by a
range of factors that include:
• Negative terms of trade,
• Trade barriers
• Flooding of African markets with subsidised goods from the USA, Europe and Asia
• Global trade systems that concentrate the wealth in the food industry in a few monopoly traders and retailers
• Domestic food and agricultural polices that do not adequately support food production
• Micro level factors, such as intra-household food distribution, gender roles and caring practices.
Women contribute 70 to 80% of household food production in SSA, 65% and 45% in Latin America and the Caribbean. They achieve this despite unequal access to land, to inputs such as improved seeds and fertiliser and to information (Chopra 2004).
Graph 1. Increasing yield and output from an equalisation of inputs between men and women; Burkina Faso.
These trends have increased the domination of the food supply chain by a small number of massive transnational corporations (TNCs).