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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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• Six corporations account for 85% of world trade in grain • Eight account for 60% of global coffee sales • Seven for 90% of the tea consumed in the West • Three for 83% for world trade in coca • Three for 80% of bananas (Madeley 2002) • Cargill, controls 80% of grain distribution throughout the world (Kneen 1996) • Ten agrochemical companies control 81% of the $29 billion global agrochemical market • In Asia, three companies (Cargill, Pioneer and CPDeKalb) currently control almost 70% of the seed market, supplying hybrid seed for 25% of the total corn area • Four corporations now own nearly 45% of all patents for staple crops such as rice, maize, wheat and potatoes (Action Aid 2003)

• In South Africa, Monsanto completely controls the national market for genetically modified seed, 60% of the hybrid maize market and 90% of the wheat market

• Three large retailers are responsible for over 70% of the total food sales [in ESA]. (Chopra 2004) As in other areas, the WTO, IMF and World Bank reinforce each others policy measures, intensifying big business control over food supply, promoting liberalisation of food markets, greater reliance on food imports paid for by exports and reduced national food reserves. These policies have had negative effects across the region: An independent IMF evaluation found for example that the liberalisation of the state marketing board contributed to a 30% increase in rural poverty between 1991 and 1994 (Lambrechts and Barry 2003 in Chopra 2004). These policies have been associated with a significant increase in food insecurity and under nutrition in the region.

The following points could contribute to winning struggles over food


• Placing priority on food production for domestic and local markets, based on peasant and family farmer diversified and agro-ecologically based production systems • Ensuring fair prices for farmers, which means the power to protect internal markets from low-priced, dumped imports • Providing access to land, water, forests, fishing areas and other productive resources through genuine redistribution • Recognising and promoting the role of women in food production and equitable access and control over productive resources • Increasing community control over productive resources, as opposed to the corporate ownership of land, water, genetic and other resources • Protecting seeds, the basis of food and life itself, for the free exchange and use of farmers, which means no patents on life and a moratorium on the genetically modified crops • Increasing public investment in support of the productive activities of families and communities, geared toward empowerment, local control and production of food for people and local markets.

• Health and social policy choices can promote or weaken food sovereignty, such as in the negative impact of policies that promote infant or school feeding through imported milk or commercial food products, and the positive impact of those that use locally grown high energy foods.

6.2 Privatisation and commercialisation of essential services for health39 The financing of health systems is an important determinant of an equitable health system, and thus a critical site of struggle. McCoy (2003) raises the following three principles of an equitably financed health


• Households contribute to healthcare financing progressively, that is according to their ability to pay rather than according to their risk of illness or need for healthcare. This effectively means a system whereby the rich are cross-subsidising the poor for their healthcare costs. Health financing through a national tax system with tax rates that are graduated by income is one form of progressive financing.

• The principle of pre-payment, which means that the financing of healthcare is largely pre-paid, rather than financed on a cash-forservice basis. Pre-payment is usually achieved through taxes, health insurance, community health financing schemes and medical savings plans, and helps protect poor households from unpredictable and expensive costs. A health system in which individuals or households are forced into poverty through their purchase of healthcare, or forced to do without healthcare because of the cost, is unfair.ii • That healthcare finance is pooled so as to benefit from being able to share out the health risks of the young and healthy with the sick and elderly. Health financing that segments the young and the healthy from the elderly and the sick typically results in the poorer and sicker members of society struggling and ultimately failing to finance their own healthcare.

Medical insurance companies that provide healthcare cover for the young and the healthy while excluding the risks associated with insuring the elderly or those with chronic diseases are essentially cherry-picking the lucrative and profitable elements of the healthcare market whilst leaving the sick and the elderly to be covered, in most instances, by the public or charitable sectors. Although legislation to enforce community rating helps to promote equity within the pool of those who are privately insured, as experienced in South Africa, it does not always prevent a growing divide between those who are insured and those who are uninsured.

There is a significant body of literature on the privatisation of essential services (water, electricity, waste management etc.) and the negative impacts on health. This is a critical site of struggle with health consequences.

Currently in Southern Africa a number of problems are undermining universal comprehensive health systems through progressive, pooled

prepayment financing:

• The pattern of healthcare financing in many countries is segmenting health systems according to socio-economic strata, particularly where a relatively small group of the middle and upper class finance a private medical industry through insurance and direct fee-for-service payments, leading to an overall picture of a large share of total healthcare expenditure being consumed by a small share of the socio-economically privileged members of society.

• Where social health insurance schemes exist, these often serve low-income earners in formal employment, leaving the public and charitable sectors to provide healthcare for the unemployed and ultra-poor, widening the divide between the workers and the unemployed. Segmentation of the health system according to socio-economic strata invariably results in a service for the poor becoming a poor service, as the influence, aspirations and resources of higher income groups in mobilising and advocating good healthcare are located elsewhere in the health system.

• In many SADC countries government revenue is a shrinking contributor to health financing and donor and out of pocket payments an increasing contributor. User charges in particular have become a more widely used option for financing healthcare over the past two decades as economic crises and healthcare reforms have emphasised a greater role for individuals in purchasing of healthcare, despite the negative effects on equity, access and on the progressive nature of health financing.

These financing shifts have been associated with changes in the organisation of health services. Traditionally public financing has been associated with public sector delivery. Greater out of pocket payments has stimulated the growth of an unorganised, commercialised and pluralistic healthcare market. The weakening of public sector funding and provision has led to the unorganised growth of the private health sector. A pluralistic market of providers compete for individual customers who lack the information required to make informed purchasing decisions as well as the collective bargaining power to ensure ethical provider behaviour.

There has also been a deliberate encouragement of the growth of the private sector market by donors, the World Bank and international initiatives such as the General Agreement on Trade in Services (GATS), which has been accompanied by a downgrading of the size, authority and value of the government and the public sector. Donors and international finance institutions have led a model of "welfare pluralism" with a range of non-government and private providers involved in welfare provision. This complements the orthodox thinking of smaller states, but aims to address the vacuum left by the reality of under funded and diminished state capacities in providing basic services to poor communities. It accentuates the phenomena of poor care for the poor (except in those small "islands of excellence" for the poor which are sustained by NGOs or academic institutions through "special projects"). In many countries, the fragmented streams of health financing from donors, government and the households means that it is not even possible to accurately know how the level of per capita health expenditure varies from one district to another.

The unbundling, fragmentation, marketisation and commercialisation of

healthcare is a critical site of struggle to:

• Advocate and put in place financing systems that promote riskpooling, re-distribution, prepayment and universality and that avoid the widening of divisions between income groups within the health system • Resist the commercialisation and privatisation of the health system, either formally (often at higher levels of the system) or informally through increased reliance on user charges and out of pocket payments • Reject abdication of the role of the state in health and ensure that the state allocates the Abuja commitment of 15% of government spending to health, backed by debt cancellation policies, to strengthen and increase investment in public sector health services • Advocate the priority for funds to flow to the primary healthcare and district level of health systems, where they have greatest population benefit and can involve communities in decision-making • Resist states making any commitments in health or health related sectors under the GATS, to confront regionally existing commitments that limit national authorities in the interests of public health and to push states to exercise greater circumspection in the international trade system to protect health.

6.3 Expanding treatment access through equitable health systems and control over essential drugs While cheap medicines for anti-retroviral and opportunistic infection treatment will not, by themselves, provide equitable access to HIV/Aids care and treatment, the issue of drug production, pricing and access has become a critical site of struggle.

The pharmaceutical industry has a pervasive role in the health sector, given the subsidies they receive from tax breaks and publicly financed research, their influence on governments and international institutions, and the current inequitable pattern of medicine consumption (see Figure below). To battles over access, price and profits have been added new issues of intellectual property rights and the financing of research and development for public goods (McCoy 2003).

While pressure from activists and competition from generics has brought the costs of some medicines down, the TRIPS agreement now protects all new, patented medicines from any generic competition for a period of twenty years. Although the November 2001 Doha Declaration stated that the TRIPS Agreement should not prevent member states from taking measures to protect public health and gave developing countries the right to access cheaper generic versions of medicines in cases of public health emergencies, there has since been a steady backtracking away from the spirit and law of the Declaration.

The US Trade Department pushed for strict limitations to be placed on the situations under which countries may be exempt from TRIPS for public health reasons, and a review of the US government's bilateral policies on patents and medicines conducted in 2002 found that the US government was using bilateral trade and patent agreements as well as the threat of sanctions and associated diplomatic and political pressures to undermine countries that produce generic medicines and/or consider importing them.

New free trade agreements, such as the US-SACU agreement, seek to undermine the gains won around the TRIPS agreements by bringing forward the dates for full application of the agreement in the countries covered40.

The sites of struggle around this issue include:

• Building or supporting alternative models to develop new medicines and vaccines that are based on co-operation, information sharing and non-profit motives.

• Exploring options of regionally publicly financed research and development for drugs as a means to getting rid of the patent-induced economic distortions.

Civil society organisations such as the Treatment Action Campaign (TAC) www.tac.org.za and Health Action International (Africa) have taken up these issues, as have some states in Africa, Latin America and Asia. Civil society organisations such as the Treatment Action Campaign (TAC) www.tac.org.za and Health Action International (Africa) have taken up these issues, as have some states in Africa, Latin America and Asia.

• Fighting for the unhindered freedom to implement the spirit and the law of the Doha declaration, and to lobby for the exemption of essential medicines from the prescriptions of the TRIPS agreement.

• Monitoring the pricing and mark-ups of pharmaceutical products (and medical technology) • Promoting regional integration of drug regulatory systems, drug monitoring and information services, and promote local production of essential drugs for regional markets.

Chart 1. Drug markets as compared to population numbers

6.4 Migration of health personnel The attrition of health personnel from health systems, particularly the public sector services at district level, has been raised earlier. The push and pull factors that impact on the movement of healthcare workers arise within and beyond the health system and include low pay, poor working conditions, unrealistic work loads, poor infrastructure, political insecurity, crime, taxation levels and falling service standards. Movement is also influenced by pull factors, including aggressive recruitment by recipient countries, improved quality of life, study and specialisation opportunities and improved pay.

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