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USA/Africa: Global Health Policy

AfricaFocus Bulletin
Feb 25, 2009 (090225)
(Reposted from sources cited below)

Editor's Note

"We believe that U.S. health and development assistance should address both the root causes of ill health - poverty and inequality - and be directed toward building public sector institutions to help governments respond to the needs of their people. Aid should be transparent on both donor and recipient sides and accountable to the target population - the poor who need services most." - Global Health Recommendations for a New Administration and Congress

This AfricaFocus Bulletin contains (1) an editorial from The New York Times urging that funds for global health be maintained and expanded, despite budget pressures, (2) the executive summary of a set of recommendations on global health policy from six leading U.S. health and development groups, and (3) excerpts from a poll from late 2008 showing strong support for government responsibility for basic health care in 24 countries, including the United States.

Another AfricaFocus Bulletin sent out today contains a summary of a new report from Oxfam International countering arguments against primary reliance on private-sector health care expansion, and brief references to two resources fo health care planning in development countries.

For previous AfricaFocus Bulletins on health issues, visit http://www.africafocus.org/healthexp.php

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

Boosting Global AIDS Funds

New York Times Editorial - February 24, 2009

http://www.nytimes.com/2009/02/24/opinion/24tue4.html

The international AIDS community is buzzing with anxiety over unconfirmed reports that the Obama administration may hold down American financing for international AIDS programs that need greatly increased support. We hope that the new budget blueprint to be released this week will leave enough room to grant these and other vital health programs the money they need to care for millions of sick people and to prevent the spread of additional disease around the world.

Just last year, we celebrated passage of a bill that authorized spending $48 billion over five years to fight AIDS, tuberculosis and malaria through bilateral agreements with hard-hit countries, a substantial increase over past efforts. To meet that goal, Congress would have to appropriate at least $9 billion a year. It fumbled. The House is poised to approve appropriations of only $4.9 billion for bilateral AIDS programs in fiscal year 2009 plus another $900 million for the Global Fund to Fight AIDS, Tuberculosis and Malaria.

AIDS activists fear that the Obama administration is now planning to ask for only slightly more than that for the fiscal 2010 budget and will also hold American contributions to the global fund well below the levels that program is seeking.

We recognize that the new administration is searching for ways to stimulate the domestic economy and slow the erosion of jobs. But there are strong arguments - moral and strategic - for why the United States should do a lot more to help fight AIDS, malaria and tuberculosis around the world.

Left uncontrolled, infectious diseases can destabilize whole regions, especially when hunger is spreading around the globe. Improving the health systems of impoverished countries would help burnish our tarnished image, and it would contribute to our security by lessening the risk of importing infectious diseases.

Global Health Recommendations for a New Administration and Congress

http://globalhealth2009.org

For Further Information

Partners In Health
Donna Barry dbarry@pih.org 617-432-5256

Fran‡ois-Xavier Bagnoud Center for Health and Human Rights
Arlan Fuller afuller@hsph.harvard.edu 617-432-0656

Physicians for Human Rights
Pat Daoust pdaoust@phrusa.org 617-301-4200

Health Alliance International
Wendy Johnson wendyj@igc.org 206-543-8382

RESULTS
Paul Jensen pjensen@results.org 202-783-7100

ActionAid
Karen Hansen-Kuhnkaren.hansen-kuhn@actionaid.org 202-835-1240

Introduction

We are at a pivotal point in United States history as the Obama Administration and the 111th Congress begin. We embrace the message of change and hope that brought this new administration to ascendance and look forward to the application of these principles in all sectors of government. While the U.S. financial crisis is likely foremost on the minds of many in Washington, the current global crisis threatens to worsen the extreme privation suffered by those in the developing world. At the writing of this document, 25% of the developing world lives in dire poverty and 80% of the world lives in countries where income inequality is worsening. Such social inequity threatens not only the health of the globe but peace, security, and the prospects of financial recovery. The U.S. government role in providing aid for health and development has never been more critical.

In the year 2000, the 189 member states of the United Nations agreed upon a set of goals the Millennium Development Goals (MDGs) the achievement of which would be prioritized by both developing countries and the wealthier countries that provide assistance. The MDGs highlighted the critical links between improving health, education, and the status of women and children and achieving meaningful and equitable development for the world's poor. However, with little financial commitment from the developed world, meager progress has been made towards achieving the MDGs.

Much of the assistance to poor countries in the last three decades has been given with the goal of building market-based strategies to attain development, with the idea that these strategies would be self- sustaining. Yet, as we see in our own country today, the private sector has insufficient responsibility to protect the vulnerable. Not surprisingly, market strategies in the developing world have failed to provide the services needed to the world's poorest. Additionally, money for health has typically been given to U.S. organizations to deliver a single or small cluster of interventions as opposed to building systems to deliver care and addressing the root causes of disease. We believe that accountability and a rights-based approach is best served if services are delivered in the public sector in a democratic society in which the populace has a say in the implementation.

A poignant example of the failure to deliver health to the world's poor is the fact that the number of women who die in childbirth has remained constant despite 40 years of development assistance targeted toward "safe motherhood." Programs taught traditional birth attendants sterile techniques for home deliveries and when to refer women for medical care. Yet no money was spent on the development of modern medical facilities with access to blood, surgery, and the skilled providers needed to avert maternal death. The rare services that do exist in poor countries are simply too costly for the majority of poor women.

We believe that U.S. health and development assistance should address both the root causes of ill health poverty and inequality and be directed toward building public sector institutions to help governments respond to the needs of their people. Aid should be transparent on both donor and recipient sides and accountable to the target population the poor who need services most. The new Administration and Congress have a unique opportunity to redefine foreign aid policy to help those most impoverished and to save lives. Implementing the recommendations of this paper would have an enormous impact. For further details related to each recommendation, we encourage you to refer to our longer, accompanying document (which can be found at
http://www.globalhealth2009.org).

Recommendations

Improving Means of Funding

Commit to a comprehensive approach to health:

1. Develop sustained financing to effectively and efficiently disburse funds to health programs with multi-year funding cycles rather than annual appropriations
2. Increase Official Development Assistance to 0.7% of GNI and proportionately increase funding for all global health programs, capitalizing on vertical funding currently available, with a focus on maximizing outcomes.
3. Fully appropriate the authorized $48 billion for HIV/AIDS, tuberculosis, and malaria for 2009 2013 (PEPFAR).
4. End the vertical versus horizontal funding debate and commit to a comprehensive health care approach.

Address inefficiency in aid:

1. Develop a framework to better evaluate programs and measure their effectiveness and efficacy.
2. Require all agencies and initiatives to assess performance of programs and individual projects; examine money flows and the variability of impact which may not be seen at the macro level so as to determine more efficient multilateral mechanisms and NGOs through which to channel money.
3. Institute a policy of complete transparency in U.S. foreign aid, shedding light on the costs that significantly decrease the percentage of aid reaching recipient countries.

Improving Health Care Delivery

Build local / national capacity:

1. Direct more U.S. aid to recipient country public sectors to develop health systems and encourage other donor countries to follow suit. Such funds should be allocated to refurbish facilities, hire and train new clinical and administrative staffs, compensate existing Ministry of Health staff, and waive patient user fees.
2. Increase the total number of health workers in resource-poor areas to, at a minimum, 2.3 doctors, nurses, and trained midwives, and 1.8 health auxiliaries (including community health workers) per 1,000 residents; provide full support for pre-service training and retention for at least 140,000 new health professionals.
3. Revise U.S. policy regarding compensation of community health workers for their services, moving beyond an unsustainable model that relies on local residents to volunteer their time for health and development projects that benefit the community.

Reduce child mortality:

1. Support child health programs with an integrated approach focusing on family, clean water, nutrition, health care, education, and social protection to adequately address the essential elements of children's lives.
2. Continue to make greater investments in vaccination campaigns to address the threat of pneumonia, polio, measles, tetanus, and diphtheria common killers of children in resource-poor areas.
3. Combat malnutrition by enhancing preventive efforts by providing nutritious foods, increasing use of ready-to-use therapeutic food, and acknowledging access to food as a vital component in improving child health.

Improve women's health:

1. Increase funding for reducing maternal mortality, family planning, and reproductive health services; revise the ABC policy using scientific evidence; and repeal the Mexico City Policy (i.e. the Global Gag Rule).
2. Remove financial barriers to care, specifically user fees for prenatal and obstetrical services, since maternal mortality is strongly correlated with poverty.
3. Address issues documented to be inextricably linked to women's health, including economic empowerment for women, psychosocial support, and support for women who are victims of domestic abuse/violence.

HIV/AIDS:

1. Ensure the $48 billion Congress has authorized for HIV/AIDS, TB and Malaria over the next five years is fully appropriated.
2. Remove the social and economic barriers to treatment adherence by providing "wrap-around services" such as nutrition, clean water, housing, and childcare support.
3. Fund development of new prevention and treatment technologies vaccines, more reliable diagnostics, and new classes of therapeutics.
4. Scale up coordinated TB-HIV services and require PEPFAR recipients to incorporate the Three I's (intensified case finding, isoniazid preventive therapy, and infection control) into programming in high TB-HIV burden countries.

Tuberculosis:

1. Create a presidential initiative on global tuberculosis.
2. Expand access to TB treatment in high burden countries and develop a strategy to reach the U.S. target of providing 5 million successful DOTS treatments.
3. Address drug-resistant TB by expanding laboratory capacity and treatment in high burden regions, and funding development of new, effective diagnostic tools and drugs.
4. Fully fund U.S. bilateral TB programs supported through PEPFAR, USAID, and CDC; contribute the U.S. fair share of funding to programs such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Malaria:

1. Require the PMI Coordinator to comprehensively evaluate all programs to determine effective and ineffective programs and policies; use these findings to promote best practices with all PMI fund recipients.
2. Place a greater focus on implementation and health care delivery via a newly developed Malaria Initiative Strategy.
3. Set concrete limits on the use of PMI funds, which may go to technical assistance and consultants.
4. Fully fund U.S. bilateral malaria programs through PMI, USAID, and CDC and contribute the U.S. fair share of funding to programs such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Decrease extreme poverty and hunger:

1. Immediately fund additional emergency food assistance to prevent further death and disease.
2. Direct the State Department, USDA, USAID, U.S. Treasury, and other agencies to assist governments in developing food sovereignty by allowing them to support small-hold farmers, improve market access in developing countries, and utilize protective tariffs for food production.
3. Collaborate with recipient countries to institute progressive policies on land reform and agricultural development.
4. Track food aid to ensure its efficient and effective delivery and substantially decrease the large amounts of aid to U.S. transport companies and agribusiness.

Revising Development Policies and Financing Architecture

Redefine foreign aid policy and goals:

1. Instruct the Department of Treasury to work with the IMF Executive Board to review and change the restrictiveness of IMF macroeconomic policies, and widely publicize such policy changes.
2. Work with the Department of Treasury and IMF to develop increased public spending policy options, which have been fully vetted by a broader group of stakeholders.
3. Require U.S. government contractors to adhere to the principles of the NGO Code of Conduct.

Recognizing the Full Scope of Human Rights

Ratify the currently signed treaties:

1. The International Covenant on Economic, Social and Cultural Rights
2. The Convention on the Elimination of All Forms of Discrimination Against Women
3. The Convention on the Rights of the Child
4. The International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families
5. The International Labor Organization Conventions
6. The International Criminal Court 7. The Kyoto Protocol

World Publics See Government as Responsible For Ensuring Basic Healthcare, Food, and Education Needs

But Big Variations on How Well Their Government is Performing

http://www.worldpublicopinion.org

November 10, 2008

[excerpts of summary only see http://tinyurl.com/avwr7h for complete summary and full report]

A new WorldPublicOpinion.org poll of 21 nations around the world finds that large majorities in every country say their government should be responsible for ensuring that citizens can meet their basic needs for food, healthcare, and education.

On average, across all countries polled, nine in 10 say that their government has the responsibility to ensure access to food, healthcare, and education.

"Clearly there is universal consensus that governments have a responsibility to address the social and economic needs of their citizens," comments Steven Kull, director of
WorldPublicOpinion.org.

However, the poll found major variations in how well people perceive their governments to be fulfilling these responsibilities. Overall, respondents expressing the highest levels of satisfaction with their government's performance in meeting such needs are found in China, Great Britain, Jordan, and the Palestinian Territories. The lowest levels are found in Russia, Ukraine, Argentina, and Nigeria.

These results show overwhelming public support for the principles presented in the Universal Declaration of Human Rights which is celebrating its 60th anniversary this year. It states that: "Everyone has the right to...food, medical care...[and] education." Signatories to the declaration commit "by progressive measures, national and international, to secure" these rights.

The poll of 21,321 respondents was conducted between July 15 and September 26, 2008 by WorldPublicOpinion.org, a collaborative research project involving research centers from around the world and managed by the Program on International Policy Attitudes (PIPA) at the University of Maryland. Margins of error range from +/-2 to 4 percent.

Interviews were conducted in 21 nations, including most of the largest nations--China, India, the United States, Indonesia, Nigeria, and Russia--as well as Argentina, Azerbaijan, Egypt, France, Germany, Great Britain, Italy, Jordan, Kenya, Mexico, the Palestinian Territories, South Korea, Thailand, Turkey, and Ukraine. Interviews were also conducted in Taiwan, Hong Kong, and Macau. The publics included represent 61 percent of the world population.

Government Responsibility for Basic Needs

When asked whether their "government should be responsible for ensuring that its citizens can meet their basic need for food," or whether "you think that is not the government's responsibility," majorities of 70 to 97 percent in all 21 countries say government should be responsible for this. The average is 87 percent.

The most universal support is found in eight publics where more than nine in 10 believe the government should be responsible for citizen's need for food: Indonesia (97%), China (96%), Jordan (96%), Kenya (96%), Argentina (94%), Azerbaijan (93%), Germany (93%), and Italy (92%). Even the lowest majorities saying the government is responsible in this case are well above half, including Indians (70%), Americans (74%), and Russians (77%).

The publics with significant numbers saying the government does not have the responsibility to ensure access to food include the United States (25%), the Palestinian Territories (17%), Egypt (14%), and France (13%).

When asked the same question about "the basic need for healthcare," majorities of the same magnitude (70-97%) in all countries polled see ensuring that people can meet their need for healthcare as one of government's responsibilities. The average majority is 92 percent and in all but five countries support is greater than 90 percent.

Ninety-seven percent say the government should have this responsibility in Argentina, Italy, Ukraine, Jordan, and Indonesia, and 96 percent agree in Azerbaijan, Mexico, Russia, Turkey, Kenya, and China. Ninety-five percent take this view in Germany and Nigeria, 93 percent in Britain and South Korea, and 92 percent in France. Only India (70%), the United States (77%), the Palestinian Territories (79%), Egypt (81%), and Thailand (88%) have less than 90 percent saying the government has the responsibility to provide healthcare.

In only a few publics do significant numbers reject the government having the responsibility to ensure access for healthcare; 21 percent of Americans say the government is not responsible, followed, again, by Palestinians (19%), and Egyptians (14%).

On education, majorities ranging from 64 to 98 percent also see the government as responsible for ensuring that people can meet their basic needs. The average majority is 91 percent and in only six nations do majorities of less than 90 percent take this position.

Virtually unanimous majorities in Argentina (98%) and China (98%) say the government has the responsibility to ensure its citizens' educational needs are met. In three countries, 97 percent agree (Indonesia, Turkey, and Jordan), 96 percent in two countries (Mexico and Great Britain), 95 percent in four countries (Italy, Ukraine, South Korea, and Kenya), 94 percent in Russia, 93 percent in Germany, and 91 percent in Nigeria.

Very large majorities slightly below the global average say the government has this responsibility in Thailand, (90%), Azerbaijan (89%), France (89%), the Palestinian Territories (85%), and the United States (83%). Egypt (77%) and India (64%) have the smallest majorities in support, although 19 percent in India volunteer "depends" as their answer.

Egyptians have the largest minority saying the government is not responsible for education (19%), followed by Americans (16%).

These results show overwhelming public support for the standards offered by the Universal Declaration of Human Rights. Article 25 states that: "Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care." Article 26 adds that: "Everyone has the right to education. Education shall be free, at least in the elementary stages." (The Declaration does not imply that state education should be the only means to achieve universal education; in fact, the article also states that "parents have a prior right to choose the kind of education that shall be given to their children.")

Assessments of Government Efforts

Respondents were asked how well they feel the government is ensuring that people can meet their basic needs for food, education, and healthcare. They were not asked to assess how well their government was fulfilling these responsibilities in absolute terms, but rather in the context of "the limits of the[ir] ...government's resources." Broadly, publics answered in ways that clearly distinguished between different responsibilities and took into account constraints on the government's means. Improvements over recent decades, as measured by bodies such as the World Health Organization, seem to have been registered by publics.

The UN Development Programme rates 177 countries by their level of human development (the Human Development Index). In reporting this poll, countries that receive a ranking of 1-35 were classified as "developed," 36-80 as "middle tier" and 81-177 as "developing."

Among the six developed countries in the poll, the one public that gives their government positive ratings in all categories is Great Britain. The United States gets positive ratings in regard to food and education, but not healthcare. Germans give positive ratings for food and healthcare, but not for education. The French give positive ratings for education and healthcare, but not for food. South Koreans give a positive rating for education, but not for food or healthcare. Italians give poor rating for food and healthcare, and divided ratings for education.

Among the five middle tier countries, views are consistently negative. Argentines, Russians, and Ukrainians give their countries negative ratings in all areas. Mexicans are negative in regard to education and food, though positive about healthcare. Thais give negative ratings on food and healthcare, though lean positively on education.

Interestingly, views tend to be the most positive in the 10 developing nations--underscoring how governments are assessed relative to their efforts and progress rather than in absolute terms. In China, India, Jordan, and the Palestinian Territories, majorities give positive ratings for all categories. In Turkey, Indonesia, and Kenya majorities are satisfied in all areas except food. Azerbaijanis are satisfied in all areas except healthcare. Egyptians are only satisfied in the area of education, while Nigerians are dissatisfied in all areas.

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