David Sanders Director: School of Public Health University of the Western Cape

1. WHAT CIVIL SOCIETY CAN CONTRIBUTE : RESEARCH, TRAINING AND ADVOCACY TO ADDRESS CHILD HUNGER AND UNDERNUTRITION David SandersDirector: School of Public HealthUniversity of the Western Cape Member of Global Steering GroupPeoples Health Movement A WHO Collaborating Centre for Research and Training in Human Resources for Health

2. Outline of Presentation • Trends in child health and nutrition in the era of Primary Health Care - 1980 to 2004 – with special emphasis on Africa’s health situation • Impact of globalisation, health sector reform and HIV/AIDS on poverty, health “determinants”, health systems and human resources for health • The role of research, training and advocacy in addressing inequities and capacity weaknesses, with illustrative examples from Southern Africa

3. Despite successes, growing inequalities in global healthwidening gap in infant mortality experience IMR: babies dying before age 1 per thousand born live SSA World UNICEF: State of the World’s Children

4. U5MR in Sub-Saharan Africa The State of the World’s Children 2003. UNICEF

5. Global health inequities • A woman has a nine in ten chance of reaching the age of 65 years in a high-income OECD country, • but a four in ten chance in Malawi. • In Tanzania, every sixth child born alive will die before the age of five years, • while in high income OECD countries, every 167th child dies before the age of five.

6. Growing inequalities in child health – within countries

7. Slide Date: October 03 Declining Health Systems Global Immunization 1980-2002, DTP3 coverage global coverage at 75% in 2002 Source: WHO/UNICEF estimates, 2003

8. Leading global risk factors and contributionsto global burden of disease : % DALYs, World

9. Rates of childhood stunting

10. Undernutrition Inadequatedietary intake Disease Inadequate carefor children & women Inadequate health services& unhealthy environments Inadequate access to food Resources & controlhuman, economic & organisational resources Political & ideological factors, economic structure Potential resources The determinants of child mortalityConceptual framework of causality Outcome Immediatecauses Underlyingcauses Basic causes

12. 2002 FOOD CRISES IN SOUTHERN AFRICA ZIMBABWE: food shortages: 31.4% of pregnant women in rural areas HIV+ MALAWI: >70% of population facing food shortages; adult HIV prevalence 15% ZAMBIA: second year of crop failure: few food stocks: adult HIV prevalence 21.5% MOCAMBIQUE: severe floods 2000, 2001 and 2007: drought 2002: adult HIV prevalence 13% LESOTHO: second year of food shortages: maize prices high; adult HIV prevalence 31%

13. Double Burden

14. Increased Oil Consumption

15. Rising Consumption of Poultry

16. BUT what are the key ‘Basic Causes’ of Africa’s Health and Health Care Crisis? • Increasing poverty and inequality worsened by inequitable globalisation, • Selective PHC and Health sector “reform”, and • HIV/AIDS • ….. result in slow progress and reversals.

17. The debt crisis, structural adjustment and globalisation: • A crucial development in the current phase of globalisation…

18. External debt grows

19. External debt • Between 1970 and 2002, African countries borrowed $540 billion from foreign sources, paid back $550 billion (in principal and interest), but still owe $295 billion (UNCTAD 2004) • Africa spends more on debt servicing each year than on health and education -- “the building blocks of the AIDS response” (Piot 2004)

20. Debt Service Payments Dwarf Development Assistance Inflows

21. Structural Adjustment Programmes: the main components • Cuts in public enterprise deficits • Reduction in public sector spending & employment • Introduction of cost recovery in health and education sectors • Phased removal of subsidies • Devaluation of local currency • Trade and financial market liberalisation

22. Impact of SAPs on health • “The majority of studies in Africa, whether theoretical or empirical, are negative towards structural adjustment and its effects on health outcomes” Breman and Shelton, WHO CMH WG6, 2001

23. Globalisation is primarily about trade… Globalization, defined as the process of increasing economic, political, and social interdependence and global integration which takes place as capital, traded goods, persons, concepts, images, ideas, and values diffuse across state boundaries, is occurring at ever increasing rates (Hurrell, 1995, p.447).

24. …..unfair trade

25. Northern agricultural subsidies:Japan, the EU and the USSource: UNDP HDR 2005

26. Northern agricultural subsidies go to large farms, not smallSource: UNDP HDR 2005

27. Unfair Trade (1) • “..drawing the poorest countries into the global economy is the surest way to address their fundamental aspirations” (G8 Communiqué, Genoa, July 22, 2001) • BUT… many developing countries have destroyed domestic economic sectors, such as textiles and clothing in Zambia (Jeter 2002) and poultry in Ghana (Atarah 2005), by lowering trade barriers and accepting the resulting social dislocations as the price of global integration .

28. Unfair Trade (2) • In addition industrialized countries apply much higher tariffs (tariff peaks), sometimes amounting to more than 100 percent, to the labour-intensive exports that are of special importance to developing countries. For example, the EU tariff on raw cocoa exported from Ghana is just 0.5 percent, but the tariff rises to 30.6 percent on chocolate imported from the same country (Elliott 2004b). Thus, although 90 percent of cocoa beans are grown in developing countries, they account for just four percent of the value of global chocolate production (IMF, 2002).

29. The result… unequal growth of wealth within countries Trends in income inequality, selected Latin American & Caribbean countries Share of national income, ratio of top to bottom decile Source: de Ferranti et al, 2004 (Table A.2)

30. The result… unequal growth of wealth between countries

31. ..and unequal distribution of global income UNDP 1997

32. According to the World Bank’s most recent figures, in sub-Saharan Africa 313 million people, or almost half the population, live below a standardized poverty line of $1/day or less (Chen and Ravallion 2004). • Sub-Saharan Africa is the only region of the world in which the number of people living in extreme poverty has increased – indeed, almost doubling between 1981 and 2001. ..and growth of poverty

33. SAPs, by lowering public expenditures and workers’ salaries, abetted low level corruption as a means of survival (Hanlon, How Northern Donors Promote Corruption, The Corner House,2004) Superpowers in Africa “backed venal despots who were less interested in developing their national economies than in looting the assets of their countries…” Amongst worst MNC bribery offenders are those located in G8 countries (Transparency International) Governance - Bribery & Corruption

34. Why should a Japanese cow enjoy a higher income than an African citizen?

35. The Health System, its financing and Health Sector ‘Reform’

36. Sub-Saharan African Country per capita expenditures on health (1997-2000)Recommended expenditure: >$60/capita (Brundtland); >$34/capita (CMH) World Bank, World Development Report 2004

37. For instance, Ethiopia spends 22% of its national budget on health and education, but this amounts to only US$1.50 per capita on health. Even if Ethiopiawere to spend its entire budget on healthcare, it would still not meet the WHO target of US$30–40 per capita (Save the Children 2003). • “Countries just don’t have enough money.” Rt. Hon. Hilary Benn, April 2004, WFPHA/UKPHA, Brighton

38. Public Health package: Immunizations School-based health services Family planning and nutrition education Programs to reduce tobacco and alcohol consumption Actions to improve the household environment Clinical package: Pregnancy-related services Family planning and STD services Tuberculosis control, mainly through drug therapy Care for the common serious illnesses of young children - IMCI Health sector ‘reform’Quest for efficiency A focus on cost-effective technologies and a neglect of social and environmental determinantsof health has proposed essential “packages” of interventions – reminiscent of selective PHC..

39. CEA cannot evaluate the effectiveness of ‘broader’ interventions that may result in health improvement through numerous direct and indirect mechanisms “[C]ost-effectiveness analyses have shown improved water supply andsanitation to be costly ways of improving people’s health. …. encouraging people to wash their hands and making soap available have reduced the incidence of diarrhoeal disease by 32% to 43%... (Commission on Macroeconomics and Health,2001/02) For example, water provision can: Improve hygiene practice and thus reduce incidence of diarrhoeal disease Save women’s time for caring and economic activity, thus improving household income and food security Contribute to increased agricultural production, thus improving household income and food security

40. ..subverting the Mission of Public Health • “Ensuring the conditions in which people can be healthy” (Institute of Medicine)

42. Health sector ‘reform’ Quest for efficiencycont.- The move from equity and comprehensiveness to efficiency and selectiveness leads to: • A return to vertical programmes; • Erosion of intersectoral work and community health infrastructures • Fragmentation of health services and reversal of health gains

43. AIDS and Aid may both disrupt health systems… In 2000, Tanzania was preparing 2,400 quarterly reports on separate aid-funded projects and hosted 1,000 donor visit meetings a year. At last count there were over 90 GHIs (the best known being GAVI, GFATM, Pepfar), each funding different diseases and programmes. Labonte, 2005, presentation to Nuffield Trust

44. Health systems & personnel in Africa • Health personnel vital, consume between 60 – 80% of recurrent public health expenditure (WB, 1994).

45. Burden of disease Share of population Share of health workers Our Common Interest 2005:184

46. NURSE REGISTRATION IN UK :Increase during a period when a “ban” on active international recruitment had just come into effect Buchan et al 2003

47. The brain drain • In relation to health care professionals, especially nurses … there are aggressive and targeted international recruitment initiatives. • The UK government, for example, has stated that international recruitment is part of the solution to meeting its staffing needs. • This type of active recruitment can have a marked effect on a sending country, especially because it … is aimed at getting significant numbers of workers from the country …

48. International migration—winners & losers • How much do importing countries gain from international migration? UN Conference on Trade and Development (UNCTAD):for each professional aged between 25 and 35 years, US$ $184,000 is saved in training costs by rich countries (UNECA, 2000)

49. Global HIV prevalence • 40 million people around the world live with HIV - more than the population of Poland. • Nearly two-thirds of them live in Sub-Saharan Africa, where in the two hardest hit countries HIV prevalence is almost 40%. • The global HIV/Aids epidemic killed more than 3 million people in 2003 • there are emerging and growing epidemics in China, Indonesia, Papua New Guinea, Vietnam, several Central Asian Republics, the Baltic States, and North Africa. The AIDS debate, BBC News

50. Enhancing Capacity for Public Nutrition Action Decentralised health services have dramatically increased need for public health skills – for policy, advocacy, planning, programme design, implementation, monitoring and evaluation