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The
second sex
Irungu
Houghton
September
21, 2006
http://www.pambazuka.org/en/category/features/37269
This week, African
Health Ministers and Experts meet in Maputo, Mozambique to adopt
an action plan which will deliver on the 2005 Gaborone Declaration.
The Declaration committed African governments to universal access
to comprehensive sexual and reproductive health services in Africa.
Irũngũ Houghton reviews emerging policies on sexual and
reproductive health, the reality for women and girls and what governments
need to adopt during this Ministerial.
Since 2001,
Africa’s leaders have committed the African Union (AU) and their
governments to promote and protect the right to health in a series
of international and continental legal protocols and declarations.
These commitments provide a comprehensive package for addressing
the challenges of maternal mortality, HIV/AIDS, violence and disease.
The
Promise of the Continental Policy Triangle
On 26
and 27 April 2001, African Heads of States and governments of the
Organisation of African Unity (OAU) declared that they would allocate
15% of their annual national budgets to health services in order
to meet "the exceptional challenge of HIV/AIDS, Tuberculosis
and Other Related Infectious Diseases".1
Health issues have been a consistent item on the agenda of meetings
of African leaders for the last five years. The adoption of the
Continental Sexual and Reproductive Health Policy Framework by 53
African Health Ministers in October 2005 was a landmark moment in
the struggle to improve the lives and health of women and girls
in Africa.2 This year, the Africa Common
Position on Universal Access for the UN General Assembly Special
Session (UNGASS) in New York saw African Governments undertake to
ensure; "100% access to sexual and reproductive health services
including antenatal care".
These policy
statements received legal underpinning when the Protocol to the
African Charter on Human and Peoples’ Rights on the Rights of Women
in Africa came into force on 25th November 2005.3
The Protocol provides a critical framework to access sexual and
reproductive health services such as safe abortion, pregnancy, childbirth
and HIV, among others. Its provisions state that women’s sexual
and reproductive health should be both respected and promoted.4
This policy triangle of the Abuja Declaration, Continental Sexual
and Reproductive Health Policy framework and the Protocol clearly
establishes the obligation on African states to address the healthcare
needs of all citizens, but in particular the rights of women and
girls.
"The reality
of sexual abuse and HIV/AIDS must make us rage against women’s oppression.
I call on African leaders sitting here to protect and promote the
human rights of all people and vulnerable groups, particularly women
and girls. We ask you not to fail us again." (Ms. Nkhensani
Mavasa, Deputy Chairperson, Treatment Action Campaign, UN General
Assembly, May 2006)
While there
has been significant improvement in women’s health globally, none
of this progress has benefited mothers in sub-Saharan Africa. Notwithstanding
the international and African commitments, inadequate access to
quality health services, unsafe abortions and lack of reproductive
health care cause the deaths of at least 250,000 women each year
in Africa, one of the highest rates in the world. Women in the United
Kingdom have a 1 in 5,800 lifetime risk of maternal death, in Ethiopia
the equivalent risk is 1:14.
High maternal
death rates have multiple causes, but one major underlying problem
is the deep-rooted inequalities between men and women. Women have
fewer opportunities for education, they do a disproportionate high
share of manual work, have less influence on policy making and are
disadvantaged in terms of nutrition and access to health care. Lack
of access to health care is a major cause of maternal mortality.
Even where there
are positive legislative and policy frameworks, women often battle
to exercise these rights within the family and the community. Traditional
gender norms and practices, along with the unequal status of women,
relegate women to being primarily responsible for contraception
and childcare, with little power to negotiate when, with whom and
why to have sex.
Inequalities
in health are exacerbated by unequal access to other public services.
For example, the number of years that a girl spends in primary education
has a direct and positive correlation with her chances of avoiding
HIV, her children surviving, and her subsequent income thereafter.
Yet on average, girls in Africa spend only three years in school.
5
It is within
this context that women and girls are more vulnerable to HIV. Women
comprise 57% of all adults infected with the virus in sub Saharan
Africa. Of these, younger women account for a disproportionately
large number of new infections. According to the African Union,
AIDS, malaria and tuberculosis threaten life on a scale unparalleled,
erases between 1-2% of Africa’s growth rate and reduces life expectancy
by 25% for some countries.6
Key to the loss
of women’s control over their own sexuality is the prevalence of
female genital mutilation, domestic iolence, and rape. More than
90 million women and girls are survivors of female genital mutilation,
a practice outlawed in many national laws across Africa and under
the Protocol.7Violence against
women is a recurrent problem in many countries. In Kenya for instance,
despite a relatively peaceful history, 49% of women have experienced
violence, with one in four having experienced violence in the previous
12 months.8
Putting
the money where it is needed
A
key precondition for accelerating the provision of universal access
to sexual and reproductive health services in Africa is the adequate
funding of effective healthcare systems. However, there is a sharp
disparity between the stated intention to act and the resources
pledged to enable these laudable commitments to be implemented.
Five years after
the Abuja Summit, only Botswana and The Gambia have met the 15%
target for national expenditure. 15 countries mostly from West and
Central Africa spent less than 5% with only 18 Africa states spending
more than 10% on healthcare. Yet, since 2000, 85% and 77% of African
countries have formed national AIDS machineries and approved relevant
health policies.9
According the
World Health Organisation, the minimum expenditure on healthcare
per person per year, necessary to provide an essential package of
health services is US$ 34. In 29 countries, government expenditure
per person per year was less than US$ 10. This includes Angola that
has one of the fastest growing economies on the continent.
The burden of
this funding gap invariably falls on the poorest and most vulnerable
sections of the population. Inadequate investment in primary healthcare
infrastructure, acute shortage of human resources, ineffective or
non-existent data collection and information management systems
and the lack of inexpensive medicines and basic equipment all combine
to disproportionately affect the poorest and most vulnerable. In
order to close the financing gap, many countries have been encouraged
to impose user fees on healthcare services.
User fees
have proved to be a barrier to many poor men and women who simply
cannot afford to access healthcare even with minimum fees. Throughout
the 1990s, Ugandans faced high costs for fragmented health services.
When in the run up to the 2001 presidential election, President
Museveni ended user fees for all government health clinics, the
public response was phenomenal. Most health facilities saw 50 to
100 per cent increases in patients. This access was particularly
significant for poor women in rural areas who could not afford to
pay for care.
Oxfam research
shows that relatively small investments can yield high returns in
terms of saving lives. The cost of providing basic services for
mothers and infants averages US$3 per capita in Africa. This year,
approximately 63,000 women will die from obstetric problems in Ethiopia,
Mozambique, Tanzania and Uganda. An investment of US$411 million
would prevent 80 percent of these deaths: – roughly US$700 for every
maternal and child life saved.
African governments
could reverse the situation by dropping user fees, improving the
effectiveness of the health caresystem and raising their health
expenditure to 15%. External development assistance is necessary
to expand the financing available, preferably within a predictable
and long-term cycle that targets front line services like primary
and reproductive health care. It is estimated that an initial immediate
investment of $90 billion per annum is required for healthcare personnel,
hospitals and other infrastructure, medicines and so forth in Africa,
as against the $25 billion promised for Africa by 2010.10
Back
to the Basics: Engendered Health Services and Access to Essential
Medicines
The year 2005 saw an important return to the concept of
a developmental state in Africa. This state would enshrine the right
to essential services, the fight against poverty and economic growth
as core obligations.11 Recent Oxfam
research into Essential Services re-affirms the primacy of governments
in the provision of effective, universally accessible and regulated
health and services.
There is a crisis
of health workers in Africa. At least 10 countries (Liberia, Uganda,
the Central African Republic, Mali, Chad, Eritrea, Ethiopia, Rwanda,
Somalia and The Gambia) have only enough trained health workers
to cover 10% of the population. The African Union should maintain
its position that additional financing should be found not only
for medical facilities and medicines, but also for the recruitment
and remuneration of doctors, nurses and other health cadres.
African governments,
parliaments and civil society organisations must guard against public
resource diversion away from social services through lack of prioritisation,
corruption, misuse of national resources and military expenditure.
A number of African countries including Sudan, Angola and Ethiopia
are currently experiencing rapid economic growth, yet they continue
to spend a paltry 2-5% on health expenditure.
Several African
organisations and parliamentarians have cited the IMF/World Bank
Medium Term Expenditure Frameworks/Ceilings (three year planning
tools) as too restrictive on public expenditure on health and education.
African governments should consider carefully all policy advice
that undermines their capacity to promote and realise the right
to health.12 The comments of Kenyan
Assistant Minister Hon Enock Kibunguchy are relevant for many African
countries. In March of this year he said, "The country needs
10,000 health workers to offer improved services… We have to put
our foot down and employ. We can tell the International Monetary
Fund and the World Bank to go to hell." Kenya urgently needs 7,000
nurses, 600 doctors and 2,000 clinicians and laboratory experts.
In the absence of employment, government estimates indicate that
1,000 nurses leave the country every year.
African governments
must demand that IMF assistance be modelled on long-term growth
rather than short-term sustainability, in order to fulfil internationally
agreed commitments to achieve the Millennium Development Goals,
rather than the narrow goal of sustaining debt repayments from low-income
countries. The Global Call to Action gainst Poverty as well as specialist
African debt networks such as the Jubilee movement in Africa and
AFRODAD have joined the African Union call in 2005 for full debt
cancellation to be extended to many more countries. To do otherwise,
would be to render sustainable financing for Universal Access in
Africa unachievable.
What
do Africa’s leaders need to do next?
African
governments must deliver on the Abuja Commitment to allocate 15%
of the national budget to health services by setting annual funding
targets that will finance comprehensive national public health plans
that particularly target men and women living and working in poverty.
Targeted provision of quality reproductive and health services to
women by establishing and strengthen existing antenatal, delivery,
post-natal and family planning services for all African women would
go a long way in making the lives of women more safe and dignified.
To do this would require the recruitment, training, and retention
of an adequate healthcare workforce in line with international standards
and with special attention to remuneration of female health workers
in rural areas.
Further, more
countries must remove user fees for primary health care and sexual
and reproductive health services and essential medicine. By enacting
and implementing national laws that enshrine the AU Protocol on
the Rights of Women in Africa especially Articles 5 and 14, governments
would demonstrate a clear commitment to end female genital mutilation
in Africa and violence against women.
Despite the
tremendous investment of development NGOs in the areas of HIV/AIDS,
reproductive and primary health, only a small number of civil society
organisations are attending the Maputo Ministerial meetings. On
their return, they can do no better than to hold their leaders and
industrialised countries to account for the global and continental
commitments made over the last five years. One way of doing this
would be to strengthen citizen representation and state oversight
mechanisms in monitoring public services at national and local levels.
* This article is drawn from a policy briefing written by Irũngũ
Houghton, Oxfam Pan Africa Policy Advisor which was developed and
presented to the Special Session of Ministers, Maputo, Mozambique,
September 18-22th . He can be contacted at irunguh@oxfam.org.uk
* Please send
comments to editor@pambazuka.org
or comment online at www.pambazuka.org
References:
1.The OAU officially
became the African Union on 9 July 2002 at the Durban Summit.
2. The AU Special
Summit in Abuja reviewed progress since the 2001 Abuja Declarations
on HIV/AIDS, Malaria and Tuberculosis.
3. For an extract
of the Protocol on the Rights of Women in Africa, see www.african-union.org
4. In a few
countries like South Africa, the Constitution provides women with
more rights than the African Women’s Protocol. However, for others
like Zamibia, it is an advance on national legislation. Under Zambian
law, a panel of 3 doctors have to agree that the mother’s health
is threatened. The law does not provide for termination even in
cases of rape, sexual assault or incest. See Mukasa R; (2005): Protocol
on the Rights of Women in Africa: Harnessing a Potential Force for
Change, Oxfam GB Southern Africa Office.
5. Oxfam; (2006):
In the Public Interest: Health, Education, and Water and Sanitation
for All.
6. African Union;
(2005): Progress Report on the Implementation of the Plans of Action
of the Abuja Declaration for Malaria, HIV/AIDS and Tuberculosis.
7. Solidarity
for African Women’s Rights Coalition and the African Union Commission;(2006):
Breathing Life into the African Women’s Protocol on Women’s Rights
in Africa.
8. UNICEF; (2006):
Violence against Women and Girls in the Era of HIV and AIDS in Kenya.
9. African Union;
(2005): Progress Report on the Implementation of the Plans of Action
of the Abuja Declaration for Malaria, HIV/AIDS and Tuberculosis.
10. Oxfam; (2004):
The Cost of Childbirth: How Women are Paying for Broken Promises
on Aid.
11. Apart from
African Union positions and declarations, other influential development
literature such as the Commission for Africa report, 2005, the UN
Human Development Report took up this theme squarely in 2005.
12. Statement
from 75 representatives of Civil Society Groups and SADC Parliamentarians
to African Heads of States, Health Ministers meeting at African
Union/UN meeting on Universal Access to Act Immediately to Save
Africa from worsening HIV/AIDS Epidemic, Johannesburg, 3rd March
2006
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