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[afro-nets] PHM and the 3x5 Initiative

  • Subject: [afro-nets] PHM and the 3x5 Initiative
  • From: Claudio Schuftan <claudio@hcmc.netnam.vn>
  • Date: Mon, 7 Jun 2004 00:58:07 +0700
  • Cc:
  • User-agent: Internet Messaging Program (IMP) 3.1

PHM and the 3x5 Initiative

Symposium by the NGO Forum for Health and HIV/AIDS Department of
WHO at the 57th World Health Assembly, Geneva, May 2004

Making the Difference
3/5 Initiative and Civil Society?s Response

Statement made on behalf of the Peoples Health Movement (PHM) by
Thelma Narayan with inputs from several PHM members

1. Introduction

* The Peoples Health Movement (PHM) is a mass movement present
in around 100 countries. PHM was born out of a historic summit,
the first Peoples Health Assembly (PHA), an alternative to the
World Health Assembly (WHA), held in Bangladesh in December
2000, with over 1400 participants from 75 countries. It has
grown since then in strength and impact. The PHM goal is to re-
establish health and equitable development as high priorities in
local, national and international policy making, with primary
health care as a strategy. The Peoples Charter for Health, one
of the largest consensus documents on health, adopted at the PHA
and subsequently translated into 44 languages, forms the frame-
work for action. PHM has an ongoing interaction with the World
Health Organization (WHO) emphasizing the need to focus on pri-
mary health care and the determinants of health. Details of PHM
activities can be obtained from the website www.phmovement.org.

* PHM organized an International Health Forum (IHF) in Mumbai,
India in January 2004. This was attended by 750 participants
from 50 countries. The Mumbai Declaration articulates the PHM
position on important current health issues including HIV/AIDS.
It was an opportunity to discuss and debate the WHO 3x5 initia-
tive on HIV/AIDS with senior WHO staff who participated in the

* A large PHM meeting on Primary Health Care at the World Social
Forum, also in January 2004 in Mumbai, discussed the HIV / AIDS
response as well.

* Subsequently PHM developed a draft Peoples Charter on HIV/AIDS
as a campaign document amplifying the voices of people and call-
ing for immediate action. This is being discussed by several
groups worldwide before finalization in May 2004. It will be
launched at the International AIDS Conference in Bangkok in July

* The PHM is joining with AIDS activists, combining our respec-
tive strengths.

2. The PHM response to the 3 x 5 programme

* The PHM response to the 3 x 5 programme response is part of
the ongoing constructive, critical dialogue with WHO. WHO?s
policies and action are critical to the health of people, par-
ticularly the social majority, the poor. In the past the impact
has been both positive and negative. We are particularly con-
cerned about the distortion of primary health care and the in-
creasing influence of corporates in the policy agenda. Inade-
quate policies and poor implementation have disastrous effects.

* PHM welcomes WHOs commitments to health as a justice issue. It
appreciates the fact that after a long gap it has rediscovered
the value of primary health care and health systems, as men-
tioned in the 3 x 5 documents, and the World Health Report,
2003. However we note that the Director General?s Speech at the
57th WHA did not mention them.

* PHM appreciates the core principles of 3x5 of urgency, equity
and sustainability, and is in agreement with the approach of
learning by doing; of decentralization with the country focus;
partnership with civil society, with the leadership role of the

* PHM looks forward to working in critical partnership with WHO.
However WHO needs to specify in greater detail how it plans to
strengthen primary health care, health systems and infrastruc-
ture with measurable, time bound indicators of progress. We
would also emphasise principles of self-reliance, non-dependence
on donors and social accountability. In order to fulfill the
Right to Health and Health Care WHO will need to ensure that
vested interests do not distort and overwhelm health systems and

3. Comments and Suggestions

The HIV/AIDS pandemic, one of the great humanitarian crises of
all times and our collective response to it, needs to be viewed
from different perspectives. Openness to questions from below is
an essential part of the policy process..

While access to Anti Retroviral Treatment (ART) and to essential
medicines is critical, and is a response to the treatment access
campaign, our concern is that 3 x 5 should not be over medical-
ised and remain a diagnostics and drugs driven campaign of the
dominant system of medicine. It should not divert scarce health
resources from other key areas of health care activity, which
could result in widening existing health inequalities.

We urge WHO and 3 x 5 to:

1. Question a purely technical-pharmaceutical response to a dis-
ease with socially rooted causes and consequences. There is a
need to urgently address the social determinants of disease
transmission such as growing impoverishment, indebtedness war,
migration, and displacement ­ the ?discontents of globaliza-
tion?. PHM in 2002 had suggested a Poverty and Health Commis-
sion, and are pleased that a Commission on Social and Environ-
mental Determinants of Health is being established. We are sure
3 x 5 will take active part in developing and operationalsing
its recommendations and engaging with the World Bank, Interna-
tional Monetary Fund, the World Trade Organization and others on
the impact of trade on health; the role of global finance; need
for debt reduction; and immediate expansion of overseas develop-
ment assistance to 0.7% of GDP of donor countries.

2. Work towards reduction of high drug costs by addressing the
issue of drug patents, utilizing good quality generics and
guarding against donors tying their funding to brand medicines.
The AIDS epidemic has become an industry within which there are
many vested interests.

3. Avoid donor dependence and move away from the drug-
diagnostic- producer ­ doctor ­ donor nexus, to a more community
and people controlled approach.

4. In many countries, health systems are dysfunctional and un-
der- resourced.. Structural adjustment programmes and neo lib-
eral reform measures have contributed to an undermining of pub-
lic health systems and the capacity of governments to provide
effective health stewardship. In this context the 3x5 initiative
could result in top-down, vertical and treatment focused pro-
grammes further distorting and fragmenting fragile health sys-
tems and undermining a comprehensive, coherent and sustainable
approach to health and development.

5. Enhance involvement of people, Persons living with HIV and
AIDs, affected communities and civil society in decision making,
planning, implementation and review, allowing for diverse ap-
proaches, including the use of indigenous systems of medicine,
local health traditions, adjunct supportive therapies and heal-
ing systems.

6. Give greater attention and resources to community based ini-
tiatives, life skills education, women?s health empowerment and
working with boys and men.

7. Ensure greater coordination and transparency of fund flows
into HIV/AIDS activities with public, social audits. Funding
should not be used to leverage political mileage and policy

Health Systems

8. We endorse to the primacy being given to the state sector,
despite its corruption, bureaucracy and apathy. However greater
thought and clarity is required towards developing mechanisms
for strengthening state health systems. There is a need to fi-
nance health systems, not just ARTs alone; to reduce staff va-
cancies brought about by down-sizing euphemistically called
right sizing; to improve staff morale and technical capacity; to
provide supportive supervision to community health workers and
health professionals, ensuring quality and accountability; and
to give centrality to patient and community involvement and
feedback. WHO and 3x5 could assist countries to achieve health
financing and staffing norms.

* Strong government and WHO leadership is required not just for
ART, but for health systems strengthening to tackle the myriad
priority health problems comprehensively. For instance the over
70% anemic persons in the population; to reduce low birth weight
found in 25% of newborns; to improve nutritional status of under
fives only 10% of whom are normal weight for height; to tackle
the high burden of water and sanitation related diseases.

* PHM could help 3 x 5 to not just use primary health care as a
vehicle for ART, but to strengthen it as a system so that
HIV/AIDS and other priority diseases and issues are effectively
cared for.

* While 3 x5 is an opportunity to strengthen health systems it
can also further fragment and weaken it, like the Global Polio
Eradication Initiative and other global public private vertical
initiatives, if we are not careful. In India and globally, immu-
nization coverage rates are dropping, with only 50% of under
fives totally immunized. There are shortages of tetanus toxoid
and measles vaccines for months. Whooping cough and diphtheria
are reappearing.

* To strengthen health systems we need to address issues such as
privatization, commercialization and top down vertical pro-

* Studies and experience reveal the chaos in prescription prac-
tices and treatment , including of HIV/AIDS, in the private sec-
tor, which is large and largely unregulated in many parts of the
world. A health system approach would include regulation and ac-
creditation mechanisms in both the public and private sector to
prevent the profit motive from undermining the right to health

* Despite the Macroeconomic Commission on Health, health budgets
are steadily declining In India the public sector on average
spends 4 to 8 US Dollars per capita per year on health. In this
context women do not receive good antenatal care and treatment
for anemia. Are they likely to get good quality ART?

* The complexity of administering toxic ART drug regimens
through these week systems to chronically undernourished people
is enormous. ARVs are not toffees to be handed around. Non-
adherence and treatment dropout rates are high, case-finding is
low and counseling is notional. HIV transmission through poor
health care practices is an issue needing greater attention.

* It is necessary to make transparent and available all country
related criteria for patient selection; and to promote adoption
of common treatment guidelines and procedures by all multi-
lateral institutions, donors and NGOs.

* There is a need to monitor the systems wide effect of the 3x5

* To conclude, rather than looking at the problem through the
disease prism of HIV/AIDS, TB and malaria alone; could we also
look through the primary health care lens and the basic determi-
nants of health prism, in order to place the response to
HIV/AIDS in context.

Claudio Schuftan