The Second Sex
2006-09-21, Issue 270
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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”.  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.  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.  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.  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. 
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. 
Key to the loss of women’s control over their own sexuality is the prevalence of female genital mutilation, domestic violence, 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.  Violence 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. 
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. 
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 care system 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. 
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.  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.  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 Against 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 firstname.lastname@example.org
* Please send comments to email@example.com or comment online at www.pambazuka.org
The OAU officially became the African Union on 9 July 2002 at the Durban Summit.
The AU Special Summit in Abuja reviewed progress since the 2001 Abuja Declarations on HIV/AIDS, Malaria and Tuberculosis.
For an extract of the Protocol on the Rights of Women in Africa, see www.african-union.org
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.
Oxfam; (2006): In the Public Interest: Health, Education, and Water and Sanitation for All.
African Union; (2005): Progress Report on the Implementation of the Plans of Action of the Abuja Declaration for Malaria, HIV/AIDS and Tuberculosis.
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.
UNICEF; (2006): Violence against Women and Girls in the Era of HIV and AIDS in Kenya.
African Union; (2005): Progress Report on the Implementation of the Plans of Action of the Abuja Declaration for Malaria, HIV/AIDS and Tuberculosis.
Oxfam; (2004): The Cost of Childbirth: How Women are Paying for Broken Promises on Aid.
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.
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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