PHA-Exchange> PHM and the 3x5 Initiative

[claudio at hcmc.netnam.vn]

SYMPOSIUM BY THE NGO FORUM FOR HEALTH
 AND HIV/AIDS DEPARTMENT OF WHO 
AT THE 57thWORLD 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 by Thelma Narayan with 
inputs from several PHM members

                                                        
1.	Introduction

Ø	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 
framework for action.  PHM has an ongoing interaction with the World Health 
Organization (WHO)  emphasizing the need to focus on primary health care and 
the determinants of health. Details of PHM activities can be obtained from the 
website www.phmovement.org.

Ø	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 initiative  on HIV/AIDS with senior WHO staff who participated in the 
Forum.

Ø	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.

Ø	Subsequently PHM developed a draft  Peoples Charter on HIV/AIDS as a 
campaign document amplifying the voices of people and calling 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 2004. 

Ø	The PHM is joining with AIDS activists, combining our respective 
strengths.

2.	The PHM response to the 3 x 5 programme

Ø	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, particularly the social majority, the poor.  
In the past the impact has been both positive and negative. We are particularly 
concerned about the distortion of primary health care and the increasing 
influence of corporates in the policy agenda.  Inadequate policies and poor 
implementation have disastrous effects.

Ø	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 mentioned 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.

Ø	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 state.

Ø	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 infrastructure 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 priorities.

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 medicalised 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 disease 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 
globalization”.  PHM in 2002 had suggested a Poverty and Health Commission, and 
are pleased that a Commission on Social and Environmental 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, International 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 development 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 under-
resourced.. Structural adjustment programmes and  neo liberal reform measures 
have contributed to an undermining of public 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 programmes 
further distorting and fragmenting fragile health systems 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 approaches, including the use 
of indigenous systems of medicine, local health traditions, adjunct  supportive 
therapies and healing systems.

6.	Give greater attention and resources to community based initiatives, 
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 change.

	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 finance health systems, not just ARTs alone; to 
reduce staff vacancies 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.

Ø	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.

Ø	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.

Ø	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, immunization 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.

Ø	To strengthen health systems we need to address issues such as 
privatization, commercialization and top down vertical programmes.

Ø	Studies and experience reveal the chaos in prescription practices and 
treatment , including of HIV/AIDS, in the private sector, which is large and 
largely  unregulated in many parts of the world.  A health system approach 
would include regulation and accreditation mechanisms in both the public and 
private sector to prevent the profit motive from undermining the right to 
health care.

Ø	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?

Ø	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.

Ø	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.

Ø	There is a need to monitor the systems wide effect of the 3x5 
initiative.    

Ø	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 determinants of health  prism, in order to place 
the response to HIV/AIDS in context.


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