Development Policy

Health & Poverty Reduction in Developing Countries

EXPLANATORY STATEMENT
from John Bowis's Report on the Commission's communication on Health and Poverty Reduction in Developing Countries
(COM(2002) 129 – C5-0334/2002 – 2002/2178(COS))
PE 310.512

"The health of the people is really the foundation upon
which all their happiness and all their powers as a state depend."
Benjamin Disraeli

European competence and experience

The European Union, collectively and through its individual Member States, has given itself a
competence and a duty to provide support for the low-income countries of the developing
world. Such support involves money, personnel, training and know-how. It sometimes
means emergency humanitarian aid to respond to disasters, but most of the time it means
development aid, to enable our partners in the developing world to overcome the obstacles to
their achievement of the economic and social progress, that our Western world has come to
expect, after centuries of uneven effort and momentum.

Over two centuries, we in Western Europe have been coping with disease, hunger, wars and
population movement. Within living memory many of our citizens faced poverty and
hardship. Where there were dramatic improvements, these were often consequent upon
advances in medical science and social theory. Our pattern of progress has not been uniform
and we continue to be in development mode, but we learn from each other and we have
resources and experience, which may be helpful to others.

The lesson that health and wealth are interdependent is an old one and a current one. Even
within our own countries, with the single exception of breast cancer, there is evidence of a
disproportionate number of cases of disease, disorder and disability among people on low
incomes. How much more is that the case when one compares rich and poor countries.
Wealth means, on average, better health; poverty, on average, means ill health; and ill health
means poverty for nations, families and individuals.

The challenges

In developing countries, 28,000 children under five die every day from diseases easily
preventable by currently available medicines. Diarrhoreal diseases kill over 1.5 million
children a year. African women face a 1 in 13 risk of dying during pregnancy and childbirth.
By 2020 non-communicable diseases (cardiovascular, cancer, respiratory, diabetes) will
account for 80% of the global burden of disease, with mental health disorders the fastest
growing. 1.1 billion people are without access to clean water and 2.4 billion lack hygienic
sanitation. 3 million die every year of water-borne diseases (typhoid, dysentery, cholera,
hepatitis, malaria, trachoma, fluorosis and Japanese encephalitis). Tuberculosis kills 2 million
a year and is estimated to cost poor countries over $12 billion a year (WHO). 1 million die of
malaria and 300 million suffer from acute malarial illnesses. If malaria in Africa had been
tackled 30 years ago, when effective control measure became available, Africa would, it is
estimated, have been $100 billion better off (WHO). The impact of HIV/AIDS is well
documented; in Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe one in five adults live with it; and seven million agricultural workers across 25 African countries
have died since 1985. Ninety-five per cent of the five million new cases every year are in
low-income countries in the South. There are 25 million people living with AIDS in Africa
and 6 million in the new growth area in South, Southeast and Central Asia in particular.

HIV/AIDS

Where AIDS is concerned, we face a vicious cycle of infection, incapacity and poverty,
alongside the 16 million deaths. We see two million deaths a year in Africa: a quarter of all
Africa's deaths. Ten per cent of people between fifteen and fifty years of age are living with
AIDS. There are 10 million AIDS orphans. The people, who expected to be looked after by
their families in their old age, are now unable to have that care and support, because their
children are dead. The elderly are going back to work to scrape a living to provide for their
orphaned grandchildren. That is the scene confronting us.

When The Economist went to Zambia, it saw two-thirds of the patients in one hospital dying
of AIDS. People's limbs, they reported, looked like broken broomsticks. They were desperate,
not for retroviral drugs but food. They were too poor to afford either. Poverty hastens death;
and death accelerates the survivors' descent into poverty. Zambia's Department of Health
estimates half the population will die of AIDS. In some countries teachers are recruited for
training at a rate 25% above need, because that will be the wastage through AIDS during
training.

Range of diseases

A child in a developing country is ten times more likely to die of a vaccine-preventable
disease than a child in Europe.

Lifestyles contribute to ill health. Indoor air pollution, caused by burning unprocessed solid
fuels, particularly biomass (crop residues, wood and dung), in people's homes, can cause
acute respiratory infections, tuberculosis, chronic obstructive pulmonary disease, and lung
cancer as well as asthma, cataract and blindness, anaemia and adverse pregnancy outcomes.

40 million people in developing countries live with epilepsy and 32 million receive no
treatment, when for tiny amounts of money and medication some 80% could lead seizure-free
lives. Without them they are excluded from economic and social activity.

Mental health disorders are rampant in developing countries, as in Europe. Often they march
with, and at the same pace as, diseases such as HIV/AIDS. Mental disorders need more
medical and social supervision than most physical disorders and yet doctors, hospitals, clinics
and community services are rare or non-existent in many developing countries. Medication
and therapies are scarce while stigma adds to the suffering of the disorder. One in four of the
population in all parts of the world lives with mental, behavioural and neurological disorders
or mental retardation. Most are treatable; many are preventable or curable; all are
manageable. One of the tragedies of the developing world is the low priority given to this
fundamental area of human health and its impact on and from poverty.

These are the stark and challenging facts about ill health and its link to and from poverty.
Without health there can be no wealth. That is the global challenge, which the European
Union is rightly determined to play its part in meeting.

Achievability

The good news is that it need not cost enormous sums to make a difference and that, very
often, improved delivery of healthcare can lead to substantial improvements in quality of life.
Small sums of money can prevent needless deaths from treatable health problems. Infant
deaths from diarrhoea could be significantly reduced - the cost of 125 doses of oral
rehydration salts is €7. For €4 Oxfam provides specially designed lidded water containers
that keep water safe and clean, reducing the risk of exposure to disease.

Changes in the application of resources are equally important. For example, the National
Programme on Immunisation shows a continuing and dramatic decline in the incidence of
fatal childhood diseases in Nigeria, including tetanus, poliomyelitis, diptheria, measles,
tuberculosis, yellow fever, and cerebrospinal meningitis, which have been responsible for
high infant mortality in the country. The key to the decline was a change in public perception
about routine immunisation. The programme adopted a house to house strategy, in which
each immunisation team was permanently stationed in a community for the duration of the
immunisation exercise. In earlier exercises the vaccination teams had been continually on the
move.

The Communication

Broadly the Commission's Communication is to be very much welcomed. It rightly links
policy to the Millennium Development Goals (MDGs). MDG 4, 5 and 6 are, however, seen
as the "health goals", while the importance of Goal 8 of MDG is often forgotten. Goal 8
includes Indicator 33, to measure the proportion of Official Development Assistance (ODA)
allocated to basic social services, including primary health care, nutrition, safe water and
sanitation. It also includes Target 17 and Indicator 46 which are concerned with cooperation
with pharmaceutical companies to provide access to essential drugs in developing countries
and Target 10 which relates to access to safe drinking water.

The main reservation, on an otherwise very welcome Communication, is the limited scope of
the proposal. HIV/AIDS, TB and Malaria are among the most important health challenges. It
is right to give them special attention, but they are by no means the only health threats. The
Communication largely ignores non-communicable and other diseases. Many people in many
developing countries are vulnerable to asthma, upper respiratory infections and
neuropsychiatric disorders. South Africa has 2 million diabetes mellatus cases. Nor does the
Communication mention other diseases, such as chages, soil-transmitted helminths,
schistosomiasis, lymphatic filariasis, guinea worm / dracuncoliasis, trypanosomiasis and
dengue. Many of these have low levels of mortality but high levels of morbidity and
disability. As has been said, the great extermination campaigns saved millions of children
from an early death but left them to face diminished lives because of the neglect of the
diseases that weaken rather than kill.

Lymphatic filariasis, for example, affects over 80 countries in Africa, Asia, the Americas and
the Western Pacific with 1.1 billion people at risk. Investment in these diseases can pay dividends and Chinese economists have estimated that every $1 invested in the elimination of
lymphatic filariasis brings a return of $15.

Too often Country Strategy Papers (CSPs) and Sector Wide Approaches (SWAps) have
tended to be high on rhetoric but low on proposals specific to health and education. To date
out of the 61 CSPs published, only 9 have chosen health as a focal area for cooperation
representing just 4.3% of programmable resources.

It is also important that policy should be sufficiently flexible to respond to regional variations
in the pattern of diseases, for example, between the Caribbean and Africa. We also need to
emphasise that poverty and health is not just a medical and care issue; it is linked to the wider
programme of nutrition, safe water, sanitation, housing, education and the environment and
rehabilitation, re-training and employment.

Hunger

Hunger is important to the health and poverty equation. The public's perception of hunger is
very often the televisual one of famine. The major problem is, however, malnutrition. One
aspect of this is poor water, which leads to disease, disability and death and a less productive
workforce. That, in turn, leads to low-incomes, which leads to malnutrition, and so on - the
cycle of deprivation, that needs to be broken.

It is exacerbated when humanitarian aid undermines local farmers and local economies. We
give our food surpluses to low-income countries, not realising that the harm it can do to the
farming economy in those countries. It is exacerbated again, when we close our European
doors to their food exports. Protectionism against developing countries takes some $100
billion from them - much more than the total volume of development aid. If they could
increase their exports to us by just 5%, this would generate $350 billion.

It is a quarter of a century since targets were set. In 1996 we aimed to halve the 800 million
undernourished people by 2015, at the rate of 22 million a year. The numbers are falling by
only 6 million a year. The target will not be reached until 2030. And per capita food
production has not increased in the high-debt, low-income countries, especially in sub-Saharan
Africa. Yet the United Nations Development Programme estimates that it would take
just $13 billion a year to solve this problem - the same amount that Europe and America
spends on cosmetics.

In the last 50 years almost 400 million world-wide have died from hunger and poor sanitation.
That is three times the number of people killed in all the wars fought in the entire 20th
century. Every year some nine million people die from hunger. That is 24,000 deaths a day.

Action and cost

World Bank estimates suggest the central goal of halving poverty by 2015 would require a
rapid doubling of ODA flows. According to the report of the Commission on
Macroeconomics and Health (December 2001), $31 billion of additional aid financing to the
health sector from this date to 2015 will be required to meet the MDGs in this sector.

The EU development budget has been criticised for its lack focus on poverty. The present
Commission's communication goes some way in addressing this but we will have to wait and
see whether there can be real progress on the ground. There needs to be significant shift of
resources to social sectors, particularly basic health and education.

According to the Commission, in 2001 it disbursed just 3.4% (€ 201,62 million) of the
combined general budget of the Commission and European Development Fund on health. If
macro-economic support is going to take a greater slice of the development aid budget, one
must question how the health sector will be served and how this will be measured. The
European Parliament has consistently called for 35% of development aid to be allocated to
health and education, and for appropriations for Least Developed Countries (LDCs) not to be
diverted to non-LDC countries.

Health systems in many developing countries are starved of resources. The countries
themselves will need to mobilise increased investment for better health outcomes and
initiatives such as that of African Governments (Abuja 2001) to commit 15% of national
budgets to health are welcome. Yet in most low-income countries the international
community will need to complement country level public and private investments with long
term financial support; many countries will require technical support and capacity building
rather than major financial transfers.

Developing countries have inadequate access to affordable services and drugs. The reasons
are complex and include the effects of international and national pricing policies, tariffs,
taxation and the implementation of intellectual property rights agreements. Options to further
improve access and affordability include the exploration of the use of differential pricing
(tiered pricing), voluntary licensing agreements, parallel trading, technology transfer, increase
in local capacity for production, and the use of generic and patented products.

Summary

We need to see an upgraded EC Development commitment to support in the health field.
Increased financial inputs to the social sectors by themselves do not necessarily result in
improved outcomes in health. More efficiently targeted investment is the key. Performance of
health systems and the support given to health has to be measured better; trends have to be
monitored in a co-ordinated manner and capacities developed to do so. One thing is certain,
Europe must stop draining developing countries of medical skills; currently, according to the
WHO, developing countries lose 63,000 doctors annually and receive back on 1,300. Overall
we need to see a programme of more action and not just fine words.