Interview with ECA Executive Secretary, KY Amoako

African countries have scaled up their HIV/AIDS response, but more needs to be done, according to UN Under Secretary-General and Economic Commission for Africa (ECA) Executive Secretary, KY Amoako. In an interview with PlusNews, Amoako said that the key to tackling most of the continent's health problems was to strengthen economies. He was optimistic that the Abuja Declaration on HIV/AIDS in April 2001 would be implemented. He also discussed the impact of the Global Fund in Africa and the role of women in fighting the HIV/AIDS pandemic. QUESTION: In the Abuja Declaration, African leaders committed themselves to allocating at least 15 percent of their national budget to the improvement of the health sector. What has happened since then, has there been any progress on this, and do you think this was a realistic target? ANSWER: A lot has happened since the Abuja Declaration on HIV/AIDS, TB, Malaria and Other Infectious Diseases (ORID). That declaration was monumental not only with respect to the commitments entered into by the heads of state of African countries but also because it signalled the breaking of silence on HIV/AIDS at all levels of government in our region. It built on previous efforts by the OAU such as the Tunis, Dakar, and Lome Declarations and amplified the consensus reached at the Africa Development Forum (ADF) 2000 on "AIDS: Africa’s Leadership Challenge" convened by ECA about 15 months ago. At the Lusaka, Zambia OAU Heads of State summit, the declaration was endorsed and its "Framework Plan of Action" approved. Evidence from all corners of the continent indicates that countries are scaling up their HIV/AIDS activities. National AIDS councils have been set up. Civil society organisations and faith-based institutions have become active combatants as foot soldiers in the war against HIV/AIDS. Public awareness of HIV/AIDS is greater today than it was before. There is evidence that these efforts are beginning to bear fruit. Prevalence rates have fallen in countries such as Nigeria, Uganda, and Kenya. In other countries the infection rate has either plateaued or is increasing at a decreasing rate. However, a lot still remains to be done. Countries need not be judged solely on whether or not they are meeting the 15 percent commitment but on the outcome of their efforts. You never know how much you can achieve with very little. African countries are very poor. Over 331 million people - more than the population of South America - in sub-Saharan Africa live on less than US $1 per day. Economies are either stagnant or have experienced growth reversals. Given this, many countries will surely find it difficult to meet the 15 percent target without significant external support. In my view therefore, countries should be judged according to their efforts to achieve the 15 percent, not on whether or not they have actually achieved it. Trend should be no less important than the target. Q: The ADF 2000 Plan of Action for effective leadership on HIV/AIDS put forward a number of resolutions. In view of a history of resolutions not being implemented in Africa, how will the ECA make sure that these commitments are kept and fully carried out? Are there any mechanisms in place for this? A: You are right in talking about the number of commitments, resolutions and declarations signed by African leaders. The lack of implementation of these resolutions by many of our countries should not always be interpreted as evidence of a lack of will. In many cases, variables or indicators according to which these declarations or resolutions will be monitored are seldom developed. In others, countries lack the resources, the capacity, in short, the wherewithal to follow through. With respect to the Abuja Declaration and the consensus reached at ADF 2000 on HIV/AIDS, efforts are underway to translate these commitments into reality. We at the ECA have established a health unit in the Economic and Social Policy Division to enable us provide assistance to member states in their efforts to follow through on these commitments. ECA and OAU, with assistance from UNAIDS and WHO are preparing an annual report on HIV/AIDS, TB, and malaria which will report and serve as a monitor of the implementation of the commitments made. It is hoped that this report will be presented to African heads of state during their summit meeting in Pretoria, South Africa, later this year. In addition, the 2002 Economic Report on Africa (ERA), to be shortly published by ECA, includes a chapter on health that - although it focuses on new health technologies to fight HIV/AIDS, TB, and malaria - makes the case for intensified efforts to implement African resolutions on health in general and on HIV/AIDS, TB, and malaria in particular. The Regional Economic Communities (RECs) have also become involved. But above all, the best mechanism for ensuring that these resolutions are translated into reality is the involvement of people themselves at all levels of African society. In Kenya, for example, through public pressure, AIDS councils have been established in all constituencies and members of parliament are increasingly been judged by the constituents according to how they are involved in the fight against HIV/AIDS. Through this, citizens are able to bring pressure to bear on their governments. At ADF III, a parallel meeting on ADF 2000 and HIV/AIDS is going on. This joint initiative of ECA and UNAIDS is aimed at keeping HIV/AIDS as a front-burner issue. It is also considering the implications for disease control and the rights of citizens of regional and political integration. This and the other efforts I have mentioned above serve to encourage African leaders to be faithful to the resolutions on HIV/AIDS that they have signed. Q: The African Consensus and plan of action calls for special attention on the status of women. How can governments ensure that women are involved in HIV/AIDS issues? Have any steps been taken since the meeting in Addis Ababa to ensure this happens? A: Women are most affected. Infection rates are higher among them than among men. They are the primary care givers. In some parts of the continent, they are treated as chattel, inherited and disinherited upon the death of their spouse. They have no property rights. ECA is working to improve the status of women in Africa. It has a long history of doing that. In 1975, it established a separate division - the African Centre for Women - to serve as the arrowhead of efforts to improve the status of women. That Centre has done commendable work. Recognising the enormous amount of work that still has to be done, that division has been strengthened and its remit expanded. Now known as the African Centre for Gender and Development, the division is working on mainstreaming of gender in development. It is assisting member states to begin to produce gender-disaggregated data. Efforts are also underway to develop a Computable General Equilibrium Model for African countries that explicitly takes account of women’s work. There are efforts in many member states to improve the status of women. Obviously the most effective way to improve the status of women is to empower them - economically, legally, socially, and politically. ECA through the work of its African Centre for Gender and Development is encouraging and assisting member states to do this. Q: In South Africa, the government has come in for criticism over its HIV/AIDS policy, which has been marked by what many perceive to be a lack of political commitment. What can be done when national governments appear reluctant to tackle the epidemic head-on? A: There has been a lot of controversy around South Africa’s policy on HIV/AIDS. It is possible that comments in the media truly and accurately represent what is going on in that country. People should not mistake debates on policy direction for reluctance to act. Debates, to the extent that they help sharpen focus and facilitate the emergence of consensus, are useful and important. The government of South Africa, I understand, has more than doubled outlay for HIV/AIDS. It is providing antiretroviral (ARV) treatment to pregnant mothers at 18 pilot sites. The vice president at a recent press conference stated that the government will not bar anyone from purchasing ARVs as private citizens - at their own cost. I understand that the government is undertaking additional research to determine the effectiveness of the ARVs in the presence of co-factors (to HIV/AIDS) contributing to poor health and vulnerability to disease in the country. I think that the government should be at least given the benefit to conclude and publish the results of their on-going research. What is important to note though, is that expenditures on HIV/AIDS are increasing in South Africa. This is seldom reported in the popular press. Q: What is Africa's biggest challenge in dealing with HIV/AIDS? A: Poverty is definitely Africa's biggest development challenge. People are so desperately poor that "saving yourself today for tomorrow" is a meaningless and empty concept. If our economies grow and the resulting increase in resources is well managed, then governments will be in a better position to fund health programmes, including HIV/AIDS programmes. In some odd but obvious way, the key to tackling most of Africa's health problems is to grow our economies. Q: The provision of ARVs is still difficult for most African countries. How can national governments mobilise resources to provide treatment for people living with HIV/AIDS? Do you think the local production of pharmaceuticals is feasible for African countries? A: This is a very important issue. ARVs are expensive. HAARTs (highly active antiretroviral therapy) are even more expensive. African countries, being poor will not be able to fund the purchase of these drugs in numbers large enough to treat every infected individual. In many countries, most of the infected are poor and are in no position to afford the drugs. A number of options are open to African countries. They can take advantage of regional drug procurement arrangements; or pool together in sub-regions to purchase these drugs at a lower price. Pooling together will enable them to bargain for lower prices. For example, ECOWAS (Economic Community for West African States) member countries may decide to buy the drugs together. This will give them enormous bargaining power with the drug companies. They can also purchase generic drugs from either Brazil or India. I do think that local production of pharmaceuticals is possible. But this may not be possible on a single country basis. Many African countries are poor and small. Pharmaceuticals are expensive. The average cost of a drug is high. The minimum efficient scale for local production to make sense may be impossible to reach in many countries. There is therefore a need for regional integration. An integrated regional market will provide a large enough market for the pharmaceuticals firms to make local (in the broader, African, sense) production possible. ADF III, now taking place in Addis Ababa, is focused on regional and economic integration and will highlight the benefits of integration for issues such as this. An economically and political integrated Africa will make for the harmoniSation of policies, taxes and other incentives in addition to providing a large enough market. Patents should not constitute a barrier to the local production of drugs. The use of safeguards (such as compulsory licensing) to override patents is legal within TRIPS (trade-related aspects of intellectual property rights) and has been strongly reinforced in Doha by the World Trade Organisation. The Doha Agreement reads: "The TRIPS Agreement does not and should not prevent members from taking action to protect public health...Each member has the right to grant compulsory licenses and the freedom to determine the grounds upon which such licenses are granted." In view of this, those African countries that signed the Bangui agreement (with major pharmaceutical companies) may need to revisit that agreement. Q: Will the Global AIDS Fund make enough of an impact in overcoming the HIV/AIDS pandemic in Africa? Has the global response been sufficient? A: A correction is probably in order here. There is actually no Global Fund for HIV/AIDS. What was created following the UN General Assembly Special Summit (UNGASS) in July 2001 was a Global Fund for AIDS, Tuberculosis, and Malaria (ATM). The goal was to raise US $10 billion a year. So far, the response can best be described as tepid. Only about US $2 billion has been raised. The Governing Board of the Board has been established and the Fund is now receiving applications for the first set of disbursements. We hope that with time, donor countries’ faith in the ability of this Fund to produce a global public good, reduction of the threat of infectious diseases worldwide will increase and that they will elevate their support for the fund. As discussed in the chapter on health in the forthcoming Economic Report on Africa, the tools which can change the course of the epidemic are in our grasp. The benefits of ARV in terms of reducing transmission have been amply demonstrated. But as you pointed out in one of your questions, these treatment protocols are very expensive are not within the reach of many African countries. In developing countries, according to UNAIDS, about 200,000 HIV-infected persons are on ARV drug treatment. Of these, about 100,000 live in Brazil. But Africa has the largest number of HIV-infected persons. The reason why there are few HIV-infected Africans on ARV drug treatment is obviously, cost. These drugs are simply not within the reach of most of the infected in Africa. Donor support will be needed in the interim to increase the number of HIV-infected people in Africa receiving the treatment. The Global Fund for ATM will make an impact in this area to the extent that it places at the disposal of African countries, additional funds to battle HIV/AIDS, TB, and Malaria with. Let us hope that as successes are recorded and as donors become convinced that their money will be put to the most productive use - saving lives and giving new hope to people for whom the word hope may no longer exist - response to the Fund will increase.