Partners for Domestic Investment in Health

Partners from UNAIDS, the United Nations Economic Commission for Africa, African Union, African Development Bank and the Global Fund gathered in Marrakech, Morocco to examine and discuss this issue. Organized at the side lines of the African Development Forum, the meeting focused on urging low and middle income countries to raise more domestic finances for health. Participants called for a new paradigm in health financing.

Michel Sidibé, Executive Director of UNAIDS, gave the keynote address and said that as more and more low income countries transition into the middle income status, they should reconsider their investments in health. In the same spirit of shared responsibility and solidarity, Sidibé said, rich nations should also maintain their commitments to financing health programs.

Abdalla Hamdok, Deputy Executive Secretary of the United Nations Economic Commission for Africa, said that investments in health form a critical pillar of economic growth and should be strongly linked to other sectors. Unless Africa focuses on health in its totality, the continent cannot achieve economic transformation. "Health is at the heart of development," he said.

Itai Rusike of African Civil Society Platform made a passionate call for a country-level movement of partners for domestic financing for health made up of the civil society, parliamentarians, private sector and all other stakeholders. Such an effort, coupled with stronger governance mechanisms, would mean great African solutions to African health, he said.

Shu-Shu Tekle-Haimanot, Senior Specialist for Advocacy and Partnerships at the Global Fund, said the Marrakech meeting was a significant step toward better health in Africa. “Partnerships hold the key to progress,” she said. “With implementing countries leading the way, this partnership can achieve our goals of raising funds and saving many lives.”

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Gender Inequality

As a child growing up in a small rural village in the west of Kenya, Seri Wendoh saw for herself what the realities of gender politics looked and felt like. Seri and the other girls walked miles every day to collect water. They helped in the fields after school and did jobs at home before they started their homework. She watched as her female classmates, who were just as clever and as hard working, were forced to leave school because their parents couldn’t afford to carry on paying for their education or because they had to get married.

As Seri saw what was going on around her she realized that she couldn’t sit back and wait for things to happen, she had to take action to bring about change. This realization started her on a journey. It led to the International Planned Parenthood Federation, where she is technical advisor on gender and rights.

Seri accepts that her and her siblings were lucky. Her mother was a school teacher and her father was a farmer. She was able to go to university in Nairobi where she did a degree and then a Masters. She was then able to do doctoral research on the links between race, class and gender at Leeds University in the UK. After completing her PhD, Seri returned to Kenya and taught at the university. She was able to carry out extensive research into power relationships and how they are played out in sexual and gender-based violence. Her research highlighted the impact that negative attitudes about gender had on women’s access to sexual and reproductive health and rights but also on the meaningful participation of poor and marginalized people.

Seri has worked with women’s organizations both at the grass-roots and at the national levels in Africa. Observing and reporting on gender-based violence was difficult, but through it all, she said, she saw women demonstrate extraordinary strength and resilience. The experience also taught her that “in order to achieve gender equality men and boys had to be considered as part of the solution, not just as part of the problem.” Seri went on to explain that men have to be able to access services, have to become partners, and have to be part of constructive change.

Seri observed that the Global Fund has included an emphasis on community, rights, and gender in its new funding model. In her view, it is critical that people on the ground – but especially women and girls – can feed into and be an active part of the process.

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Girls and Women

To halt the spread of infectious diseases, and achieve real impact, the world needs to engage more closely with women like Wilhelmina Amakali. Seated on a plastic chair that strains to find a foothold on an incline of one of the many hills that dot the Namibian capital, Windhoek, Wilhelmina told the story of her life casually, as a matter of fact.

She spoke of her near-death experience with tuberculosis and the steep climb to beat back the disease; of her man, the father of her children, their dicey relationship and of his multiple sex partners. She started dating him when she was 21. At 41, he was nearly twice her age. Years later, she would develop concerns about the relationship. To be specific, about his affairs with other women. “At some point I knew we were three women,” she said. Still, that didn’t mean she could leave as they had a child together, and a second was on the way.

A growing number of studies single out gender inequality as a major driver of HIV and other infectious diseases. On HIV, such epidemiological intelligence points to multiple sexual partners as a key driver to the spread of the disease. Southern Africa, the region where Wilhelmina lives, continues to be the epicenter of HIV in the world. Yoked to tradition and limited by economic means, women here continue to date or to marry much older men who may have concurrent multiple partners, who are more likely to be living with HIV.

As a result, women are disproportionately affected by the disease. In 2013, UNAIDS reported that women in Southern and Eastern Africa account for 58 percent of adults living with HIV and for 53 percent of all adult AIDS deaths. It said that substantial social and psychosocial changes are needed to turn the tide against the destructive effects of vulnerability of women in the region.

But even as experts caution that these practices fuel the spread the virus, they know not to be overly prescriptive.

“We are not here to judge so we do not tell people what to do in their sex lives. People in sexual networks should be aware of the risks involved and act appropriately,” said Ade Fakoya, Senior Disease Coordinator for HIV at the Global Fund. “You either have to leave the network or as much as possible take measures to protect yourself from being exposed to infection.”

The Global Fund recognizes the need for more comprehensive approaches to give women tools that can help fight the spread of the disease. It’s not just HIV. There are numerous factors that also predispose women and girls to TB and malaria. Women and girls are at particular risk of malaria during pregnancy as immunity to the disease is diminished during his period. In southern Africa, women aged 15-24 have twice the rates of TB of men of the same age.

Women in a village in Thies province, Senegal, are trained to become community health workers. The Global Fund / Didier Ruef

With the creation of a Gender Equality Strategy, the Global Fund is seeking to support women to mount a holistic defense against the diseases. Motoko Seko, Technical Advisor on Gender at the Global Fund, says the strategy seeks to engage women in design and implementation of projects to address human rights and specific needs of girls and women, and guide the Global Fund’s leadership in gender issues both in the programs it supports and in its own internal operations.

The Gender Equality Strategy also targets men in situations that disproportionately expose them to diseases. For instance, norms of masculinity increase men’s vulnerability to HIV, encouraging high-risk sexual behavior and deterring them from seeking health care. In southern Africa, men working in the mines are excessively affected by tuberculosis. In the same region, men have been left behind in access to treatment. The Global Fund is supporting programs specifically targeted to these challenges posed by existing gender norms.

In the same vein, it is important to engage men and boys on why it is important to stop using violence as a way of conflict resolution, says Seko. One in three women worldwide have experienced either physical or sexual violence or both from men. Women who have been exposed to intimate partner violence are 50 percent more likely to acquire HIV than those who have not.

Lesser economic influence and lower socio-cultural status in many countries leave women and girls disadvantaged in their relations with men. In poverty, the risk of disease infections takes a subordinate status in the hierarchy of concerns. Women in economic dependency of male partners are exposed to violence and sexual aggression, losing control over their sexual and reproductive lives.

Today, Wilhelmina works as a Monitoring and Evaluation Officer with Penduka, a non-governmental organization that receives support from the Global Fund for its TB program. Penduka pursues an all-inclusive strategy of bettering the lives of women.  Economic empowerment is key to helping women fight diseases, says Elizabeth Kauna, the chairperson of the organization.

Besides their TB department, Penduka has hospitality and production units, which raise income for a network of women across the country. Kauna says that Penduka was created as a wake-up call for women in the margins of the society who are often exploited by their men. “We are helping them to have their own income,” says Kauna. “We want them to be able to raise their voices and say ‘no’.”

In her own way, Wilhelmina has played her part in serving her community sometimes against many odds. She was infected with TB when she offered to nurse a family that had been infected with the disease. For no fee, she would feed and clean the patients oblivious of the risk she exposed herself to TB.

And even when she got sick, she could not tell what she was suffering from. Doctors were slow to diagnose her, until one day when she collapsed and was rushed to hospital in a state of unconsciousness. It was here that the doctors discovered she had advanced tuberculosis. As she gained strength, she again began to work as a volunteer in TB programs and earned the status of a top community health worker. Years later, she has risen through the ranks to be in charge of data for 584 TB patients under Penduka.

With a job, more knowledge about tuberculosis and public health and a great deal of passion and conviction in fighting diseases, Wilhelmina is a world away from the shy girl who fell in love with the father of her children 14 years ago.

There’s something about the 35-year-old – the big bright eyes, her lanky but strong frame, the fire with which she talks about community service — that says she is a change agent in her country. In different places around the world, women like Wilhelmina are becoming more empowered. After ten years “sharing my man with other women,” and with her job as a health worker blossoming, Wilhelmina said she wanted out. “Today he has five women,” Wilhelmina said throwing a quick glance up the hill. “But I am not in his list of women any more. I left him.”