Choice of a standard of proof in public health - how much evidence is enough to justify adoption of an intervention or policy change - is perhaps the central conceptual question in public policy on health inequalities. As a matter of values and priorities, there is no algorithm for doing this choice nor can it be made on scientific grounds. 
It is high time we foreground this point not only in discussions of public policy on health inequalities, but also in the training of researchers, practitioners and policy specialists.  Understanding standards of proof must be recognized as a core professional competence, and incorporated into the relevant curricula.

By Ted Schrecker

Professor of Global Health Policy, Newcastle University, UK

Co-editor, Journal of Public Health

What Public Health Policy Can Learn from the Murders of Nicole Brown Simpson and Ron Goldman

 

For readers of tender years and no immediate access to Wikipedia, Nicole Brown Simpson was the ex-wife of former (US) football superstar O.J. Simpson, who in 1994 was accused of murdering her and a companion, Ron Goldman.  Mr. Simpson was acquitted of criminal charges in the deaths, but later found liable in a civil suit brought by the victims’ families for wrongful death damages.  This outcome is superficially perverse, but legally plausible in common law countries because the standard of proof in criminal proceedings – every element of the offence must be proved beyond a reasonable doubt – is more demanding than in civil proceedings, where the standard of proof refers to the balance of probabilities or a preponderance of the evidence.  This reflects a judgement about the dangers of being wrong in different kinds of ways: it is considered more objectionable to convict an innocent defendant than to hold that the same defendant must pay damages to those who have been wronged, or their survivors.

In public health, application of an analogy with legal proceedings is nothing new.  Forty years ago, environmental economist Talbot Page published a critically important article about a class of hazards he called environmental risks, like certain kinds of toxic discharges, with such characteristics as incomplete knowledge of mechanism, long latency periods and serious if not irreversible effects.  Scientific research on these hazards, he pointed out, is organized around limiting ‘false positive’ results – for example, inferring a causal relationship where none in fact exists.  In the case of criminal trials, limiting false positive results (that is, convictions of the innocent) is theoretically embodied in the principle of requiring proof beyond a reasonable doubt.  However, Page argued that the approach of limiting false positives may be inappropriate in environmental policy because of the consequences of failing to take action to control a hazard that is later found to cause, say, cancer or birth defects with lifelong consequences.  “In its extreme,” wrote Page, “the approach of limiting false positives requires positive evidence of ‘dead bodies’ before acting”.

Unfortunately, this is not an extreme.  With a few exceptions, that has been the default position in public policy with regard to health inequalities and social determinants of health.  As David Stuckler and Sanjay Basu have pointed out, “in countries where austerity is ascendant, we’re undergoing a massive and untested experiment on human health, and left to count the dead.”  Exactly.  The logic is that of industrial employers who insist that only findings from prospective epidemiological studies will justify regulating workplace processes that give their workers cancer.  In 10 or 20 years, longitudinal studies of populations exposed to austerity may provide stronger evidence than is now available of the long-term health impacts of the attack on social provision and the targeting of poor communities that have been the centrepieces of post-2010 social policy in the UK, or the youth unemployment rates of 40-50 percent that are the legacies of the financial crisis and subsequent austerity in Italy, Spain and Greece.   Vindication of what many of us have been saying all along will be cold comfort to the survivors.

Choice of a standard of proof – how much evidence is enough to justify adoption of an intervention or policy change – is perhaps the central conceptual question in public policy on health inequalities, and the contrasting positions can be dramatic.  As noted in my previous posting, in 2010 Sir Michael Marmot and colleagues wrote: ‘It is hard to see how even ideologically driven commentators could think that having insufficient money to live on is irrelevant to health inequalities’.  On the other hand, a senior fellow of the somewhat left-of-centre Brookings Institution recently wrote in the Journal of the American Medical Association that: “The evidence on social determinants of health is growing, but is still insufficient to convince many key decision makers. For instance, there is good research on the link between such housing problems as mould or substandard accommodations and health, and between family or social ‘toxic’ stress and long-term mental health and other patterns. But purported linkages between health and other social conditions, such as general poverty, lack reliable evidence. Much more basic research is needed to understand the key determinants.”

As in the legal system, the choice of a standard of proof in public health cannot be made on scientific grounds.  There is no algorithm for doing so.  It is a matter of values and priorities – in the first instance, those of the ‘key decision-makers’ referred to, in a decontextualized way, in the JAMA article.  One must ask: do they really think that living in poverty or relying on low-wage, precarious employment are unrelated to the possibilities for living healthily?  That such situations don’t involve toxic stress?  (The work of Linda Tirado and Barbara Ehrenreich, among others, is eloquent on this point.)  Sadly, this lack of comprehension is shared by many of our professional colleagues.  The reply to an article I published on this issue in 2013 described me as “noisy” in the second paragraph – completely missing the analytical point, as do many others.

Forty years on from the appearance of Page’s landmark article, it is time to foreground this point not only in discussions of public policy on health inequalities, but also in the training of researchers, practitioners and policy specialists.  Understanding standards of proof must be recognized as a core professional competence, and incorporated into the relevant curricula.

 

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Author’s apology: a few of the hyperlinks in this posting may lead to articles that are behind a paywall.  If you have trouble accessing these, please contact me and I will ensure that you obtain a copy.

In his own words, the director of National Medical Stores (NMS) Mr. Moses Kamabare said “the stores are full of drugs to the point that I am asking my suppliers to hold future deliveries as I try to work out stocks from the system”. Reading the NMS Director’s statement and considering the regular drug stock-outs in the country makes one wonder who is fooling the other. This is an indicator that someone in the system is incompetent in managing their job of furnishing the correct data to the relevant authorities. This article intends to examine the pros and cons of the nature of the system that NMS uses in procuring the drugs for Ugandans to avoid stock outs

By Bukenya Denis Joseph*

Human Rights Research Documentation Centre (HURIC) Kampala, Uganda

Understanding the Systems that Influence Distribution Channels for Drugs in Uganda for Better Inventory Procedures

 

Access to medicines is a fundamental right to health in both patients and health workers as they both play a major role in the fulfillment of the right to health. The patient is the end user and mostly said to be on the demand side of the supply chain. Health workers being the intermediary in this vehicle of the rights based approach should also be accorded the attention they deserve as the protagonists of access to medicines.

It is impasse as to what happens when the demand for medicines versus the supply chain of essential medicines causes denial of essential medicines to patients. This will curtail the attainable standards of health recommended by the WHO guiding principles on access to medicines. This then begs the question of blame on who is responsible for the citizenry access to medicines. Owing to the foregoing, we borrow a leaf from the shortfalls of the Ugandan supply chain of medicines.

In his own words, the director of National Medical Stores (NMS) Mr. Moses Kamabare said “the stores are full of drugs to the point that I am asking my suppliers to hold future deliveries as I try to work out stocks from the system” (Abusharizi, 2012). Reading the NMS Director’s statement and considering the regular drug stock-outs in the country makes one wonder who is fooling the other. This is an indicator that someone in the system is incompetent in managing their job of furnishing the correct data to the relevant authorities. It could be a deliberate move by individuals in the system so as to increase clientele for their private clinics. You cannot rule out the fact that the system is too porous to furnish the right information to the medical stores at NMS. It is also worrying that instead of looking for more funds from the Ministry of Finance to improve the NMS stocks, money is sought to conduct disposal of expired drugs. That will be a discussion for another day. This article intends to examine the pros and cons of the nature of the system that NMS uses in procuring the drugs for Ugandans to avoid stock outs.

The Uganda National Medical Stores (NMS) is run on a pull and push system. There are persistent drug stock-outs in the country due to failed deliveries. Many a time we have instances of facilities in Uganda receiving deliveries that were not on their demand lists. Meaning that the suppliers are forced to push stocks out of their stores hence the paradox of who is to blame. It is estimated that at least $ 550, 000 worth of antiretroviral and 10 million antimalarial drugs does reportedly expire in the NMS warehouses (Department of Pharmacy, 2010). May be we need more competent managers to avert the calamity that befalls the tax payers’ money in Uganda. According to the WHO report on distribution as a barrier to access to medicines, published in 2012, it categorically states that the last mile is achieved when the patient gets his medicine in time given the distance covered meaning that regardless to whether the distances travelled to the facilities that distribute the required drugs are near to the consumer or far, a person should be able to access the required medicines on arrival to a designated premise.

In regard to our distribution channels under the push and pull system, the pharmaceutical supply system comprises of 3 major players that is one national medical store and two private non-profit organizations engaged in the system of distribution of drugs in the country and in Africa at large. Uganda has a centralized medical store that manages the distribution and allocation of the medicines to the patients with the main goal of ensuring that the last mile which is the distance to the last customer (patient) is achieved in a timely manner and in the right proportions and conditions for consumption.

To a certain extent, the push system of supply of medicine is based on projected or predicted demand. In this system there is often a failure to correspond with the actual or consumed demand; this inaccuracy causes sizable dent in the distribution chain of drugs in Uganda hence the excesses in the register. That couples with the associated required storage space as the main causes for this. However, there are some advantages to this system; for instance there is only the worry of absence of an inventory, customer satisfaction and government predictability in supply unlike the pull system that can be manipulated to suite individual’s evil motives.  Considering the issue of predictability, the government plans its finances ahead of time in regard to the actual procurement and storage (WHO, 2015)

The two systems seem to complement each other in regards to the encumbering short falls. In the pull system of the supply chain, there is elimination of the excesses in the inventory in the distribution and procurement is only effected on the signals given. The signals are prompted by demand; the pull strategy, also allows for a single piece flow or a one-piece flow system. This eliminates the bulk buying, the need for batch sizes, and a lot of products bought since only one product at a time is being worked which is a time-saving procedure. The single piece flow system additionally cuts unnecessary expenditures such as the need for space caused by excess inventory due to overstocking. This method also allows for reduction in the costs of labor associated with space requirement and stock handling significantly. Disadvantages to the pull strategy do however exist like falling subject to over demand which results in an excess in actual customer demand, hence bringing about shortage of supply and inability to meet customer demand. Eventually we shall have customer dissatisfaction.

Considering all in the above, it is advisable and prudent to operate under a hybrid of the two supply systems. This is what Uganda has tried to do over time although for political reasons; many of the authorities in the management of the system will be heard eloquently saying that Uganda is working under the pull system. They would love to show Ugandans that the system is accommodating of all views. To be more specific and realistic, it is very difficult for any entity run these systems on one pure system, be it the pull or push system. In the nutshell, there are several shortfalls in the Ugandan system where change is long overdue. All has to be precipitated by the various advocates through critiquing and pointing out the challenges in the system. There will be a need to weed out all the bad elements that are crippling the system hence an impediment to access to medicines.

Moving forward

The government of Uganda needs to ensure a speedy and timely access of essential medicines as required by the citizenry through streamlined inventory channels that represent the correct data. This will be made possible through:

1. Training of health workers, store managers on issues of record keeping and inventory management in regards to the demands and inventory of medicines in each health center; this training should focus mainly on inventory (order placement and stock taking) to remove the chaotic drug overstock at main warehouses given that even minimal technical training can confer a completive advantage in the labor market.
2. The government should implement a reward system for its workers in places that are hard to reach and very remote in demographic with incentives such as children education, proper housing developments and also better salaries to reduce on labor turnover.
3. There should be a stock in and out monitor meant to characterize the data of stocks from different regions and the trends should be analyzed for purposes of effective monitor. As time goes by, it will help us to reduce on the cost of inventory monitoring. This will further reduce the inconsistences by putting into consideration the unique peculiarities that exist at the different health facilities.
4. It is also recommended that national medical stores involve stakeholders at every stages of medicines and supplies planning, especially the district health officers, who are the final consumers facing entities in the supply chain.
5. Finally, the government should adopt a revolving drug fund system, in the form of ‘Special Pharmacies and drug stores’ to enhance availability of essential drugs in public health facilities and thus improve the quality of health care.

 

References

Abusharizi, P. (2012, May 9). Do We Really Have Drug Shortage ? Retrieved December 22nd, 2017, from http://www.cehurd.org/2012/05/do-we-really-have-drug-shortage

Department of Pharmacy, M. U. (2010, May 9th). Expiry of medicines in supply outlets in Uganda. Bull World Health Organ. 2010 Feb; 88(2): 154–158, 1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2814474/

WHO. (2015, December Tuesday). Essential Medicines and Health Products. Retrieved January 23rd, 2015, from www.who.int: http://www.who.int/medicines/areas/access/supply/en/index5.html

 

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 *Bukenya Denis Joseph, a Legal practitioner with a bachelor’s degree from Makerere University faculty of Law and post graduate with the award of a Master of Arts in Human Rights from the Uganda Martyrs University. A degree with the International People’s Health’s University online (IPOL). Coordinator of the Human Rights Research Documentation Centre and also coordinating the People’s Health University Uganda Circle and also working as the Sub-regional leader of the East and Southern circle of the People’s Health Movement.

 

Health Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Health Breaking News: Link 271

 

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In the contemporary policy environment, one element in particular connects health inequalities around the world: Neoliberalism as a set of norms that guide and justify policy, ultimately equating financial worth with moral worth. The connections are not only conceptual of course; they are also material and institutional, operating through such channels as campaign money, capital flight and the networks of power and privilege epitomised by the World Economic Forum, where the global super-elite meet to worry about the threat  posed to their fortunes by the rest of us

By Ted Schrecker

Professor of Global Health Policy, Newcastle University, UK

Co-editor, Journal of Public Health

On Health Inequalities, Davos, and Deadly Neoliberalism

 

‘If livin’ were a thing that money could buy / The rich would live and the poor would die.’  It is, and these lines, from a spiritual temporarily made famous in the 1960s by Joan Baez, remain the best succinct description of the origins of health inequalities.

Occasionally, that reality thrusts itself into the consciousness of the high-income world, as in the case of Hurricane Katrina and the Grenfell Tower disaster.  In the case of Katrina, when the hurricane hit and the levees broke (after years of governmental neglect), evacuation plans presumed that everyone had access to an automobile.  Those who could afford to do so packed up the car and drove to higher ground.  Others, overwhelmingly poor and African-American, were left to fend for themselves as refugees in their own country.  The disposability of certain populations, from the point of view of the powerful, was similarly evident in the case of the Grenfell Tower fire, where local government in an ultra-wealthy London borough appears to have skimped on basic fire protection measures in a social housing block.  Apart from high-profile disasters, the wisdom of the spiritual’s words is evident on a daily basis, although it seldom hits the headlines: in the small city of Stockton-on-Tees in the north of England where I live, differences in male life expectancy between the most and least deprived wards are larger than the national average differences between England and Tanzania.

Outside the high-income world, global health researchers and practitioners constantly confront the realities described in an article on ‘priorities for safe motherhood interventions in resource-scarce settings’.  The authors wrote (in 2010) that the basic interventions recommended by WHO – still far below the standard of care that would be considered normal in the high-income world – would cost US$1.80 per person per year in Uganda, but Uganda was spending only US $0.50 per person on maternal and newborn care.  So, in the health economists’ ubiquitous mantra, priorities must be set.

The researchers who carry out these exercises cannot be faulted, and there is plenty of blame to go around, starting with the fact that a decade later, Uganda’s government was still not meeting  the target of allocating 15 percent of public expenditure to health that was agreed among African Union countries in 2001.  But that is only part of the picture, and it is important to move beyond the familiar vocabulary of resource-scarce settings to ask why some settings are resource-scarce and others not.  Those of us who do so in the academic world are considerably fewer in number than those who take such scarcities as given.  We are not nearly as well funded – the Trades Union Congress and people thrown out of work when transnational corporations relocate contract production from Mexico to China do not fund a lot of research – and (no coincidence) at greater risk of precarious employment.

Nevertheless, we continue to insist that intellectually responsible answers in the global frame of reference must start with colonialism and its legacies.  They must consider more recent historical episodes such as the devastating legacy of structural adjustment programmes that – according to Nobel laureate and former World Bank chief economist Joseph Stiglitz – resulted in ‘a lost quarter-century’ of development in Africa.  A recent study shows that although the World Bank and International Monetary Fund abandoned the vocabulary of structural adjustment around the turn of the century, the relevant practices continue with little change.  Meanwhile, the logic of structural adjustment has been replicated in the decade of (selective) austerity programmes that followed the financial crisis.  Inquiries into the origins of resource scarcity must further consider such factors as the ‘disequalising’ effects of a global economic order that provides abundant opportunities for capital flight, which starves even countries with well intentioned governments of resources needed for health, education, and economic development.

In the contemporary policy environment, one element in particular connects health inequalities around the world:  neoliberalism or, in the words of billionaire investor George Soros (what irony), market fundamentalism. Neoliberalism as a set of norms that guide and justify policy, ultimately equating financial worth with moral worth, conceptually links the dynamics of structural adjustment and capital flight with the fates of the victims in New Orleans and Kensington and Chelsea, and with those of working people quietly living shortened lives of desperation in Stockton-on-Tees (and other deindustrialised communities in the UK, the United States, and elsewhere).  The connections are not only conceptual of course; they are also material and institutional, operating through such channels as campaign money, capital flight and the networks of power and privilege epitomised by the World Economic Forum, where the global super-elite meet to worry about the threat posed to their fortunes by the rest of us.

Tracing these connections, in contexts half way around the world or as close to home as our local NHS trust in England, is time-consuming and often emotionally draining.  Yet the enterprise is essential to the larger task of demonstrating that neoliberalism is, ultimately and inescapably, deadly – a point clearly understood by at least one media outlet reporting on the Grenfell Tower fire.  Well spotted, say I.

Especially when the context involves social determinants of health, the question of how much evidence suffices to demonstrate this is contested terrain.  Sir Michael Marmot (who chaired the landmark WHO Commission on that topic) and colleagues wrote in 2010 that: ‘It is hard to see how even ideologically driven commentators could think that having insufficient money to live on is irrelevant to health inequalities’.  This is preternatural optimism, as any observer of recent British health inequalities policy will realise, but further discussion must be left for another posting.

 

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Author’s apology:  a few of the hyperlinks in this posting may lead to articles that are behind a paywall.  If you have trouble accessing these, please contact me and I will ensure that you obtain a copy.

Some of the major challenges faced by Pakistan include high maternal and child mortality rates, increasing double burden of communicable and non communicable diseases, poorly funded and poorly governed health systems, lack of accountability and corruption and low health literacy rates, along with ongoing challenges like terrorism and susceptibility to natural disasters like floods and earthquakes. Pakistan spends less than 2% of her GDP on healthcare services. This results in majority of population spending out of their own scant resources

By Nighat Khan

Affiliate at Global eHealth Academy University of Edinburgh

Challenges in Universal Health Coverage in Developing Countries like Pakistan

 

Article 25 of United Nations’ Universal Declaration of Human Rights 1948, states that “Everyone has the right to a standard of living adequate for the healthand well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.” (1).

More recently out of the 17 Sustainable Development Goals (SDGs) adopted by the UN General Assembly in September 2015, SDG 3 focuses on health with target 3.8 of SDG 3 referring to achieving universal health coverage (UHC). The latter includes financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all, as the foundation stone for achieving all health related targets (2).

After seven decades of the Declaration, the dream of universal coverage (UHC) and health as a basic human right remains a distant reality for majority of inhabitants of the globe in countries like Pakistan. Poor access to promotive, preventive, curative and rehabilitative services of minimal acceptable quality is evident from country profilereports by the WHO, World Bank and UNESCO (3,4 &5).

According to one study, out-of-pocket payment for healthcare leads to an estimated 44 million households to suffer financial burden and 25 million are pushed into poverty each year (6).

More recently WHO reported that nearly 100 million people are pushed into extreme poverty due to health care expenses and over 800 million spent at least 10% of their household budget on health (7).

Protection from high cost of healthcare facilitates better access to healthcare as well as reducing depletion of their poor financial reserves (8).

Countries where public health service delivery is functioning well, with access to acute and chronic care for adults and children and better availability of medicines, show encouraging outcomes, with less out-of-pocket spending.

In a recent series of Lancet, Hogan and coworkers (9), identified four focus areas, i.e. reproductive, maternal, neonatal and child health (RMNCH), communicable diseases, non- communicable diseases (NCDs), service capacity and access and to reach UHC service coverage index, and used geometric means across these four areas. Major inequalities were reported in the baseline estimates across the countries.

The case of Pakistan

Some of the major challenges faced by Pakistan include high maternal and child mortality rates, increasing double burden of communicable and non communicable diseases, poorly funded and poorly governed health systems, lack of accountability and corruption and low health literacy rates, along with ongoing challenges like terrorism and susceptibility to natural disasters like floods and earthquakes. Pakistan spends less than 2% of her GDP on healthcare services. This results in majority of population spending out of their own scant resources (10).

In Pakistan, like any other developing country, health care provision is by public and private sectors. Studies suggest that it is the poor access to public health services, lack of availability of essential medicines and supplies as well as most importantly the perceptions about substandard quality services by public institutions which account for resorting to expensive private medical services. Expensive non-generic essential medicines are purchased for fear of generic being less potent or counterfeit.

Pakistan is one of the six countries with highest maternal and child mortality rates, in contrast to some improvements globally. Pasha et al (11), reported major discrepancies within the country with some regions like Thatta, a southern coastal town, had maternal mortality almost three times higher than other regions (313/100,000 versus 116/100,000). Stillbirth (56.5 versus 22.9/1000 births), neonatal mortality (50.0 versus 20.7/1000 live births) and perinatal mortality rates (95.2 versus 39/1000 births) were twice as high in the region as compared to national rates. Despite the official claims Pakistan is the only country in Global Network where maternal mortality has increased from 231/100,000 to 353/100,000 over their period of study. Despite the tall official claims, urban-rural health inequities are glaring and require urgent official attention.

In another recent study Zakar et al (12), reported only 36.6% women made four or more antenatal visits, 59% were attended by skilled birth attendant and 55.3% gave birth in a health care facility. The authors reported positive correlation between education and socio-economic status of the woman and negative correlation with birth order and her own autonomy. Their findings reemphasize the inequities between rich and poor women

Deforestation in many areas of Pakistan has led to massive monsoon floods since 2010, which pushed the goals to improve the health indicators further down by diverting the existing resources to rehabilitation and disaster management. Geographically the country lies on earthquake fault lines (13). In 2005, Pakistan suffered from one of the deadliest earthquakes in the northern regions killing 80,000 to 100,000 people with extensive damage to already fragile infrastructure like roads and bridges. The rehabilitation is still incomplete after over a decade (14).

Poor health literacy and ancient taboos and practices bar an individual from seeking existing services. LMICs are fraught with such socio-cultural beliefs. It becomes State’s responsibility to provide basic accurate health information through mass campaigns using various resources like information technology, including mobile messages and social and electronic media.

Pakistan is one of the few countries which failed to eradicate polio despite the availability of polio vaccine. Various misconceptions regarding polio vaccination in Pakistan led to a number of children not being vaccinated by parents. If concerted efforts were made by the state to ensure that accurate information regarding the safety of vaccine is imparted to her citizens, we may never had see polio-stricken children in Pakistan (15,16).

Climate changes and water shortages in a traditional agricultural state is leading to rapid urbanization. As a result the infrastructure is under stress in major cities likes Karachi and Lahore due to huge internal migration of the population. Job competition and unemployment has led to drastic increase in urban crime rates.

Rapid urbanization and a growing middle class is accompanied by adoption of urban lifestyle. Rise in Non Communicable Diseases (NCDs) like hypertension, diabetes, cardiovascular, mental illnesses (for e.g. depression) and cancer, while the country is still struggling to fully eradicate infectious diseases and vector borne outbreaks is double jeopardy for countries like Pakistan (17).  It is predicted that by 2020, NCDs will cause seven out of ten deaths in LMICs (18). Chronic infections like TB and malaria, dengue and chikungunya outbreaks continue to exact a heavy toll on fragile health systems in many LMICs.

Counterfeit medicines have swamped the country’s market with dangerous trends of self- medication.There is no official pharmacovigilance system in the country. Pharmaceutical regulation is carried out by Drug Regulatory Authority of Pakistan (DRAP). National essential medicine list (NEML), which is based on the WHO standards to encourage generic prescribing, is followed only in public sector hospitals, while private sector prescribers are heavily influenced by pharmaceutical marketing. Pharmaceutical companies have promoted a culture of corruption amongst physicians with the result that the prescribing of generics is very poor. Concerns have been raised about over prescribing and self-medication by the patients, as they can buy almost all medicines with or without prescriptions (19).

After a constitutional amendment in 2011, health and education services were decentralized to the five provincial governments rather than a federal ministry (20). While this was supposed to serve as a source of healthy competition amongst these provinces, leading to improvement in services, it has led to five more potential settings for corruption.

No service delivery is successful without strong and committed leadership. Rwanda has been able to bring positive changes in its health indicators after long drawn conflict, due to committed leadership (21).

For past decade and a half the province of Khyber-Pakhtoonkhwa (KPK) in north-west region of Pakistan had one of the highest rates of terrorist attacks in the country. Girl education and women empowerment suffered the most in hands of terrorists. Effective provincial leadership since 2013, led not only to improvement in law and order situation but a concerted focus on state schools and healthcare facilities led to drastic improvements in child enrolment in state schools and health services, within the same budgetary constraints.

Some positive steps have been taken in provinces like Khyber-Pakhtoonkhwa province where a health insurance scheme has been initiated along with financial incentive for expectant mothers for antenatal visits and child vaccination (22).The province successfully carried out a tree plantation drive and planted nearly one billion trees in the flood prone regions of the province (23).

It cannot be stressed enough here that strong leadership and commitment, proper accountability and political will underpin the foundation of states’ attempts to provide UHC. The natural disasters are inevitable but better preparedness and anticipation of these dangers cause fewer loss of lives of citizens.

 

References

1. http://www.un.org/en/universal-declaration-human-rights ( Accessed December 10th, 2017)
2. http://www.un.org/sustainabledevelopment/sustainable-development-goals (Accessed December 10th, 2017)
3. http://www.who.int/gho/publications/world_health_statistics/2017/en/ (Accessed December 12^th ,2017)
4. https://data.worldbank.org/topic/health (Accessed December 12^th ,2017)
5. https://data.unicef.org/resources/resource-type/country-profiles/ (Accessed December 12^th ,2017)
6. Jacobs, B., Bigdeli, M., Pelt, M.V., Ir, P., Salze, C. and Criel, B., 2008. Bridging community‐based health insurance and social protection for health care–a step in the direction of universal coverage? Tropical Medicine & International Health, 13(2), pp.140-143.
7. http://www.who.int/mediacentre/factsheets/fs395/en/ (Accessed December 12^th ,2017)
8. Xu, K., Evans, D.B., Carrin, G., Aguilar-Rivera, A.M., Musgrove, P. and Evans, T., 2007. Protecting households from catastrophic health spending. Health affairs, 26(4), pp.972-983.
9. Hogan, D.R., Stevens, G.A., Hosseinpoor, A.R. and Boerma, T., 2017. Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services. The Lancet Global Health.
10. http://www.worldbank.org/en/country/pakistan/overview (Accessed December 12^th ,2017)
11. Pasha, O., Goldenberg, R.L., McClure, E.M., Saleem, S., Goudar, S.S., Althabe, F., Patel, A., Esamai, F., Garces, A., Chomba, E. and Mazariegos, M., 2010. Communities, birth attendants and health facilities: a continuum of emergency maternal and newborn care (the Global Network’s EmONC trial). BMC pregnancy and childbirth, 10(1), p.82.
12. Zakar, R., Zakar, M.Z., Aqil, N., Chaudhry, A. and Nasrullah, M., 2017. Determinants of maternal health care services utilization in Pakistan: evidence from Pakistan demographic and health survey, 2012–13. Journal of Obstetrics and Gynaecology, 37(3), pp.330-337.
13. Khan, S.R. and Khan, S.R., 2009. Assessing poverty–deforestation links: Evidence from Swat, Pakistan. Ecological Economics, 68(10), pp.2607-2618.
14. Rathore, F.A., Farooq, F., Muzammil, S., New, P.W., Ahmad, N. and Haig, A.J., 2008. Spinal cord injury management and rehabilitation: highlights and shortcomings from the 2005 earthquake in Pakistan. Archives of physical medicine and rehabilitation, 89(3), pp.579-585.
15. Khan, M.U., Ahmad, A., Aqeel, T., Salman, S., Ibrahim, Q., Idrees, J. and Khan, M.U., 2015. Knowledge, attitudes and perceptions towards polio immunization among residents of two highly affected regions of Pakistan. BMC Public Health, 15(1), p.1100.
16. Murakami, H., Kobayashi, M., Hachiya, M., Khan, Z.S., Hassan, S.Q. and Sakurada, S., 2014. Refusal of oral polio vaccine in northwestern Pakistan: a qualitative and quantitative study. Vaccine, 32(12), pp.1382-1387.
17. Gowani, A., Ahmed, H.I., Khalid, W., Muqeet, A., Abdullah, S., Khoja, S. and Kamal, A.K., 2016. Facilitators and barriers to NCD prevention in Pakistanis–invincibility or inevitability: a qualitative research study. BMC research notes, 9(1), p.282.
18. World Health Organization, 2013. Global action plan for the prevention and control of noncommunicable diseases 2013-2020.
19. Atif, M., Ahmad, M., Saleem, Q., Curley, L. and Qamar-uz-Zaman, M., 2017. Pharmaceutical Policy in Pakistan. In Pharmaceutical Policy in Countries with Developing Healthcare Systems(pp. 25-44). Springer International Publishing.
20. Nishtar, S., Boerma, T., Amjad, S., Alam, A.Y., Khalid, F., ulHaq, I. and Mirza, Y.A., 2013. Pakistan’s health system: performance and prospects after the 18th Constitutional Amendment. The Lancet, 381(9884), pp.2193-2206.
21. Sekabaraga, C., Diop, F. and Soucat, A., 2011. Can innovative health financing policies increase access to MDG-related services? Evidence from Rwanda. Health policy and planning, 26(suppl_2), pp.ii52-ii62.
22. Ramsay, S., 2015. Implementing the WHO Safe Childbirth Checklist in Pakistan. A new approach to reducing maternal and newborn mortality in Khyber Pakhtunkhwa.
23. Kharl, S. and Xie, X., Green Growth Initiative will lead toward sustainable development of natural resources in Pakistan: an investigation of “Billion Tree Tsunami Afforestation Project”.

 

Health Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Health Breaking News: Link 270

 

Global Summit On IP And Access Discusses Impact Of TRIPS-Plus Measures On Public Health 

Heads Of State At Davos’ Door: Trump, Modi, Macron, May 

PhRMA letter on Colombia Resolution 5246 

Global health can’t wait: Can the “Macron momentum” deliver in 2018? 

Why 2018 global growth will be strong, and why there is still cause for concern, in 10 charts 

Searching For Stability: The Political Future Of The Affordable Care Act 

New DFID chief shows tougher side 

Expert Panel charts a road map for WHO’s engagement on transparency and R&D 

Visualizing an alternative biomedical R&D system 

Conferenza Nazionale della Cooperazione allo Sviluppo, Roma 24-25 gennaio 2018 Auditorium Parco della Musica 

XV CONGRESSO NAZIONALE SIMM 2018: Dinamiche di salute e migrazioni tra continuità e nuovi bisogni. Catania, 18-20 aprile 2018  

Untangling inequalities: why power and intersectionality are essential concepts 

China’s Emerging Role In Global Health  

Europe’s largest pension fund to drop tobacco and nuclear weapons investments 

Commission urges Greece to implement smoking ban in public places 

Harmonized clinical trial methodologies for localized cutaneous leishmaniasis and potential for extensive network with capacities for clinical evaluation 

Pakistani database to help deal with genetic disorders 

Should your NGO hire a data scientist? 

Our Flawed Health Care System: Philanthropy Can Give Consumers A Voice, A Stage, And A Seat At The Table 

Philanthropy Forecast, 2018: Trends and Issues To Watch 

Kenya launches drugs manufacturing plant to ease imports 

What were the biggest outbreaks of 2017? 

Funding outlook shifts in fight against antimicrobial resistance 

Lawmakers discuss policies to accelerate global energy transformation 

Sustainable Energy Critical for Achieving Overall Goals of Paris Climate Agreement 

EU’s air pollution pariahs summoned to Brussels 

Are GMOs the key to global food security? 

EU Parliament ends palm oil and caps crop-based biofuels at 2017 levels 

The struggle to survive South Sudan’s hunger season 

Uncharted Waters : The New Economics of Water Scarcity and Variability 

Health Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Health Breaking News: Link 269

 

Who actually funds the UN and other multilaterals? 

5 African crises to watch in 2018 

Business leaders aren’t backing up their promises on sustainable development goals 

A bottom-up approach to achieving UN SDGs 

On the Docket for Development in 2018: CGD Experts Weigh in 

ODA and Private Sector Instruments: new rules raise major concerns 

Co-Creating Solutions to Prevent the Preventable and Treat the Treatable 

Madagascar can build stronger health systems to fight plague and prevent the next epidemic 

WHO Director-General: invest in health to end plague in Madagascar 

Diphtheria’s Resurgence Is a Lesson in Public Health Failure 

Diphtheria vaccination held in Cox’s Bazar schools 

Drug-resistant infections are a looming challenge around the world 

WHO prequalifies breakthrough vaccine for typhoid 

5 Reasons the Global Gap in Rotavirus Vaccine Access is Shrinking 

Discovery of novel, orally bioavailable, antileishmanial compounds using phenotypic screening 

Ten failings in global neglected tropical diseases control 

What about drinking is associated with shorter life in poorer people? 

The Modern Slavery Act – are we aiming too low? 

The great Oxfam end of year quiz 2017 

The Data Revolution Should Not Leave Women and Girls Behind 

Hospital Detentions for Non-payment of Fees: A Denial of Rights and Dignity 

African efforts are leading sustainable changes 

Nigeria: Bill and Melinda Gates Foundation to Help Nigeria Repay U.S.$76 Million Polio Facility 

Philanthropy Forecast, 2018: Trends and Issues To Watch 

UN Environment and WHO agree to major collaboration on environmental health risks 

Climate change: Trump says US ‘could conceivably’ rejoin Paris deal 

Kenyan innovation takes plastic bags out of forestry 

UK government spells out plan to shut down coal plants 

Clean Energy Sources Manage to Cut Electricity Bill in Chile 

Africa’s planned dams could disrupt electricity supply 

 

 

 

 

 

 

 

 

 

Universal Health Coverage (UHC) is a human right deeply rooted in the social-justice approach to health. Unfortunately, in several Low and Middle Income Countries (LMICs) it is still a mirage at a time when its achievement is not obvious in the High Income Countries (HICs) either. As such, UHC rests on everyday fight with uncertain results

By Pietro Dionisio

EU health project manager at Medea SRL, Florence, Italy

Degree in Political Science, International Relations Cesare Alfieri School, University of Florence, Italy

The Uncertain Status of UHC and the Latent Balance of the Social-Justice Approach to Health

 

Since the Alma-Ata Declaration, in 1978, the health and human right movement entered the international stage and rooted in the early 1990s in response to the HIV/AIDS epidemic.

According to the movement, the link between health and human rights means that everyone should have the right to the highest attainable standard of physical and mental health. As such, the definition of a healthcare system should be driven by standards including adequate infrastructure availability, high quality services provision, transparent health information, as well as the active participation by individuals and communities in decisions affecting health, non-discrimination, and other relevant mainstays.

The human right to health is protected in several declarations and covenants. Among these, the “Universal Declaration of Human Rights” and the “International Covenant on Economic, Social and Cultural Rights” maintain that healthcare system must be accessible to everyone (child, mothers and disadvantaged people first), while being equipped to prevent catastrophic health conditions.

A social-justice approach to health could actually safeguard the right to access health services and goods.

This approach requires a full understanding of the socio-economic, cultural and political contexts and their implications for healthcare services and resource allocation according to the collective needs. It also requires a commitment to share and learn from the communities and local experts. As such, the role of the central governments in putting aside the industry interests for the benefit of the collectivity should be emphasized.

In the face of this equity-based ideal approach, a grim reality shows how Universal Health Coverage (UHC) and a social-justice approach to health still lag behind as hardly achievable conquests for million people worldwide.

Concerning this, few examples from Asia, Africa and North America are enlightening.

In India the cost of rolling out UHC would actually be only 0.28% of Country’s GDP (the current GDP is estimated at $ 2,26 trillion), and well within the Country’s health expenditure. However, a mix of misplaced priorities, adding to a lack of evidence-based decision-making, are thwarting the achievement of a UHC system. For instance, while more new health insurance packages came-up in the last year, their utility is frustrated by distant health facilities and no trained healthcare workers providing services. The situation is so critic that despite India has become the global pharmacy for myriad inexpensive drugs, 63 million of its people sink into poverty each year because of unaffordable healthcare costs.

Among other issues, resources misallocation is an usual practice in African countries. As such, a huge number of African people look at UHC as a mirage, though for some critical health services and interventions an impressive progress in coverage has been registered. The most rapid improvement has been the change in supply of insecticide treated bed nets for children, which increased on average by about 15% per year between 2006 and 2014. All of the maternal health indicators have also improved over the last 20 years. Antenatal care visits and skilled birth attendance have also both increased from about 40% in 1990, to around 60% in 2014. In spite of this, wide disparities remain within countries including relevant to skilled birth attendants, treatment regimens for severe illnesses, and to access to more complex interventions. Even for schedulable routine services such as immunizations, very few countries are achieving universal coverage since the Regional immunization coverage, irrespective of its rise from 57% in 2000 to 76% in 2015, has remained below the expected target.

Furthermore, the UHC achievement in several African countries is undermined by the poor quality of care meaning, among other things, significant deficits in essential drugs and medical equipment availability, as well as in the knowledge and practices of frontline health workers.

However, if India and African countries cases are emblematic for LMIC, the most striking case is the U.S one. The former President, Barack Obama, implemented the Affordable Care Act, nicknamed Obamacare, as the first concrete American step towards the launching of a UHC system in the Country.

The Trump’s administration is endangering the Act and the President has begun a personal fight against the Law. In 2017, He and Republicans failed in their effort to cut Medicaid but they are going to try again in 2018. In fact, the strategy is to dismantle it on his own by scrapping subsidies to health insurance companies that help pay Out-of-Pocket Payments (OOPs) of low-income people, thus letting insurance premiums soar and fleeing insurance companies from the health law’s online marketplaces.

This inexplicable attitude towards the Act is grounded on conviction that healthcare entitlements are the big drivers of the U.S. debt. However, this approach is baffled by the propensity of many States, such as Maine and Virginia, for vowing to expand Medicaid.

UHC cannot be considered an once and for all achievement. The contexts mentioned above are just few and superficially analyzed examples on how the UHC issue is both relevant and critical as an often forgotten people right. As such, no wonder that even in those countries professing democratic attitude and having the needed cultural and economic resources UHC is a hardly achievable goal.

Accomplishing UHC requires properly equipped policies in place. In this regard, a focus on providing good coverage for a well-defined basket of benefits would be preferable to shallow coverage for any service with high patient cost sharing.

Financial sustainability needs to be built into the system from the start, including by exploring options to broaden revenue sources and prioritize the appropriate use of resources. Reforms in delivery systems should prioritize investment in non-hospital services, high-quality primary and community care services, and in public health programs. Nonetheless, these requirements often crash against the political will of decision makers thus making impossible stemming the tide of health inequities.

Tough progress results on a world scale are clear, the blatant examples here show how much has yet to be done and how, even in HICs, results not followed by a strong political will risk to be aleatory in the long run.

 

 

 

 

Health Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Health Breaking News: Link 268

 

Ten humanitarian crises to look out for in 2018 

2018 Brings No End to Violence Against Rohingya as Refugees Continue to Flee to Bangladesh 

Human Rights Reader 432 

9 Stories that will Drive the Global Agenda in 2018 

EU looks ahead to 2018 as budget negotiations loom 

BRICS 2018: South Africa sets the pace 

The WHO and New Public Management: Value for Money or heading for a Cruel Disappointment? 

WHO accused of ‘institutional ageism’ over five-year work programme  

MSF: 2018 wishlist 

Drug Policy: The Year In Review, And The Year Ahead 

NIH wants to give Gilead a new, government subsidized monopoly on CAR T technology, this one for CD-30 proteins 

Chilean Cámara de Diputados Votes Overwhelmingly To Proceed With Compulsory Licenses for HCV Drugs 

Putting More Value Into Biopharmaceutical Value Assessments  

Is Obamacare Harming Quality? (Part 1) 

Action on Smoking & Health (ASH): the big picture 

Smoking bans make married people happier than anyone else 

WHO: Curb ads for junk food, sweets and beer to fight obesity 

W.H.O. Approves a Safe, Inexpensive Typhoid Vaccine 

From Polio To Poverty To Sex Ed: 9 Predictions For 2018 

2018 World TB Day Theme Announced 

Race To Eradicate Guinea Worm And Polio Experienced Roadblocks In 2017 

Drug-resistant infections are a looming challenge around the world 

Sexually transmitted infections—Research priorities for new challenges 

China closes its domestic ivory market 

The Gates Foundation Gives Big for Climate Change. Does It Have the Right Priorities? 

Forty per cent of global e-waste comes from Asia 

Ethiopian herders get automated weather stations 

Six member states call for glyphosate alternatives, exit plan 

UN ready to pursue new treaty to protect high seas 

2017 Was a Year of Record-Breaking Climate Events 

Authoritative insights by 2017 PEAH contributors added steam to debate on how to settle the conflicting issues that still impair equitable access to health by discriminated population settings worldwide

by  Daniele Dionisio*

PEAH – Policies for Equitable Access to Health 

2017: a Year in Review through PEAH Contributors’ Takes

 

Now that 2017 just came to its end, I wish to thank the top thinkers and academics who enthusiastically contributed articles over the year. Their authoritative insights meant a lot to PEAH scope while adding steam to debate on how to settle the conflicting issues that still impair equitable access to health by discriminated population settings worldwide.

Find out below a list of links and relevant summaries:

Brexit can be Hazardous to our Health

By Ted Schrecker  Professor of Global Health Policy, Durham University, UK

...health researchers and professionals are (or should be) asking how Brexit will, and could, affect public health.  Among the questions, informed by a political economy perspective on health and its social determinants, five stand out.One needs to remind oneself that the last word in Albert Camus’ famous essay about suicide is ‘hope’.  But it is hard to sustain in these times

Substantive Work of WHO, particularly in  Relation to Health Systems Development, Should Counter the Privatization Agenda, but Does It?

By Claudio Schuftan People’s Health Movement – PHM

Donor countries (the US in particular) continue to push WHO towards working with industry through ‘multi‐stakeholder partnerships’, rather than giving WHO the chance to implement regulatory and fiscal strategies that could make a real difference. Moreover, bilateral donors (and big philanthropies) demand WHO provides data according to their particular interests. Therefore, the types of data produced by WHO (and other UN agencies) are greatly influenced by a donor mandate that goes beyond the simple compilation of country-reported statistics

AFEW–Tajikistan Has Unique HIV Rapid Testing Point in the Country

By Olesya Kravchuk Communications Officer at AFEW (AIDS Foundation East-West) International

 Tajikistan is among the countries where HIV prevalence has increased by more than 25% over the last 10 years. In Tajikistan the number of sterile needles and other commodities for people who inject drugs per year is still very low. AFEW-Tajikistan is the only NGO in the country that has HIV voluntary counselling and rapid testing

Public-private Partnership Paradox: the Case of Gavi and Health System Strengthening

By Renée de Jong  Junior Global Health Advocate at Wemos Foundation  

The WHO model for Health System Strengthening (HSS) includes improving its six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes.... It appears that Gavi maintains a very different interpretation of HSS....vhere the interconnectedness between the building blocks is hardly taken into account

Inclusive Communication as a Mechanism to Improve Equity of Access in Health Systems

By Alex Henriquez   Research Analyst at Healthcare Improvement Scotland / Scottish Health Council

 A really equitable health system is that that ensures that people with special needs also have fair access to healthcare. This is especially relevant for people with communication needs, who may experience more barriers of access to healthcare services. Inclusive communication is an approach to communication in which information and its understanding are made accessible to everyone

Creating and Maintaining Fair, Trustworthy and Sustainable Research Collaborations

By Lauranne Botti, Manager, and Carel Ijsselmuiden, Executive Director, COHRED’s Research Fairness Initiative (RFI) 

The Research Fairness Initiative (RFI) responds to the increasing understanding of the importance of partnerships and SDG 17 by ensuring that institutions around the world can have access to an evidence-base on how to create and maintain fair, trustworthy and equitable partnerships in research and innovation

From Animosity to Murder: the Spectrum of Workplace Violence against Physicians

By Lawrence C. Loh  Dalla Lana School of Public Health, University of Toronto, and Director of Programs at The 53rd Week Ltd 

The observed increase in violence against physicians is a clear trend, supplemented by no end of anecdotal stories of physician disrespect; spitting, verbal, and physical assault, online harassment. Many of these would be criminal if done against a transit operator, but such behaviour seems to be increasingly tacitly accepted as part of a doctor’s craft

AMR as a Key Issue for BRICS and Low-Middle Income Countries

By Garance Fannie Upham Chief Editor AMR-Times Geneva, Switzerland 

Antimicrobial resistance (AMR) poses a serious threat to public health, growth and global economic stability. We affirm the need to explore in an inclusive manner to fight antimicrobial resistance by developing evidence-based ways to prevent and mitigate resistance, and unlock research and development into new and existing antimicrobials from a G20 value-added perspective, and call on the WHO, FAO, OIE and OECD to collectively report back in 2017 on options to address this including the economic aspects. In this context, we will promote prudent use of antibiotics and take into consideration huge challenges of affordability and access of antimicrobials and their impact on public health 
G20 Leaders Communique, Hangzhou Summit 4-5 September 2016, point 46

Treatment Affordability and the Entry of Biosimilars

By Fifa Rahman Postgraduate Researcher, University of Leeds, UK

 Uptake of biosimilars, i.e. cost saving highly similar versions of the stiff price reference biologic products, has been slow throughout most of Europe and the rest of the world. Without express and official government policy purchasing and recommending biosimilars, doctors will not use biosimilars and the resulting cost savings cannot be made

Is There a Fair and Equitable Access to Safe Blood Transfusion Products in the World?

By Yves Charpak MD, Public Health Specialist, PhD in Epidemiology 

Blood transfusions are today safer than any other treatment procedures today in the richest part of the world. But it is less true elsewhere, where the role of unsafe blood transfusions on major dramatic epidemic situations is certainly high although not so well documented: hepatitis B and C and E... and even HIV...it is estimated by WHO (The World Health Organization) that up to 80% of the world population who need safe blood products don’t get them

The Promise of PrEP for HIV Prevention

By Marieke Bak Research Intern at AFEW International 

A large international study among gay men and transgender women,the so-called iPrEx trial, suggested that pre-exposure prophylaxys (PrEP) by a tenofovir/emtricitabine combination can reduce the risk of HIV infection by at least 92% when the pills are taken consistently. Other trials subsequently confirmed PrEP effectiveness. PrEP is not intended as a stand-alone intervention, but rather as part of a multi-faceted strategy involving the use of condoms as well as regular follow-ups including for HIV and other sexually transmitted diseases testing

SOS a la Situation Humanitaire dans les Provinces du Tanganyika, du Kasai-Kananga, du Nord-Kivu et du Sud-Kivu en Republique Democratique du Congo/DRC

By Alphonse Kitoga Secretary General, Grands-Lacs en Action pour la Paix et le Développement Durable -The Great-Lakes in Action for Peace and the sustainable Development GLAPD_ Africa, asbl 

La République démocratique du Congo continue à être confrontée à une crise humanitaire de très grande ampleur, et cela depuis plus de deux décennies, bien que la grande majorité du territoire nationale demeure stable, mais les provinces du Sud-Kivu, du Nord-Kivu, du Tanganyika et du Kasaï central sont les théâtres des tueries, massacres et violations répétitives des droits de l’homme à l’heure actuelle

The Uganda’s “Narcotic Drugs and Psychotropic Substances (Control) Act” and how it impacts on Public Health and Human Rights

By Muhwezi Edward Harm Reduction Counselor, Uganda Harm Reduction Network 

The essence of the Uganda's Narcotic Drugs and Psychotropic Substances (Control) Act (NDPSA) is to treat people who use and inject drugs (PWUIDs) as criminals who need to be locked up instead of viewing them as human being in need of assistance. The criminalisation of drug use has had the effect of limiting the range of medical  intervention available and accessible to PWUIDs in both private and public facilities. There is no comprehensive facility for the provision of public health services to PWUIDs. There is also no treatment available within Uganda for people who are on drugs and need critical and urgent medical attention like opioid substitution therapy. And there is a direct link between the criminalisation of drug use and HIV/AIDS as well as mental health challenges

U.S.  Philanthrocapitalism and the Global Health Agenda: The Rockefeller and Gates Foundations, Past and Present

By Anne-Emanuelle Birn  Professor of Critical Development Studies, University of Toronto, Canada. and Judith Richter Affiliated Senior Researcher, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland 

Collective activism to overturn philanthrocapitalism’s hold on global health is an urgent necessity. This effort should draw from, and build upon, the resistance to the UN’s promotion of “multi-stakeholder partnerships” and neoliberal global restructuring since the 1990s. Those actors who have contributed either unwittingly, or through silent assent, or even with active collaboration, to the global health plutocracy also share responsibility in re-democratizing it

Novo Nordisk’s ‘Changing Diabetes’ Aid Programme Exacerbates Issues of Insulin Access, and Must End for Compulsory Licensing to be Effective

By Rebecca Barlow-Noone Student, University of Leeds, UK 

To establish sustainable access to insulin in Cameroon, it is an imperative that reliance on pharmaceutical aid is revoked in favour of prioritising compulsory licensing and biosimilar usage. Until Novo Nordisk’s monopoly is challenged, patients will remain in uncertainty over access to insulin and essential equipment

The Injurious TRIPS Relationship between Human Rights and Access to Medicine in Uganda

By Bukenya Denis Joseph Human Rights Research Documentation Centre (HURIC) Kampala, Uganda 

The issue to ponder about is who is this TRIPS meant to protect? Is it protecting the LDCs or the Developed Countries? The views I am trapping out there imply that the Agreement intends to protect creativity and the manufacturers so that they can expand their potential and motivate them in research. The least developed countries, Uganda inclusive need time to overcome the constraints preventing them from creating viable technological bases and Intellectual Property (IP) Laws. The IP Laws in Uganda are so muddled that they curtail the availability of affordable generic drugs in the country. Uganda as a nation would use a good training to the officers of the law in the IP section and also there is a need for increased materials on IP to be circulated amongst the health rights activists and advocates

Resistance to Isoniazid, Pyrazinamide and Fluoroquinolones in Patients with Tuberculosis

By Matteo Zignol and Mario Raviglione Global Tuberculosis Programme, World Health Organization 

Testing of resistance to isoniazid, pyrazinamide and fluoroquinolones is of paramount importance to guide treatment decisions and ensure that patients receive the best standard of care and have the highest chances to be cured. In this report the authors present an overview of the prevalence of resistance to isoniazid, pyrazinamide and fluoroquinolones and discuss the need of rapid diagnostics to detect resistance to these drugs

The Unacceptable Inequity of Orphan Drugs Access in Europe:a Call for Urgent Policy Change

By Katherine Eve Young MD, MSc, MPH Manager Pricing & Market Access Creativ-Ceutical  and Mondher Toumi Professor of Public Health University of Aix-Marseille, and CEO at Creativ-Ceutical 

The current EU policy has a low ability to align access to orphan drugs across different Member States, leaving high inequity, especially between richer and poorer countries...The variation stems from the fact that although the marketing authorisation of drugs is at the European level, pricing and reimbursement decisions, and therefore patient access, are on a national level...Perhaps, to assure equal access to orphan drugs for all rare diseases, an EU-wide procurement should be considered...The EU can procure orphan drugs centrally and charge the MS based on their affordability while setting a fixed pan-European list price. Ultimately this will result in a differential pricing scheme

Wide Area Malaria Vector Suppression

By Richard Howe  Application Dynamics School of hard knocks, aviation trades, pilot and aircraft mechanic Punta Gorda, Florida USA 

Richard Howe writes: Only one aircraft equipped with a pair of high pressure aerosol generators would be capable of treating over one million acres per night, using only 1/10 of the recommended amount of insecticide

Environment and Health in the Anthropocene: Towards Holistic Understandings and Policy Responses

By Ted Schrecker  Professor of Global Health Policy, Newcastle University, UK  Co-editor, Journal of Public Health 

The idea of the 'Anthropocene' as an epoch with unprecedented scale, scope and interactions of multiple human impacts on the biosphere, can serve as a 'window' into crucial issues related to the connections among climate change, environment and health. In such contexts, integration of the fields of environmental ethics, public health ethics and bio(medical) ethics is needed

Teenage Pregnancy in Nicaragua Towards Achieving the Sustainable Development Goals (SDGs)

By Clara Affun-Adegbulu  Intern and Research Assistant at Institute of Tropical Medicine in Antwerp (ITM) 

Nicaragua currently lags behind other countries in the LAC region as for the decline of teenage pregnancies, and although the adolescent fertility rate fell sharply between 1990 and 2000, the decline has slowed considerably

 Zero Tolerance for Female Genital Mutilation

By Jitendra Panda Country Director at Health Poverty Action Universitat Oberta de Catalunya, Somalia 

Over 200 million girls and women living across 30 countries mainly in Africa as well as Middle-East and Asia share a common misery called genital mutilation / excision also known as female circumcision or Female Genital Mutilation (FGM). An additional 30 million girls are on the verge of submitting themselves into this practice in the coming decade.....The true extent of the abuse against children beginning as young as 7 and 9 years is much more than what we see in the numbers

Ready to Use Therapeutic Food from Locally Available Food Ingredients for Children with Severe Acute Malnutrition in India

By Kishore Shintre Food Fortification Consultant, ‘Hamara Prayatan’ (‘Our Efforts’) NGO, New Delhi, India 

Tackling Severe Acute Malnutrition (SAM) among children has been a big challenge faced by several developing nations including India for decades now. Many Indian states have tried to use the packaged Ready to Use Therapeutic Food (RUTF) supplied by a few manufacturers (Indian and overseas) with limited success. Owing to the strong resistance put up by the Government Departments as well as the ‘Anganwadi ‘(Children Community) workers together with other associated people in implementing this effort due to variety of reasons it becomes imperative that we think of alternatives. One of them is producing freshly made RUTF at community level using the locally available food ingredients thereby making the food more palatable, easy to administer without changing the food habits of the children. This article deals with our experiment of creating this RUTF locally at community level tried out by our NGO Hamara Prayatan through research and development carried out at our laboratory

How Can EU Trade Policy Ensure Equitable Access to Medicines?

By Zoltán Massay-Kosubek  Policy Manager for Health Policy Coherence at the European Public Health Alliance (EPHA) 

High medicine prices is a key public health challenge in Europe and Trade policy – an exclusive EU competence can improve or exacerbate the situation. Free Trade and Investment agreements can make easier or harder for European governments to change existing policies to curb the costs of pharmaceuticals. Following a civil society dialogue meeting with EU Trade Commissioner Cecilia Malmström, the author is calling for policy between public health and trade goals on medicines, giving a priority to population health

Global Health Initiatives: What Do We Know About Their Impact On Health Systems?

By Angela Owiti Trainee at Wemos foundation

Global Health Initiatives such as GAVI, GFATM and PEPFAR have incurred criticism of being selective and narrowly defined while placing poor emphasis on - and falling short of - health systems strengthening

The Global Rise of Antibiotic Resistance

By Taye T. Balcha, MD, PhD, MPH Director of Armauer Hansen Research Institute in Addis Ababa, Ethiopia, and Donna A. Patterson, PhD Director of Africana Studies and Associate Professor of History at Delaware State University, USA

The authors turn the spotlight on the root causes of the rise of antibiotic resistance worldwide at a time when a global shortage of antibiotics has been reported by the WHO. Relevantly, the article emphasizes some solutions and calls on philanthropies, non-government organizations, regional institutions, states, and the private sector to work together and defeat the global threat posed by superbugs

Medical Ethics and Social Media in Pakistan

By Muhammad Usman Khan WFP’s Technical Consultant to Planning and Development Department

...Still, the fact that doctors hold power over their patients is indisputable. One of the fundamental duty/responsibility of governments, medical boards and hospital administrations in this regard is/should be to ensure that rules are put into place in order to diminish the probability of any abuse of this power...
 ...there are serious institutional questions that need to be addressed here and patient-doctor interaction is more complicated than we would like to believe...
 ...We need to develop a policy framework within which the various facets of patient-doctor relationship are analysed and which forms the basis for nationwide guidelines that help doctors to understand their roles and responsibility better in their social media interactions...

Latinx Who Reside in the U.S. and Availability of Accessible Health Care Resources

By Karen Mancera-Cuevas MS, MPH, CHES Senior Project Manager at Northwestern University, Feinberg School of Medicine, Chicago USA 

Resolving disparities in access to health care suffered from Latinx who reside in the U.S. includes the ability to understand the barriers created as a consequence of limited acculturation which is further compounded by social determinant of health indicators such as living situation, education, and access to social capital

Examining Public Health Positive Preventative Messaging within the Cambodian Press

By Philip J. Gover Director of Health Squared, Phnom Penh and G.J. Daan Aalders Media Intelligence advisor / entrepreneur, Amsterdam

How we think about and view health problems, and what we do about them as a result, is largely determined by how they are reported by television, radio, newspapers and social media. This article refers to a recent study whereby reports by two Cambodian newspapers across a range of key public health issues were analysed in terms of inclusion or absence of Positive Preventative Messages-PPMs (meaning any additional information enabling the reader to understand how the outcome of a story may have differed). As the authors maintain, PPMs shouldn’t be given up since using only naked facts denies the reader of critical information that could help improve health and health literacy

 

The contributions highlighted above add to PEAH internal articles published throughout the year in English or Italian language. Find the links below to English language collection:

Taking a Pill: Not So Counted On in South Africa

Do the Credit Policies of the WB, IMF & EC Damage Health?

Review: Textbook of Global Health  

The Venezuelan Powder Keg Floods in the Neighboring Countries

Brazil Crippled by Corruption

EU to Get Rid of Big Pharma-friendly SPCs

Repealing Non-Violation Provisions under TRIPS

See also the following links to Italian language articles:

 Oltre il PIL per la Misura del Benessere Globale

 Proteggere i Diritti Terrieri delle Comunità Indigene per Salvare il Pianeta

 Diritto alla Salute: il Ruolo Vitale della Legge

Antibiotico-resistenza: la risposta OMS

 ‘Orphan Drugs’ Business negli USA: un Monopolio Legalizzato

70^ma Assemblea Mondiale OMS Risoluzioni Principali

Sesta Conferenza OMS Ambiente e Salute

Operativi in Italia gli Indicatori BES

 

In the meantime, our weekly page Health Breaking News Links has been serving as a one year-long point of reference for PEAH contents, while turning the spotlight on the latest challenges by trade and governments rules to the equitable access to health in resource-limited settings.

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*Daniele Dionisio is a member of the European Parliament Working Group on Innovation, Access to Medicines and Poverty-Related Diseases. He is an advisor for “Medicines for the Developing Countries” for the Italian Society for Infectious and Tropical Diseases (SIMIT), and former director of the Infectious Disease Division at the Pistoia City Hospital (Italy). Dionisio is Head of the research project  PEAH – Policies for Equitable Access to Health. He may be reached at d.dionisio@tiscali.it  https://twitter.com/DanieleDionisio