Creating and Maintaining Fair, Trustworthy and Sustainable Research Collaborations

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

By Lauranne Botti, Manager

and Carel Ijsselmuiden, Executive Director

COHRED’s Research Fairness Initiative (RFI)

The Council on Health Research for Development-COHRED Group Geneva, Switzerland

Creating and Maintaining Fair, Trustworthy and Sustainable Research Collaborations

The recognition of the benefits that international research and innovation collaborations bring to sustainable development, especially for low- and middle-income countries, is becoming more widely recognized. The UK Department for International Development (DFID) have recently increased expenditure on research, making it clear that there is a growing concern and intention to provide means for capacity building through research collaborations.[1] In addition, the positive impacts brought on by collaborations are emphasized by the fact that Goal 17 of the UN Sustainable Development Goals (SDGs) is on Partnerships, encouraging the creation of inclusive collaborations where partners share goals, values and principles.[2] SDG 17 is a direct result of international development aid reaching new heights – in 2014, a total of $135.2 billion was spent on international cooperation for development, setting a historical record.[3]

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.

What is the RFI?

The RFI is a reporting mechanism for research programmes, institutions and nations that fosters the use and compliance with existing best practice guidelines. As a global learning platform, the RFI will raise awareness of the tools and information that stimulates the development of fair, sustainable research systems and institutional policies and practices. The RFI was conceptualized by the Council on Health Research for Development (COHRED) and was developed in global collaboration with institutions of various sectors since 2015.

How does the RFI create and maintain fair research collaborations?

The RFI raises awareness on many documents and guides that stand as best practice standards, such as the Commission for Research Partnerships with Developing Countries’ (KFPE) Guide for Transboundary Research Partnerships.[4] The tool implements these standards by encouraging institutions to report on 15 guidelines that inspire fairness, research competitiveness, partner efficiency and guides RFI Reporting Organisations (RROs) to adopt these principles within their institutional policies and practices for sustainable development.[5] The RFI also benefits its member organisations by acting as a global learning platform, leading institutions to address obstacles that can be encountered while collaborating with other partners, such as addressing capacity building, ethics standards, transparency in financial systems and fair sharing of benefits, costs and outcomes.

Who is adopting the RFI?

The RFI is in its implementation stage and is ready to engage with institutions around the world. Several institutions from government ministries, national research centres, universities, donors and businesses from Austria, Brazil, Colombia, Costa Rica, Germany, Kenya, the Philippines, Senegal, South Africa and Spain, for example, have demonstrated clear interest to implement the RFI in its first year.

The Initiative has also received a significant amount of support and backing by CAAST-Net Plus,[6] a European Union-funded project that is a network of 26 organisations, which enhances European Union and Sub-Saharan African research and innovation collaborations. As a result, the potential adoption of the RFI as a grant-assessing tool for the EU for the food security and sustainable agriculture sector is being discussed, largely expanding the reach of the global tool to areas other than the Health field. Though the tool was originally created and shaped to address issues encountered in research collaborations for health, the RFI guidelines effectively apply to international partnerships from all research and innovation sectors.

As one can see, the interest and uptake of the RFI is growing in 2017 at a time when togetherness and shared perspectives, principles and goals are more crucial to secure joint forces for sustainable development between civil society, governments and the scientific community. Successful international collaborations are central to generating high quality research, high-level competitiveness and capacity building in low- and middle-income countries.[7] All in all, the RFI is a timely intervention that will provide guidance as a key source to understand, access and put into practice standards addressing fairness, trust and sustainability in research partnerships as an innovative compliance tool that provides solutions to problems that are found in collaborations from all areas of the globe.

References

[1] Overseas Development Institute (2005). North-South Research Partnerships: A Guidance Note on the Partnering Process. Available at: https://assets.publishing.service.gov.uk/media/57a08c93ed915d3cfd001492/R8451ODI_North-SouthPartnerships_GuidanceNote.pdf (Accessed: 7 March 2017).

[2] United Nations Sustainable Development Goals (2015) Global partnerships – United Nations sustainable development. Available at: http://www.un.org/sustainabledevelopment/globalpartnerships/.

[3] ibid

[4] Swiss Commission for Research Partnerships with Developing Countries (KFPE) (2012). A Guide for Transboundary Research Partnerships: 11 Principles, 7 Questions. Available at: http://www.naturalsciences.ch/uuid/564b67b9-c39d-5184-9a94-e0b129244761?r=20161005181841_1475030362_3898d31d-7a25-55d7-8208-d9cbeada1d05.

[5] Research Fairness Initiative (2017). ‘RFI evidence-base.’ Available at: http://rfi.cohred.org/evidence-base/.

[6] CAAST-Net Plus: https://caast-net-plus.org/

[7] Nature (2015). ‘Nature Index 2015: Collaborations.’ Nature. Vol 527, Issue No. 7577 (November 12, 2015). Macmillan Publishers: London.

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

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

By Lawrence C. Loh

Dalla Lana School of Public Health, University of Toronto, and Director of Programs at The 53rd Week Ltd

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

A warm August evening, and after a long day at work, I had just finished bedtime with my kid and was unwinding in the kitchen with my wife. We were preparing for dinner; grilled chicken, and I was about to wander out on the patio with my beer and fire up the grill.

A message came in from an old friend – an internist in Ohio – saying simply “we need to talk tonight.” Focused on my plans for the evening, I simply responded that I had a number of competing deadlines before midnight, and that if he let me know what was going on, I could try to connect.

He called me, and dropped a thunderbolt: Dr. Guillermo Martinez, Mexican-born urologist practicing in Slovenia, devoted husband and father of two children, friend, and former International Federation of Medical Students Associations (IFMSA) Secretary General—dead at 36. Gunned down at his hospital by a disgruntled patient. (1)

***

One certainly doesn’t have to look very far to note that public perception of medical professionals seems to be worsening. In the midst of provincial contract disputes here in Canada, animosity around patient satisfaction scores and litigation in the U.S., and healthcare systems worldwide under strain as industrialized populations age beyond capacity, patient respect for physicians seems to be at a nadir.

Some argue that this is simply the changing physician-patient relationship, where physicians need to adapt from being unquestionably revered as teachers and healers to a new, more patient-focused normal, where service is expected and entitled. That does not, however, excuse or explain the far more disturbing trend that should not be tolerated in any circumstance: violence against physicians. Most recently, statistics from the United States Centers for Disease Control found rates of workplace violence against physicians, while traditionally low, doubled over a two year period from 2012-2014. (2)

In 2010, I returned to Toronto after a year of graduate studies in Baltimore, and watched the shooting of a spinal surgeon at Johns Hopkins unfold in live images of streets familiar to me. The first concern—being America—was terrorism, especially in Baltimore, a stone’s throw away from DC. The story that did emerge, however, was more personally disturbing. This wasn’t terrorism at all. Instead, a disgruntled family member, unhappy with an update on his mother’s care, had shot the treating physician – and soon after, perhaps realising what he had done, took his and his mother’s lives as well. A tragedy in almost every regard, with the silver lining being that the surgeon survived. (3)

Fast forward to this past summer, where residency was already a distant memory, and my ten-year med school reunion was slated for the fall. My classmates were now staff physicians building careers and families. As a public health physician, I had left full-time clinical practice behind, but often recounted to my learners how fun it was getting a consult back from an old friend. It acted, in many ways, as an indirect check-in: “good to see you’re out there, friend – and presumably doing well.” Having participated in the IFMSA as a student, I also enjoyed hearing from friends around the world that were going through similar transitions, even if our staying in touch relied increasingly on social media instead of in-person meet-ups that, the latter made increasingly difficult by distance and life pressures.

Six years on, I had long forgotten the Hopkins shooting. After all, while hitting metaphorically close to home, that whole scenario seemed so surreal and seemingly illogical. I should have recognized, however, that as my contemporaries became productive front line physicians, the unthinkable would perhaps become imperceptibly more likely.

That’s what made the news I received that August evening somewhat more poignant. In the days after Memo’s murder, the news spread throughout the IFMSA community to practicing physicians the world over. Shock abounded, as in addition to being just an all-round good guy, Guillermo was well known as an excellent surgeon who cared deeply about his patients. Initially murky details came into sharper focus: unhappy with the prognosis and the time it was taking for him to access treatment, one of his patients decided the best way to address this would be to shoot his treating physician. In turn, that patient himself was shot and killed by police while trying to escape the hospital grounds.

The months since have seen a return to daily life, though there was a London-based reunion that saw many of us who knew Guillermo reunite, reminisce, and drink a tequila toast in his honour. That he left Mexico, one of the most violent countries on earth, only to be gunned down in a hospital in Central Europe gave me pause. He had gone to work expecting to save lives; not to lose his own. How had it come to this?

***

Data suggests there are other professions that face relatively higher risks of violence in their dealings with the general public: taxi drivers, liquor store and gas station employees, and police officers. (4) The cynic in me felt that perhaps these workers be better prepared than physicians around workplace violence. After all, I rationalised, it might be a matter of expectations, that those engaged in these occupations recognize the risk of violence inherent in their work. Certainly, while a trainee on an emergency rotation might have a story or two, I felt that physicians for the most part naively believe that they are shielded by a purported public respect for the profession. The idea seemingly that patients understand that physicians are there to help, and are trying their best to do right by them.

But in thinking again on the shift towards patient-centred care and service, I began to wonder if our risk was ultimately all that different from other professions that also deal with cross-sections of the public. Add to that the fact that one’s health is so highly valued, and that patients might be in extremely vulnerable states, ready to lash out, and my wonderings became even more unsettled. 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.

Now, in fairness, there are a minority of physicians who themselves fail to treat patients and families with respect. But so many others go in with the intention of helping their patients each and every single day, and work on conditions for which the outcome is not fully within our control. When patient expectations fail to align with reality, and things take a turn for the worse, where does that leave the treating physician as a potential punching bag, or worse?

Compounding this is the fact that physicians, once revered as infallible and God-like, are now seen as cogs in a healthcare wheel. Cogs that are singularly responsible for achieving unrealistic outcome targets in an increasingly complicated world. Surely this is the pendulum swinging a bit too far, and perception needs to return to the pragmatic middle: physicians as human; determined to do their best in situations of great complexity; trying to work with rather than for patients. Humans with fallibilities, to be sure, but also with feelings, families, and friends. Family and friends who love them, support them, and ultimately pick up the pieces when violence visits.

***

While I myself have largely left clinical practice, I often think of my many friends both in Canada and around the world who still see patients. There are many patients who are suffering, and I know for a fact that the vast majority of their practitioners work their hardest to restore and optimise health within the constraints imposed by the context and system to the very best of their skills and ability.

After Guillermo’s passing, though, I sense that many of us who knew him—or who have heard the story—recognise the circumstances behind his tragic, senseless death, and perhaps see elements of those circumstances in their own interactions with certain patients. Surely, at some point in the future, one of us will be in a standoff with an angry patient around antibiotics for a cold, or an opioid refill or a decidedly unnecessary request for referral, and maybe, just maybe, doubt will creep in: “Is this it..? Is this the one that’s going to do it?”

A wise preceptor of mine once said that anger is simply unmet expectations. A fair statement, to be sure; but it does not characterize the expectations, which might very well be unrealistic or misplaced. Are we a new generation of physicians that will simply accept that we are practicing in a riskier, colder, less kind world? Or can we better shape these expectations and address this growing trend of animosity and violence towards physicians before it consumes more lives—for the sake of not only ourselves, but our patients, our communities, and our loved ones?

Dedicated to the memory of Dr. Luis Guillermo Martinez Bustamante (1980-2016)

References

(1) Spry E. Luis Guillermo Martinez Bustamante [obituary] BMJ 2016;354 doi:http//dx.doi.org/10.1136/bmj.i4864

(2) Gomaa AE, Tapp LC, Luckhaupt SE, Vanoli K, Sarmiento RF, Raudabaugh WM, Nowlin S, Sprigg SM. Occupational traumatic injuries among workers in health care facilities – United States, 2012-2014. MMWR Morb Mortal Wkly Rep. 2015 Apr 24;64(15):405-10.

(3) ABC News. Johns Hopkins Hospital: Gunman Shoots Doctor, Then Kills Self and Mother. [news story] Accessed online on November 27, 2016 from http://abcnews.go.com/US/shooting-inside-baltimores-johns-hopkins-hospital/story?id=11654462

(4) Hendricks, S.A., Jenkins, E.L., and Anderson, K.R. Trends in workplace homicides in the U.S., 1993–2002: a decade of decline. Am J Ind Med. 2007; 50: 316–325 DOI: http://dx.doi.org/10.1002/ajim.20442

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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

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Diritto alla Salute: il Ruolo Vitale della Legge

"One of the most useful aspects of this report is that it links human rights to urgent public health challenges, …. This approach, based on non-discrimination, participation, transparency and accountability, is the best way to ensure that responses are locally appropriate and sustainable."  
David Patterson, IDLO’s program manager for health law

by Daniele Dionisio

Membro, European Parliament Working Group on Innovation, Access to Medicines and Poverty-Related Diseases

Responsabile del Progetto Policies for Equitable Access to Health – PEAH

Diritto alla Salute: il Ruolo Vitale della Legge

Un nuovo report OMS intitolato ‘Advancing the Right to Health: the Vital Role of Law’ pubblicato nel gennaio 2017 descrive i molti modi in cui la legge fa la reale differenza per la salute pubblica.

Il report intende instillare consapevolezza sul ruolo che la riforma della legislazione in tema di salute pubblica può giocare nel promuovere il diritto alla salute e consentire alle persone sani standard di vita. Spingendo alla migliore comprensione di come le normative sulla salute possono essere usate per accrescere il benessere psico-fisico della popolazione, il report indirizza e assiste i governi verso un percorso di riforma della legislazione per la salute pubblica e di affermazione del diritto di ciascuno alla salute.

Il report si sofferma su temi importanti connessi al processo di riformulazione delle normative attinenti e fornisce guida su aspetti e requisiti correlati alla erogazione di nuove direttive pubbliche in tema di salute.

Con Roger Magnusson (Professore di Health Law & Governance, Sydney Law School, University of Sydney) quale autore principale, il report nasce dalla collaborazione fra OMS, International Development Law Organization (IDLO), O’Neill Institute for National and Global Health Law presso Georgetown University, Washington (DC) USA, e Sydney Law School, University of Sydney, Australia.

La struttura del report riflette il consenso raggiunto in una consultazione internazionale di esperti tenuta nel 2010 da OMS e IDLO in collaborazione con O’Neill Institute for National and Global Health Law e Sydney Law School, University.

Il documento si avvale di molteplici casi studio su come la legge abbia migliorato la salute e la sicurezza delle popolazioni, intesi come esempi e risorsa da offrire ai Paesi per apprendere dall’ esperienza di altri su scala mondiale.

Tassa sulle bibite gassate in Messico; limitazioni all’uso del sale in Sudafrica; imballaggio standardizzato generico per i prodotti del tabacco in Australia; assicurazione nazionale per la salute in Ghana; caschi obbligatori per i motociclisti in Vietnam; ACA (Affordable Care Act) negli USA: sono solo alcuni dei tantissimi esempi riportati sul ruolo vitale svolto dalla legge nel tutelare e promuovere la buona salute nel mondo.

La legge riempie titoli di giornale quando ha impatto diretto sui modelli di consumo di tutti i giorni: appunto il caso, come anticipato, della tassazione sulle bibite gassate, introdotta in Messico nel 2014 per limitare il consumo di bevande zuccherate. Parimenti, la normativa australiana per l’ imballaggio standardizzato generico dei prodotti del tabacco è diventata alfiere degli sforzi per ridurre la percentuale di fumatori.

Nel contempo, la risposta globale ad HIV-AIDS ha dimostrato come la legge possa proteggere le persone dalla discriminazione e facilitare l’accesso ai servizi di riduzione dei danni da droghe e al trattamento.

Se le leggi possono aiutare a proteggere la salute, la loro assenza o trascuratezza espongono intere popolazioni alle minacce sulla salute. Ad esempio, la debole regolamentazione dei prodotti del tabacco in alcuni Paesi permette a potenti corporazioni di commercializzare senza restrizioni e di ‘reclutare’ nuovi fumatori fra i giovani. Per contro, mentre la ‘Framework Convention on Tobacco Control’ di OMS rappresenta, in qualità di trattato internazionale, uno strumento legale per rispondere alla globale ‘tobacco epidemic’, sfortunatamente l’incapacità di alcuni Paesi ad adottarne le misure implica il persistente mantenimento dei costi di lungo termine del fumo e del suo impatto negativo sulla salute.

Di male in peggio, la legge è stata talvolta usata per offendere la salute. Persone con malattie mentali o omosessuali sono state, infatti, imprigionate o discriminate in forza di leggi che hanno pure negato loro i servizi e i diritti cui avevano titolo.

Tuttavia, quando tesa a proteggere, promuovere e affermare il diritto alla salute, la legge può servire da potente alleato.

In conclusione, il report ‘Advancing the Right to Health: the Vital Role of Law’ identifica un consistente numero di aree nodali per la salute pubblica dove la normative di legge è essenziale. Tradizionalmente queste ‘core areas’ includono: fornitura di acqua potabile e servizi igienici, monitoraggio e controllo delle minacce alla salute pubblica, contenimento delle malattie trasmissibili, e poteri straordinari in casi di emergenza. Senza trascurare il ruolo della legge nel favorire l’accesso universale a servizi sanitari di qualità per l’intera popolazione.

Costruendo su queste funzioni nodali, il report considera un ventaglio di ulteriori criticità e priorità di salute pubblica dove la legge è chiamata ad un ruolo chiave. Fra di esse, il già accennato controllo del fumo, l’accesso ai farmaci essenziali, l’emigrazione degli operatori sanitari, la nutrizione, e la salute materna, riproduttiva, infantile.

Tutto questo, giova ripeterlo, arricchito da molti esempi illustrativi delle modalità con cui differenti Paesi hanno utilizzato lo strumento di legge per proteggere la salute delle popolazioni in ottemperanza e coerenza con i diritti umani.

PER APPROFONDIRE

Advancing the right to health: the vital role of law http://apps.who.int/iris/bitstream/10665/252815/1/9789241511384-eng.pdf?ua=1

Commission on the Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008 http://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf

WHO: health and human rights http://www.who.int/mediacentre/factsheets/fs323/en/

Global Health Law Research Guide http://guides.ll.georgetown.edu/c.php?g=363447&p=2455560

United Nations: Universal Declaration of Human Rights http://www.un.org/en/universal-declaration-human-rights/

AIFA: International Treaties and the Right to Health http://www.agenziafarmaco.gov.it/en/content/international-treaties-and-right-health

Using International Human Rights Law to Guarantee the Right to Health: a Brazilian Experience http://blogs.lse.ac.uk/humanrights/2016/12/13/using-international-human-rights-law-to-guarantee-the-right-to-health-a-brazilian-experience/

WHO’s Framework Convention on Tobacco Control http://apps.who.int/iris/bitstream/10665/42811/1/9241591013.pdf?ua=1

WHO’s International Health Regulations http://www.who.int/topics/international_health_regulations/en/

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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

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Taking a Pill: Not So Counted On in South Africa

Despite noteworthy improvements in its public health system, South Africa is still facing huge problems in fighting diseases such as TB  and HIV/AIDS. Among several reasons, the poor patient adherence to medical prescription stands out.  Though the Government is trying to address the issue, the desirable results still lag behind. Future years look brighter than today’s, but additional efforts are required to pull the final goal off

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

Taking a Pill: Not So Counted On in South Africa

South Africa is improving people access to its health system. Unfortunately, though the country has the largest antiretroviral therapy (ART) program in the world, with 2.5 million patients on treatment in 2014, it also carries the third largest drug resistant (DR) and multi-drug resistant (MDR) tuberculosis (TB) burden in the world. And now that TB incidence is slightly decreasing, it remains, however, as high as 454.000 cases in 2015. According to WHO, the rate of DR TB is about 3,5% among the newly infected people and almost 7% among already treated cases.

As a main cause of TB drug resistance, the poor patient adherence to medical prescription is fueled by a number of factors that may be summed up in a couple of words: ignorance and mistrust. Especially in the poorest areas, such as Kwazulu-Natal, among others, there is a lack of knowledge about the disease, its treatment and the importance of care, as well as about the close connection between adherence and disease progression. Moreover, many patients are disillusioned by the health system. They do not trust the services the Government is providing, while preferably relying on alternative or traditional medicines.

Social stigma is something scaring TB people. Mainly in rural zones, affected people are often stigmatized and marginalized. Relevantly, the HIV stigma index found that TB ranks as the second leading cause of stigma experienced by people living with HIV, after HIV itself. More than one-third of the people who disclosed their TB infection reported being teased or insulted because of their status while about 40% reported being the subject of gossip.

From bad to worse, communities are not involved in treatment programs, thus traditional beliefs remain rooted in the villages ‘culture fostering marginalization and stigmatization.

Additionally, there are structural and institutional barriers endangering adherence to prescription. As would be the case for a poor patient-care provider communication. Clinics are often too far (as a rule in rural areas), and communication tools are not available to all. This hurdle limits doctors in promptly detecting patients at non-adherence risk. Under these circumstances, there is no psychological support from clinicians to patients.

Since 1998, South Africa has been trying to address the issue through the implementation of telemedicine services. The use of telemedicine ensures that waiting times for patients are reduced in an efficient and cost effective manner. But, whereas these strategies are promising, there are few sustained telemedicine programs due to a lack of proper management and technical capacity. Hence, a cycle of “pilot, implement, fail” is common.

As such, patients still have to face long waiting time, while services are not well integrated and medicines are scarce. The lack of medicines in rural areas is, indeed, a real threat. People seeking medical attention are often told that there is no medication and directed to a big, much more expensive hospital.

Not to mention that in South Africa there are only 0.8 doctors (in total) and 0.2 doctors (in public system) for every thousand people, compared with an average of 3.5 in developed countries. This occurs at a time when the percentage of doctors leaving the country is on the rise, with only a 30% of all doctors working in the public sector and a barely 3% of graduating doctors deciding to work in rural areas.

Despite free TB diagnosis and care, patients incur substantial direct and indirect costs particularly prior to the treatment starting. The poorest groups of patients are incurring higher costs, with fewer resources to pay for. Presently, individuals earning Rand 6000, around 422€, or more a month (roughly, 20% of the overall population) are required to pay for public healthcare system costs, though they’re subsidized.

If the public sector has some flaws, the private sector does not help. South Africa’s private healthcare system has long been regarded as among the best in the world. But, over the last 15 years, private healthcare costs as a whole have risen 59% in real terms due to an almost doubling in private hospital costs (due to an oligopoly of 3 hospital providers), a 70% increase in specialist prices (due to continuous shortage), and the rising cost of medicine and medical technology worldwide. Those looking to private care can either pay out-of-pocket or buy private prepaid plans (medical schemes), with nearly 16% of the population opting for the latter largely because they can afford it. Medical schemes are unlike medical insurance in other countries due to the Medical Schemes Act of 1998 which drew a distinction – medical schemes are non-profit organizations that belong to their members, not their owners or shareholders, and thus are forced to abide by certain rules such as not being able to discriminate against individuals based on age or health history. To this end, the Act laid out several cost-intensive scheme requirements such as the need to offer at least a lengthy list of “Prescribed Minimum Benefits”, which has pushed up scheme plan prices and discouraged innovation in more affordable coverage products.

The issues on stage are huge. Medical prescription adherence is fundamental and a governmental key challenge. In the last July, the Government unveiled machines dispensing antiretroviral drugs to people with HIV to be installed in both urban and rural areas. The aims are to reduce patient waiting time and improve adherence mainly in rural areas. Something similar could just be useful for TB too.

Institutional changes are strongly needed. These should include a revision of the Medical Schemes Act -so that more affordable schemes could be structured and provided-, and the development of reasonable guidelines for telemedicine aligning with international standards. Furthermore, the quality of services should be improved together with the involvement of communities in the treatment programs.

Last, but not least, the Government should manage to put an end to rural areas marginalization and rooted traditional remedies by countering ignorance and mistrust as the leading factors undermining good adherence to medical prescription.

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WHO and Privatization Agenda

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. (David Legge) 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

By Claudio Schuftan*

People’s Health Movement – PHM

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

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. (David Legge) 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. We know that donors seek to add value primarily through providing technical interventions (and not right to health or social determinants, for instance). So, here we are clearly faced with a biased stumbling block?* (Elizabeth Pisani, Maarten Kok)

*: Consider: While economics is not WHO’s core expertise, the impact of poverty and income maldistribution on population health clearly justifies WHO working with other agencies within or outside the UN system to focus much more attention on these questions of disparity.

Things being the way they are right now, it is difficult to make sense of the shrinking scope of WHO’s role in global health governance, partly because of the ambiguity of the slogans about ‘stakeholders’ and the fait-accompli of ‘multistakeholder platforms’ and ‘public-private partnerships’ now used profusely. The continued use of the term ‘stakeholders’ (and the bundling together of public interest civil society organizations with international NGOs, private sector enterprises and philanthropies under the term ‘non-state actors’) appears to endow all of these private ‘stakeholders’ with having the right to have a ‘seat at the table’, with only the tobacco and arms industries declared off limits. Such ‘sitting rights’ sharply jeopardize the human rights enshrined in the various human rights (HR) instruments that address the rights of real people –the right to health prominently included.** (D. Legge)

**: It is important to note that the treatment of WHO by the rich countries is part of a wider onslaught on the UN system generally. The whole UN system is held hostage to short-term, unpredictable, tightly earmarked donor funding. The same strategies of control have been applied across the UN system generally through: freezing of countries’ assessed contributions, tightly earmarking voluntary contributions, and creating dependence on private philanthropy, as well as periodic withholding of assessed contributions and applying continued pressure to adopt the multi‐stakeholder partnership model of program design and implementation that, as said, gives global corporations an undeserved ‘seat at the table’.

The Reform of WHO, aimed at realizing the vision of its Constitution, will require a global mobilization around the urgently needed democratization of global health governance; and this is not separate from, but part of, a global mobilization for HR and greater equity. Why? Because to claim that global health governance is somehow independent of global economic and political governance, is simply absurd. Nonetheless, such claims, still voiced by many, play an important political role for them in that they help to obscure the vested interests and power relations at play in the constraining (shackling) of WHO. (D. Legge)

Is WHO tinkering with a bureaucratic model inherited from the postwar era?

WHO actually seems strangely detached from the broader political turmoil unfolding around the world. Globalization has created new collective health needs that cross old spatial, temporal and political boundaries. In response, we need global health governance institutions that represent the many, not the few; are sufficiently agile to act effectively in a fast-paced world, on top of being capable of bringing together the best ideas and boundary-shattering knowledge available. (Kelley Lee)

WHO may point to its 193 member states and claim to be universally representative, but it is far from politically inclusive. Like the political alienation felt by millions around the world, many members of the global health community have turned elsewhere to move issues forward and get things done. What we see is a steady decline of WHO, clinging furiously to obsolete political institutions and bureaucratic models, yet kept alive by member states as an essential public institution. This decline is not because WHO is not needed, but because it has not adapted to and is not publicly financed for a changing world; it is not the WHO that we need today. (K. Lee)

Political innovation must become a fundamental part of the process of WHO reform. Think: How might virtual and interactive town halls improve communication between global health policy-makers and the constituencies they serve? How might the closed world of global policy-making be opened up and strengthened through virtual public consultations, feedback systems and monitoring systems –all of them also aiming at reforming WHO? How might the concept of global citizenship become institutionalized within our global health institutions, especially WHO? (K. Lee)

Prescribing “LEGO models’?

Otherwise, in the first decade of the new millennium, donors have pushed for increases in development assistance for health, yes, but in particular for medicines. This has clearly contributed to the re-legitimation of the ‘free trade agenda’ in health and has strengthened intellectual property (patents) protection regimes with their well-known negative consequences. Furthermore, in that development assistance, the mantra they preach to recipient countries is the one called ‘realistic costing of outputs’ that prescribes a LEGO model of program implementation, i.e., with each program comprising a set of planned outputs each of which comprises a known number of prescribed activities all of which have known costs. This approach leaves little, if any, room for flexibly managing complexity in planning and carrying out program implementation.*** (D. Legge)

***: WHO is made wary of prolonged project implementation processes, in part because they disrupts the ‘production schedule’ demanded by its paymasters. (Elizabeth Pisani, Maarten Kok)

What is missing from the whole discourse is carrying out a robust analysis of the root causes of the preventable global disease burden. Only this will provide clearer criteria regarding which ‘stakeholders’ (duty bearers in the proper HR lingo) are part of the problem and which are part of the solution –and therefore which of them can be trusted to have a seat at the table. Human rights principles provide such criteria and so does the WHO report on Social (and political) Determinants of Health of 2008.**** (D. Legge)

****: The importance of non-medical factors is largely recognized as being a key predictor of health. In 2008, the WHO Committee on Social Determinants of Health stated: “Social injustice is killing people on a grand scale and constitutes a greater threat to public health than a lack of doctors, medicines or health care services”. The general conditions under which people live and work thus have a major impact on health outcomes. These social determinants of health further comprise, among other, the structural determinants of socioeconomic development, working conditions, education, housing, sex and high-risk behavior… What this implies is that health care is just one of the factors to influence health and can, therefore, only be considered part of the solution. (Koen Detavernier)

The influence/control of donors over ministries of health in the South is nowhere more evident than in having kept any possibility of these ministries focusing on the human rights based approach in their agenda beyond mere lip service. Instead ministry officials keep pushing the newest slogans such as ‘universal health coverage’, ‘development assistance ‘and public-private partnerships’ that, in essence, are part of a common agenda consistent with the program of the 1% richest. They thus speak for the priorities of the 1% perhaps not realizing that they do so from within a worldview that accepts as natural and unchanging the global inequalities, the environmental degradation and the beneficence of private enterprise. (D. Legge)

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* article originally published in The Social Medicine Portal, February 11th, 2017

http://www.socialmedicine.org/2017/02/11/human-rights/substantive-work-particularly-relation-health-systems-development-counter-privatization-agenda/

Claudio Schuftan, M.D. (pediatrics and international health) was born in Chile and is currently based in Ho Chi Minh City, Vietnam where he works as a freelance consultant in public health and nutrition.

He is an Adjunct Associate Professor in the Department of International Health, Tulane School of Public Health, New Orleans, LA. He received his medical degree from the Universidad de Chile, Santiago, in 1970 and completed his residency in Pediatrics and Nutrition in the Faculty of Medicine at the same university in 1973. He also studied nutrition and nutrition planning at the Massachusetts Institute of Technology (MIT) in Cambridge, MA in 1975. Dr. Schuftan is the author of 2 books, several book chapters and over fifty five scholarly papers published in refereed journals plus over three hundred other assorted publications such as numerous training materials and manuals developed for PHC, food/nutrition activities and human rights in different countries . Since 1976, Dr. Schuftan has carried out over one hundred consulting assignments 50 countries in Africa, Asia, Latin America and the Caribbean. He has worked for UNICEF, WFP, the EU, the ADB, the UNU, , WHO, IFAD, Sida, FINNIDA, the Peace Corps, FAO, CIDA, the WCC (Geneva) and several international NGOs. His positions have included serving as Long Term Adviser to the PHC Unit of the Ministry of Health (MOH) in Hanoi, Vietnam under a Sida Project (1995-97); Senior Adviser to the Dept. of Planning, MOH, Nairobi from 1988-93; and Resident Consultant in Food and Nutrition to the Ministry of Economic Affairs and Planning, Yaounde, Cameroon (1981). He is fluent in five major languages. He is currently an active member (cschuftan@phmovement.org) of he Steering Group of the People’s Health Movement and coordinated PHM’s global right to health campaign for 5 years.

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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