Of the reviews presented or committed to be presented by countries of the Region of the Americas towards achieving the Sustainable Development Goals, there are some that have presented once, others twice or with a commitment to present a second time, while many that have not done so

By Francisco Becerra-Posada MD, MPH, DrPH

Public Health Policy

Have Countries Forgotten about the Sustainable Development Goals?

The Case of the Americas

 

The world is seeing a series of political changes, such as the ones in Mexico, Argentina, countries in Europe; unrest due to economic or policy changes as has happened in Hong Kong, France, Bolivia, Ecuador, Peru to mention a few. Economic trade war between the USA and China, and a constant threat to world peace by unilateral actions from a few countries. Also, we have seen and continue seeing the longstanding discussions and push back from establishment around climate change and its implications towards humanity as a whole.

These chaotic times we are facing make one wonder what has happened to the work countries were supposed to be doing towards achieving the Sustainable Development Goals (SDGs). There is evidence that countries have reported advances of the proposed objectives they signed up for and the reviews they have or will be presenting are stored by the UN in the Voluntary National Reviews Database.

Of the reviews presented or committed to be presented by countries of the Region of the Americas, there are some that have presented once, others twice or with a commitment to present a second time, while many that have not done so.

Of the 35 countries in the Region (not counting territories), Table 1 presents those countries that have reported or will report on the advances on the SDGs.

Table 1. Countries of the Region of the Americas that have presented or committed reviews on advances on the SDGs

  Source: Voluntary National Reviews Database,  https://sustainabledevelopment.un.org/vnrs/

Of the 35 countries in the region, 11 countries have or will present one review only by 2020. Of these seven are from the Caribbean and four of the continental region [*]: Bolivia, Canada, El Salvador and Paraguay. Of those presenting or committed to present twice, 13 countries have done so, amongst them, five countries of Central America. Only Nicaragua has not signed up for the review of their advances. Some countries of the continental Americas have yet to present or commit to: Guyana, Nicaragua, Suriname, United States and Venezuela.

The Caribbean has still to move forward and start committing to present their reviews. Of the 13 countries (including Cuba, Dominican Republic and Haiti), only six have done or committed to present the reviews.

Hopefully all SDGs are being covered and fully reviewed. Advancing towards the implementation of the planned interventions in each country is key as to diminish social determinants that hinder the advancement of a better life of millions of people that live in poverty and see their needs not fulfilled.

Hopefully the reviews speak of real advances and policy -social and economic- changes towards bringing these populations in need forward and their governments don’t leave them behind.

———————————

[*] Countries are being considered geographically, not by geo-political organizations.

News Flash 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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Failure to understand and declare an inequality emergency reflects the success of neoliberalism or ‘market fundamentalism’ as a global class project of restoring inequality and the privileges of the rich to the levels that prevailed before what has been called the ‘great compression’ that reduced inequality after World War II in much of the high-income world, and inspired egalitarian visions far outside it

By Ted Schrecker 

Professor of Global Health Policy, Newcastle University

Why No Talk of an Inequality Emergency?

 

We hear much talk now of a climate emergency.  As I was revising a talk I give frequently on ‘global health in an unequal world’, I realised that there is no talk of an inequality emergency, either globally or close to home, although the same macroeconomic trends and political choices driving increased inequality within national borders and on a variety of smaller scales are often involved wherever on the map one happens to look.  (On these inequalities at metropolitan scale, I cannot recommend too highly photographer Johnny Miller’s compelling aerial images.)

Why is there no talk of such an emergency?  Many manifestations of climate change occur on a scale that makes them fodder for our spectacle-hungry visual media: think Californian and Australian wildfires; collapsing glaciers; and catastrophic damage from hurricanes and floods.  The casualties of inequality tend to be smaller in scale and less visible: the lives ended sooner and more painfully than they should have been because of the accumulated damage done by relying on food banks and fearing the ‘brown envelope’ that initiates the vicious privatised process of fitness-for-work assessments here in the UK, or the estimated 300,000 women per year who die in pregnancy or childbirth from causes that are routinely avoided in the high-income world.   Academically, it may be effective to compare the annual toll from death in pregnancy and childbirth to the crash of two or three airliners every day of the year, as a colleague and I have done, but such comparisons have little salience in the broader, media-corrupted world of political priorities.

Relatively vast resources have been devoted to climate science – the Intergovernmental Panel on Climate Change is the world’s largest-ever scientific collaboration – and climate researchers  long ago realised that just generating more evidence was never going to be enough to generate the change needed.   So many became advocates, for example tracing 63 percent of cumulative worldwide emissions of carbon dioxide and methane between 1751 and 2010 to just 90 massive state- and investor-owned corporations (and their customers, of course).  More recently, another group of authors (supported by more than 11,000 signatories) argued that ‘Scientists have a moral obligation to clearly warn humanity of any catastrophic threat’.  Researchers on health inequalities, in particular, have generally been more circumspect.  In the UK, advocacy that looks far enough ‘upstream’ at the economic and political substrates of health inequalities – more on that point later – is unlikely to be acceptable to agencies of the capitalist state and the trustees of billionaires’ fortunes whose funding priorities shape the direction of academic research and the career paths of academics.  And the health inequalities of greatest concern, by definition, do not affect ‘all of us’.  Whether the consequences of climate change will genuinely do so is too complex a question to be investigated here, but the question is well worth asking.  Certainly, its effects will be felt first and worst by those least implicated in its origins.

Another issue is the decades-long rhetorical and ideological Thatcherite drumbeat that ‘there is no alternative’ to rising inequality and the policies that drive it.  This problem is particularly acute with regard to the austerity that has been thoroughly discredited in terms of the macroeconomic objectives of sustaining growth that it was supposed to achieve, whether in the era of World Bank and IMF-mandated structural adjustment or, more recently, in post-2010 responses to the financial crisis.  As Nobel prize-winning economist Paul Krugman commented in the run-up to the 2015 UK election: ‘All of the economic research that allegedly supported the austerity push has been discredited. On the other side of the ledger, the benefits of improved confidence failed to make their promised appearance. Since the global turn to austerity in 2010, every country that introduced significant austerity has seen its economy suffer, with the depth of the suffering closely related to the harshness of the austerity’.  Post-2015, of course, austerity in the UK became harsher still, demonstrably redistributing income and resources upward within British society, through both tax and benefit ‘reforms’ and savagely destructive cuts to local authority budgets.

Now, austerity has become normalised; it is part of the quotidian policy landscape to the extent that we are almost no longer capable of rage when the strutting, glossy Home Secretary straightfacedly claims that poverty is not the government’s problem, when the evidence is overwhelming that post-2010 public policy has systematically and premeditatedly made the problem worse.  Despite the best efforts of the fossil fuel industry, we can imagine a decarbonised economy, even though we may not be able to specify its details.  Too many of us now have difficulty imagining economic systems that do not operate as what Serge Halimi, the editor of Le Monde Diplomatique, has called an ‘inequality machine’.  A powerful antidote to this well-funded intellectual cauterisation is the United Nations Conference on Trade and Development’s 2017 blueprint for a global new deal.  How many global health researchers have read it, I wonder?  How many medical or MPH students have been asked to do so?

Back to the view looking upstream.  Failure to understand and declare an inequality emergency reflects the success of neoliberalism or ‘market fundamentalism’ as a global class project of restoring inequality and the privileges of the rich to the levels that prevailed before what has been called the ‘great compression’ that reduced inequality after World War II in much of the high-income world, and inspired egalitarian visions far outside it.  The evidence on this point can’t even be summarised here – I am glad to provide key sources – but in the context of the work that academics do, two decades of marketisation in British universities must be understood as part of the project.  Centrally funded institutions that served a public educational and scholarly purpose were dismantled, replaced by corporate-style enterprises organised around generating income from deep-pocketed funders and indebted students, with careers often ended by failure to put out salable products.

Isn’t this a form of conspiracy theory, you ask?  Empirically, the best rejoinders come from the work of journalists like Jane Mayer and historians like Stefan Collini and Nancy MacLean.  Conceptually, an especially apposite riposte comes from the brilliant legal historian Douglas Hay, who established himself in the field with the research that underpinned the following conclusion: ‘The private manipulation of the law by the wealthy and powerful’ in eighteenth-century England ‘was in truth a ruling-class conspiracy, in the most exact meaning of the word. …. The legal definition of conspiracy does not require explicit agreement; those party to it need not even all know one another, provided they are working together for the same ends.  In this case, the common assumptions of the conspirators lay so deep that they were never questioned, and rarely made explicit’ (1).  Enough said.

(1)  Hay, D.  Property, Authority, and the Criminal Law. In D. Hay et al., Albion’s Fatal Tree: Crime and Society in Eighteenth-Century England (pp. 17-64). New York: Pantheon, 1975

This posting also appears on Prof. Schrecker’s blog
 ‘Health as if Everybody Counted’

News Flash 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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Regional institutions mandated with the overall trusteeship of granting patents like African Region Intellectual Property Organization (ARIPO) responsible for the filing, administering, examining and granting of patents for 18 Contracting States of the Harare Protocol (ARIPO’s legal instrument on patents), and Organization Africaine de la Propriété Intellectuelle (OAPI) responsible for examining and granting of patents in the 16 Member States in West and Central Africa signatory to the Bangui Agreement, continue to apply insensitive practice of granting these patents which is parallel to WTO TRIPS flexibilities and pharmaceutical exemptions given to the Least Developed Countries (LDC) during this pharmaceutical transition period. Patents remain an emerging sharp sword to fragile and ever hemorrhaging health systems. This is looped in the weak implementation of TRIPS flexibilities in member state national patent laws, infamous practice of processing and granting pharmaceutical patents in LDCs by region institutions like ARIPO which has a direct implication on the member states’ access to affordable medicines, and development of a vigorous generic industry that can check the monopolies in the pharmaceutical sector to enhance availability of cheaper drugs

By Michael Ssemakula

People’s Health Movement

Patents in Pharmaceuticals: The Emerging Sharp Sword to the Fragile Health Systems in the 21^st Century

 The Work of Contemporary Struggles in Countering this Growing Global Threat to Access to Affordable Medicines

 

Quarter of the global populace faces access deficiencies to the most basic essential medicines. For the destitute and impoverished sick in the south constituency, the cost of drugs can determine whether they will be treated [1] or suffer with their ailment in excruciating pain. Numerous individuals who cannot afford the required treatment quite often resort to self-medication using traditional herbs and alternative medicines or a resignation to the natural hypothetical amazing ability of the human body to heal itself. In many instances this has left patients with severe and chronic complications as a result of a failure to treat the medical conditions early. Patents drive medicines’ and health technologies’ prices up, through subsequent monopoly statuses which permit the pharmaceutical companies to charge whatever price the demand side will shoulder. The World Trade Organization Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement, which provides twenty years’ patent protection for pharmaceuticals [2], also comprises safeguards such as compulsory licensing, to ensure that countries can prevail over the patents whenever they are a barrier to access to medicines and in the event that there is violation of patents by the patent holders.

There is an intense lobbying and pushing from the transnational pharmaceutical industry and some Western governments to protect their pharma products and technologies through patents. Patents are often taken as a conduit to provide guaranteed heavy revenue and commercial exclusivity to private companies to enhance the ‘purported’ innovation, investment in research and continuance of scientific progress [3]. But what about the innovations that are publically funded in this contemporary intellectual property regime but their outcomes are exorbitantly priced to the citizenry across the continental divides?

In the overwhelming globalization of capitalism in diverse sectors, pharmaceutical industry inclusive, the use of safeguards in TRIPS remain worryingly unfulfilled. Experience from middle income countries like, Thailand, South Africa, Guatemala and Kenya shows the heavy burdens countries face in implementing the TRIPS Agreement [4] in a manner that protects public health, and emphasizes the vital role played by civil society in defending the right to access to effective and quality affordable medicines. Regional institutions mandated with the overall trusteeship of granting patents like African Region Intellectual Property Organization (ARIPO) responsible for the filing, administering, examining and granting of patents for 18 Contracting States of the Harare Protocol (ARIPO’s legal instrument on patents), and Organization Africaine de la Propriété Intellectuelle (OAPI) responsible for examining and granting of patents in the 16 Member States in West and Central Africa signatory to the Bangui Agreement [5], continue to apply insensitive practice of granting these patents which is parallel to WTO TRIPS flexibilities and pharmaceutical exemptions given to the Least Developed Countries (LDC) during this pharmaceutical transition period. Patents remain an emerging sharp sword to fragile and ever hemorrhaging health systems. This is looped in the weak implementation of TRIPS flexibilities in member state national patent laws, infamous practice of processing and granting pharmaceutical patents in LDCs by region institutions like ARIPO which has a direct implication on the member states’ access to affordable medicines, and development of a vigorous generic industry that can check the monopolies in the pharmaceutical sector to enhance availability of cheaper drugs.

Multiple challenges disproportionately burden the shoulders of the health systems in the global south especially in the sub-Saharan Africa which suffers from numerous communicable and non-communicable (NCD) disease burdens, health epidemics such as AIDS, anthrax, Bovine Spongiform Encephalopathy, drug-resistant tuberculosis and malaria, severe acute respiratory syndrome, avian and swine flus, Ebola, Zika virus, intensified by several other economic challenges through exposure to unfair and unhealthy multilateral trading system. Newer medicines have become more available, however not available to those who need them most due to their tall price tags such as bedaquiline and delamanid which are excessively priced but effective to cure the multidrug-resistant tuberculosis (MDR-TB).

The question remain, what can we do to address the inadequacies in the drug availability and accessibility globally expressly in the high priority countries? How can we build a strong solidarity beyond just lip singing of the “word” itself “solidarity?” Multiple global struggles and movements have come up with strategies to challenge the global apartheid in health accessibility and the hegemony of capitalism as a mechanism to counter the 21^st century neoliberalism syndrome of globalization that has become a malignant neoplasm to the weak health systems.

Profitization in health through taking advantage of inelastic demand for medicines and other medical products is unequivocally a bridge giving the big Pharma super jump-pace to hold global health at ransom! Without doubt, profiting from health is perceived as an “eloquent thought” by big pharma, and also a common anti-humane practice of the corporations in the north pushing for aggressive mechanisms such as TRIPS-Plus to expand their investment multipliers through commercial exclusivity granted by patents to extremely exploit their benefits to the maximum.

More than ever, as anchors of health for all global health strategy, People’s Health Movement together with Third World Network have been so instrumental in safeguarding the full brim attention of global community to health through mobilization, strengthened health struggles, and solidarity against discriminatory health provision modalities. Their programs has encircled countering of ideological shifts and unfriendly profit driven postmodernism threats posed by the pharmaceutical corporations through a series annual trainings organized under their International People’s Health University (IPHU) program- which aims to contribute to ‘health for all’ by strengthening people’s health movements around the globe, providing space for learning, sharing and planning opportunities for people’s health activists, particularly from Third World countries. [6] The recent IPHU training in Cape Town- South Africa [7], was a global slumber breaking alarm to many global public health activists from over 12 countries across six continents about the shocking and deplorable inside of the pharmaceutical world and things big pharma don’t want us to know:- such as research and development costs, developing medicines  and other health products is not as expensive as pharmaceutical industry say! The big Pharma overstates the R&D costs of new drugs to validate their exorbitant pricing [8], and quite often classify ‘opportunity costs’ and non-research based activities [9], For eras-of-time, the global big pharma has spread a deceiving tale justifying the ever-escalating prices of medicines, vaccines, diagnostics, other health products and technologies as something essential and unavoidable. We are paying double for our medicines, some corporations’ research is taxpayer-funded especially at government and university research laboratories, from which most new version of drugs and medicine technologies originate. They get tax havens and other related financial incentives to their research investments [10] and the end result is to shamelessly privatize and patent the final outcomes of the research. The IPHU did not only end on the prices of medicines set but also how patents are granted which some violate the provisions in TRIPS flexibilies through over and over extension of time for patents after making simple compound innovations which prolong monopolies. This is a notorious pharma ploy known as patent evergreening, which lengthen their monopoly and in longrun block entry of affordable generic medicines. There is an emerging evidence that shows the granting of patents over minor modifications of existing medicine products both in the North and South [11]. This tendency has also been noted with great concern by the development, humanitarian and health stakeholders who are worried about the patent abuses where negligible incremental modifications made by big pharma result in unjustified monopolies. Countries with feeble regulations are exploited to the last penny of their health expenditure, big Pharma bullies LDCs through exploiting the gaps and inadequacies in their legal and policy frameworks, and leverage on the influence they have to change global trade rules to benefit themselves.

With participants from diverse culture, profession and career backgrounds in health, policy, academic, humanitarian, and law, the training further disclosed the philosophy of political economy of health, structure of the pharmaceutical industry, medicines related policy and regulation, a profundity learning of the relationship between intellectual property and access to medicines, the requirements of the TRIPS Agreement; public health sensitive TRIPS flexibilities, patentability criteria, opposition systems, exemptions for least developed countries (LDC); TRIPS-plus provisions and implications for access to medicines; and current and new approaches to pharmaceutical research. [12]

 

References

[1] Patents, Access to Medicines and the Role of Non-Governmental Organizations, January 1, 2004 by Nathan Ford

[2] WTO AND THE TRIPS AGREEMENT, https://www.who.int/medicines/areas/policy/wto_trips/en/

[3] WHY PATENTS ARE NECESSARY FOR THE PHARMACEUTICAL INDUSTRY, https://servier.com/en/why-patents-are-necessary-for-the-pharmaceutical-industry/

[4] Patents, Access to Medicines and the Role of Non-Governmental Organizations, January 1, 2004 by Nathan Ford

[5] UNDP WHO Workshop on the Examination of Pharmaceutical Patents: Developing a Public Health Perspective, Cape Town, 30 – 31 October 2008

[6] International People’s Health University, https://phmovement.org/iphu/

[7] https://phmovement.org/course-announcement-the-struggle-for-health-and-access-to-affordable-medicines-cape-town-november-2019/

[8] 6 things big pharma doesn’t want you to know, Access Campaign: 20 Years, https://www.msfaccess.org/6-things-big-pharma-doesnt-want-you-know

[9] 6 things big pharma doesn’t want you to know, Access Campaign: 20 Years, https://www.msfaccess.org/6-things-big-pharma-doesnt-want-you-know

[10] 6 things big pharma doesn’t want you to know, Access Campaign: 20 Years, https://www.msfaccess.org/6-things-big-pharma-doesnt-want-you-know

[11] UNDP WHO Workshop on the Examination of Pharmaceutical Patents: Developing a Public Health Perspective, Cape Town, 30 – 31 October 2008

[12] https://phmovement.org/course-announcement-the-struggle-for-health-and-access-to-affordable-medicines-cape-town-november-2019/

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We have strong technical guidance on healthy diets from WHO in one hand, and an international legal framework which obliges evidence-based State action on health in the other. Together they can reduce diet-related NCDs and promote global health. What are we waiting for?

By David Patterson

Health, Law and Development Consultants

 dpatterson@healthlawdc.com

Disclosure: From 2009 – 2018 David Patterson was senior legal expert, health, for the International Development Law Organization (IDLO). He is now a consultant with IDLO and other health, law and development organizations

Why Some Global Health Experts Didn’t Sign the Call on the United Nations for Human Rights Guidelines on Healthy Diets and Sustainable Food Systems

 

In October 2019 I and three colleagues (Dr Kent Buse, Prof Roger Magnussen and Prof Brigit Toebes) wrote a short article in the British Medical Journal.

We called on the Director-General of the World Health Organization, Dr Tedros, and the United Nations High Commissioner for Human Rights, Dr Bachelet, to lead the development of guidelines for States on human rights, healthy diets, and sustainable food systems. We also provided possible areas of focus, a proposed process, and draft principles to guide the development of the guidelines.

We shared the draft call with a wide range of experts in global health, nutrition, governance, law and human rights for comment and endorsement. There was strong interest, and within a couple of months 180 experts had signed on.

However, some people also told us that they did not agree with our approach and hence could not sign the call. Below are some of the reasons they gave.

First of all, we need to acknowledge that part of the global health community remains sceptical about the United Nations human rights framework. They question how international human rights law can be effective when there is no ‘international police force.’ In the same breath they mention the WTO and international trade law as an example of an international system ‘with teeth.’

Human rights lawyers and advocates know that the answers lie in the multiple ways in which international human rights law influences the behaviour of States and non-state actors.

Most important is the normative role, and here the detailed guidance from the human rights treaty committees is crucial. Pressure to comply then comes from multiple mechanisms, including the periodic reviews of State action under each treaty, and the State-led Universal Periodic Review process. In serious cases, State actions are scrutinized by UN Special Rapporteurs, the UN Human Rights Council, the UN Security Council and the UN General Assembly. Political processes can lead to sanctions and other international pressure. A good example is the October 2019 joint statement by 23 countries in the Human Rights Council on China’s mistreatment of Muslims in Xinjiang province. Without the norms established by human rights treaties, such criticism and action would likely be far weaker.

Human rights norms also inform positive political processes. For example, the UN General Assembly’s 2016 resolution on child, early and forced marriage is firmly grounded in international human rights law.

The international human rights legal framework also influences national judicial decisions and serves as a basis and model for national laws. In some countries international human rights obligations are incorporated directly into national law.

In July 2019, Brigit, Kent, Roger and I suggested in an article in Obesity Reviews that the value of the human rights-based approach to health had been demonstrated over several decades by its application to HIV and AIDS. This included the drafting by a diverse group of experts in 1996 of the United Nations ‘International Guidelines on HIV/AIDS and Human Rights.’

The HIV Guidelines review the application of the UN human rights treaties to the global HIV epidemic. They proved powerful in mobilizing State and non-state actors to strengthen action on HIV, notably on access to treatment and in addressing discrimination and counter-productive criminal sanctions against people living with HIV and other marginalized and vulnerable groups.

Some health experts maintain that the human rights-based approach to HIV was successful because the HIV epidemic affects mostly younger, socially and politically active populations. They question whether applying the same approach to noncommunicable diseases would be as successful. However, they miss the point that a wide range of stakeholders – civil society organizations, including faith communities and labour organizations, women’s and children’s rights organizations, public health advocates, UN system agencies and the UN General Assembly – have all embraced the human rights-based approach to HIV.

The human rights-based approach can mobilize broad community action on NCDs and other global health challenges. For example, in South Africa, the AIDS Law Project evolved into Section 27, a broad health rights organization. Section 27 and the Rural Doctors Association of Southern Africa now partner to support the Rural Health Advocacy Project.

Some global health experts questioned whether the draft call was sufficiently rigorous in its references to the private sector. However, the human rights-based approach requires States to hold the private sector accountable, and in turn makes States accountable for doing so. We referenced the UN Guiding Principles on Business and Human Rights which make this clear. We had to keep the call short – it was not intended to cover all areas of possible action. These will be explored through the development of the guidelines themselves.

There is one further, perhaps uncomfortable, reason why some global health folks don’t want to admit that international human rights law has a central role in global health. It is about hegemony and control of the global health discourse, and the global health dollar. Yet global health challenges will never be solved with bio-medical approaches alone. Conversely, the human rights-based approach is essentially democratic. It demands that affected communities are part of the solution to global health problems, not just the occasional lucky beneficiaries of laboratory-driven largesse.

Recall the 2014 case of the journalist in Sierra Leone imprisoned for questioning his government’s handling of the Ebola response, as reported by the Committee to Protect Journalists. It is a reminder that even the best technical solutions, such as a vaccine against Ebola, will never reach all those in need without strong human rights protections.

We have strong technical guidance on healthy diets from WHO in one hand, and an international legal framework which obliges evidence-based State action on health in the other. Together they can reduce diet-related NCDs and promote global health. What are we waiting for?

 

 

 

 

 

Mindful insights, including possible solutions and innovative ideas, are being offered here by a field engaged Sudanese General Medical Practitioner regarding the challenges and obstacles hindering an equitable access to health in Sudan

By Hanan Abdel Aziz Marhoum

General Medical Practitioner

Insights on Access to Health in Sudan

 

Being a General Medical Practitioner who worked for non-profit organizations from 2005 till 2017 in remote areas like Darfur Region, I do believe that I have compiled some insights and points of view regarding challenges and obstacles hindering access to health in Sudan. Though some of these insights might be very obvious and common knowledge to everyone whether inside or outside the medical field, yet I believe that we can still discuss it and give it a fresh look if we approach it from a different perspective.

Ultimately we can foresee and anticipate why and what factors are hindering our progress and innovation and hence hopefully we can alter and change and mould our innovative suggestions and solutions and be open to new ways of execution if we want to reach our goal which is provision of access to health to  ALL.

FACTORS AFFECTING ACCESS TO HEALTH IN SUDAN

Factors affecting access to health differ depending on whether the area targeted is rural or urban.

In Urban Areas main factors are:

• Brain-Drain of medical staff: Many doctors and nurses migrate from the country just a few years following graduation leading to big human resource – HR gaps especially at the big hospitals and casualties which ultimately led to a decrease in the quality of care given to patients and in some incidents due to lack of qualified staff and/or experience resulting in professional medical mistakes and loss of lives.
• Lack of motivation of staff: Due to the low salaries and incentives, staff can hardly afford their living let alone affording purchase of medical references or regular participation in advanced medical conferences/workshops/forums etc. as all these have to be done on the staff own expenses and desire without any financial support from the Ministry of Health except for post-graduates who are being given scholarships from the Ministry.
• Lack of appropriate Infra-structure and appropriate medical staff: Most of the well-equipped and well-built hospitals in Khartoum are actually belonging to the private sector and very few are belonging to the Ministry of Health and this logically results in provision of quality care and services to the patients who can afford the high expenses and fees of the private sector hospitals, while those who cannot afford it will for sure head towards less equipped hospitals or health centers or even go to traditional healers and herbal medicines practitioners. Actually in the recent 10 years the herbal medicine practitioners evolved and flourished as more of the public approached them for treatment for various diseases including even cancer. They even requested from the government a legislation of their activities and even were on the verge of making their own pharmacies. They even had regular advertisements in the national media claiming they can treat all types of serious diseases and gained many believers among the general public!!
• Inadequate allocated national budget: It is no secret that the budget allocated for health is about 1% of the national budget!!!!!! Of course Sudan being torn with conflicts and wars, the government allocated more funds to meet the needs and expenses of those conflicts. So what can the Ministry of Health do with such a small allocated budget? While affecting the National Strategic Planning for Health Services and Care, this also  affected the mapping and distribution of health services; and since adequate funds were not available, there was inadequacy and failure to execute those plans e.g. the return back of Malaria as a disease in Sudan, after it was almost completely eliminated following the withdrawal of Global Fund from financing malaria and TB programs.
• The sanctions put by the USA on Sudan and its impact on the economic status of the country: It also led to a severe shortage in meeting the demands of pharmaceutical companies importing medical drugs as the Central Bank could not secure enough currency for them to be able to import adequate amounts of drugs. This resulted in a big crisis and shortage of life-saving drugs.
• Alleviation of the financial support of medical drugs given by the Ministry of Health: this directly impacted the medicines related to chronic diseases such as renal failure, diabetes, and psychiatric diseases. Those who could not afford the purchase of their chronic regular medications had to stop taking them or to become irregular in taking those medications or to decrease their doses against and without medical advice or to seek alternative medicine drugs like honey, garlic etc.!!!!
• Political Factors: The economic status and the continuous drop in the value of the Sudanese Pound against the US Dollar impacted negatively the public and, with the added shortage in life-saving drugs and the increased fees of medical care, people started to aggregate in protests against the previous regime. Finally they ended it in April 2019 and currently the new government is trying its best with the support of the International Community to recover and support improvements in all fields.

As for the Rural Areas I will not go into much details as they are very obvious and known: so poverty, lack of qualified Human Resources and medical centers, marginalization, centralization of medical care at Khartoum level only and the main cities, influence of traditional healers, lack of education and ignorance, lack of adequate and appropriate means of transportation, lack of electricity and other essential services etc.

CONCLUSION

If we look at all the above mentioned factors we find that they are all having a common denominator which is that they resulted from more than 30 years of being under Sanctions a country put on hold for that long and this impacted its economy, led to brain-drain and progressive continuous decline in all aspects of life not just Access to Health.

So how can we innovate?

Well first we should include everybody in the brain-storming and in the discussion, we as Sudanese we should focus on altering and shifting Sudan from being a poor country to a strong and better place.

Solutions and innovative ideas related to access to health in Sudan should be unique to us, adapted to our perspective and identity in order to be achievable and successful. It should include the reality of our ethnicity being both African and Arab, it should evolve knowing that Sudan with its different regions and states and many local languages resembles a continent with many different countries so what we can execute in one country might not be the ideal or suitable solution for the other country.

We should also include the opinions of the local staff and people and approach this issue from their perspective and adapt our innovative ideas accordingly especially as we still have some gender issues and Taboos as well as we still in some regions suffer from the harmful traditional practices.

Another aspect of access to health is the umbrella of the National Health Insurance which has under it all the employees but does not include those who have no jobs except some special categories. So, how can we include those deprived from it to ensure that access to health is for all?

Finally, Access to Health is a very broad topic and unique to each country in its execution and perspective as well as in approach. Innovative suggestions will be dependent on the local understanding and approach to the topic and without the participation of the local people nothing would be accomplished. Any innovation from abroad needs to be adapted to the local culture and has to include in it the political and economic as well as the understanding of the context for it to be realistic and acceptable by the targeted community.

 

The path toward universal access to quality-assured medical products requires a multidisciplinary approach whereby pharmaceutical regulation is not seen (anymore) as a technical issue that is dealt with by technical experts in isolation, but rather as an important component of pharmaceutical systems, that is strictly interconnected to the other systems’ components; and that should benefit from collaboration with policy makers, health economists, social scientists, researchers etc.. 

In this regard, the recent publication, in the Lancet Global Health, of the Oxford Statement and call to action for global access to quality-assured medical products, is a welcome development

By Raffaella Ravinetto

Institute of Tropical Medicine

Antwerp, Belgium

The Oxford Statement and The MedsWeCanTrust Campaign

A Call for Equity in Global Health

 

Access to quality-assured medical products for all, is a fundamental prerequisite to achieve universal health coverage (UHC), but it is hampered by a variety of political, structural and financial problems. Among them, the high prevalence of substandard and falsified medical products, particularly in low- and middle-income countries (LMICs), represents a significant threat to individual and public health [1]. Health systems worldwide need to design and implement policies that ensure availability and affordability of quality-assured products.

Strengthening the capacity of National Medicines Regulatory Authorities (NMRAs) in LMICs is surely a key priority, given that to date less than 30% of the World Health Organization (WHO) Member States have a stringent NMRA, meaning a NMRA with the capacity to fully perform the functions required to ensure that medicines, vaccines and other health products, work and do not harm [2]. But problems faced by most LMICs are more complex and multifaced. In 2017, for instance, the Lancet Commission identified five areas that are crucial to essential medicines policies: assuring the quality and safety of medicines, but also paying for a basket of essential medicines; making essential medicines affordable; promoting quality use of medicines; and developing missing essential medicines [3].

This list of “priority policies” clearly shows that the path toward universal access to quality-assured medical products requires a multidisciplinary approach, including expertise in health systems, pharmaceutical regulation, quality assurance, intellectual property rights, health financing, social sciences etc. In this multidisciplinary approach, pharmaceutical regulation is not seen (anymore) as a technical issue that is dealt with by technical experts in isolation, but rather as an important component of pharmaceutical systems, that is strictly interconnected to the other systems’ components; and that should benefit from collaboration with policy makers, health economists, social scientists, researchers etc.

The recent publication, in the Lancet Global Health, of the Oxford Statement and call to action for global access to quality-assured medical products, is therefore a welcome development [4].  It comes as a follow up to the first-ever international Conference on Medicine Quality and Public Health (Oxford, United Kingdom, 2018). At that time, delegates had issued the short Oxford Statement, calling for investment, policy changes, and action to eliminate substandard and falsified medical products [5]. The newly-published Statement is significantly expanded with a Call to Action, in order to support some key-strategies of the WHO (i.e., the “Prevent, Detect and Respond” strategy; the Global Benchmarking Tool for NMRAs; and the WHO Prequalification team); to advocate for increased investments to build the capacity in regulation, manufacturing, supply chains and post-marketing surveillance; and to advocate for research on the impact of poor-quality medical products, and on the cost-effectiveness of interventions to eliminate them. The Call is accompanied by a detailed Research Agenda.

One decade ago -and perhaps, even more recently- the subject of poor-quality medicines was discussed by technical experts, and it was relatively neglected by other stakeholders in health systems and global health. Today, the Oxford Statement is supported by more than 150 signatories, issued from a variety of different professional backgrounds, skills and expertise, showing a growing  awareness of the importance of these “technical” aspects, for the performance of health systems and for the achievement of UHC.

As recognized by the signatories of the Statement, the Call to Action will be translated into concrete actions only if supported by multi-sector political commitment, and if accompanied by solid partnerships across key-stakeholders such as regulators; Ministries of Health, Finance, Trade, Research; manufacturers, distributors and purchasers of medicines; funding and implementation agencies; researchers; law enforcement agencies; and the civil society, including patients’ and grassroots organizations.  But it is already an excellent news that the initial call does not come from a group of “technicians”, but from a multidisciplinary group of committed individuals and organizations.

Those who wish to support this call, can join the #MedsWeCanTrust Campaign (https://medswecantrust.org/get-involved), a platform that raises awareness of the impact of poor-quality medicines, noting that this problem “cannot be confined to technical, isolated conversations”, since “they are a fundamental breach of patient trust with life-or-death consequences”. The Campaign strives to inspire collective action and unify a diverse and broad coalition of partners, for achieving the policy changes necessary to ensure that the medical products that reach people work. We hope that also PEAH’s readers will be inspired, and will contribute to spread the call.

 

References

[1] World Health Organization. WHO Global Surveillance and Monitoring System for substandard and falsified medical products. Geneva: World Health Organization, 2017. http://apps.who.int/medicinedocs/en/m/abstract/Js23373en/

[2]  https://www.afro.who.int/news/tanzania-first-african-country-reach-important-milestone-regulation-medicines

[3] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31599-9/fulltext

[4] Newton PN, Bond KC, on behalf of the Oxford Statement signatories. Global access to quality-assured medical products: the Oxford Statement and call to action. Lancet GH 2019; 7: e1609-11

[5] https://www.tropicalmedicine.ox.ac.uk/events/medicine-quality/mqph2018/oxford-statement