Haiti Healthcare Sector: Hard Recovery From Disastrous Years

The current Government in Haiti seems unable, owing to political instability, natural disasters and funds mismanagement, to address the high rate of communicable diseases such as HIV-AIDS, cholera and tuberculosis, as well as to improve the primary healthcare sector and achieve Universal Health Coverage. A more accurate management of financial and human resources bound-up with a higher public investment in the health sector could help overcome the impasse 

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

Haiti Healthcare Sector: Hard Recovery From Disastrous Years

 

Haiti faces huge challenges to its healthcare sector because of recurrent natural disasters such as earthquake and hurricanes (every year on average 1-2 hurricanes strike the island), making it hard for Haiti to recover or improve on its economy and keeping the Country in a constant crisis model and financial hardship.

Relevantly, the 2010 earthquake was the worst natural disaster striking Haiti in over 200 years; more than 220,000 people died, and 300,000 were injured. The earthquake had a catastrophic impact on an already fragile healthcare system, including the total destruction of, or damage to, 30 out of 49 hospitals in the disaster zone. Damages that are not yet completely recovered.

From an infectious diseases perspective, the situation is not running well now that, among other scourges, the main illnesses affecting Haitians are cholera, tuberculosis/MDR-TB and HIV-AIDS.

Even if official data are not completely reliable because of bias during data collection and monitoring, 3,111 suspected cases of cholera were reported in 2018, including 37 deaths, with an incidence rate equal to 25,5 cases per 100,000 population, which is the lowest, though still significant, recorded incidence since the beginning of the outbreak (2010).

What’s more, according to the “WHO Global TB Report 2017”, Haiti has the highest rate of TB in the Western hemisphere, with an estimated incidence of 188/100,000 in 2016. TB is even more present in some urban areas, with a rate beyond 1,000/100,000 in several slums of Port-au-Prince, the capital city. Additionally, in 2016, there were 15,567 reported cases of TB in Haiti, with an estimated 75% case detection rate. As concerns MDR-TB, WHO estimates that 2,9% of new cases and 13% of previously treated cases have MDR-TB/, with a total estimated number of 530 cases.

As for HIV-AIDS, according to the “Programme National de lutte contre la SIDA, Declaration d’engagement sur le VIH-SIDA, rapport de situation nationale, Haiti Mars 2016”, and the information bulletin released in December 2018, Haiti shows 7,600 new HIV infections and 4,700 AIDS-related deaths. There were almost 150,000 people living with HIV in 2016 with an access rate to antiretroviral therapy equal to 55% c.a.. Moreover, among pregnant women living with HIV, 71% were accessing treatment to prevent transmission to their children, at a time when an estimated <1,000 children were newly infected due to mother-to-child transmission.

Overall, new HIV infections have decreased by 25% (with a 24% decrease in AIDS-related deaths) since 2010, but have increased by 1% comparing to 1990.

If communicable disease is one of the major plagues in the Country, the backwardness and inefficiency of the healthcare system are not far behind. According to available data, despite the 2010 earthquake and the 2016 Matthew hurricane, the health outcomes have improved and health infrastructures have been re-built. However, the poorness of health equity and coverage measures, as well as the lack of water and sanitation services, that are below many other low-income countries, are slowing down progresses towards people health and infectious disease control. While Haitians can now expect to live longer, access to basic health services is still lacking.

The problems faced by the Haitian healthcare system also include the mismanagement of external financing together with poor access to, and poor quality of, primary care services.

In particular, the total expenditure for health has increased over the past 20 years mainly by external financing to NGOs, while the government has played an increasingly marginal role in financing the sector. The increase in external financing has changed the structural composition of health spending. In 1995, households were the main financiers of health system through out-of-pocket payments (46%), followed by the government (41%) and NGOs (13%). Since then, the government contribution has decreased substantially, down to 6.8% of national GDP in 2015. In the same year, out-of-pocket payments accounted for 36% of total health expenditure while NGOs and other private institutions serving households represented 44%. This context has resulted in a constant rise of external funding (featured by a low donors’ coordination) and in the lowering of domestic financing.

As mentioned, another issue undermining the Haitians’ quality of life is the poor efficiency and representation of public primary healthcare sector. According to an official report released by the Haiti’s health minister on the assessment of the quality of healthcare services, the private sector is dominant compared to the public one. In fact, out of 1,033 health institutions in the Country, just 350 are public against 493 private, whereas the remaining 190 show public-private co-participation. Moreover, only 32% of public health facilities in Haiti provide essential medicines, and only 31% possess basic medical equipment.

Under the circumstances highlighted so far, the Government should implement a strong national strategy in order to make the healthcare system more reliable and efficient.

Since financial and geographical access are key obstacles for citizens, the Haitian Government should invest more and more efficiently on primary care sector including by improving on transport system and telecare. Additionally, the Government should capitalize more on health professionals training and distribution across the Country. In fact, according to the aforementioned report, while almost 19,100 health professionals are at population service within the different public and private health institutions, unfortunately, they mainly consist of nurses, i.e. 8,202.

Medical professionals account for 3,354 people at a time when community staff consist of 3,972 officers and midwives are underrepresented (just 219). As regards distribution, specialized doctors and nurses are found more in hospitals and the Metropolitan Area, whereas community staff mainly work in health clinics and health centers without beds within the public sector.

The Government should strengthen efforts towards primary care since its prioritization would help achieve Universal Health Coverage (UHC) and extend access to essential health services for the most vulnerable and poorest population groups, while reducing out-of-pocket payments.

Actually, this is a very  hard task because of internal and external financial and political constraints. Nonetheless, guidelines released by WHO and the World Bank are on the floor for implementation and proper allocation of financial resources.

Regrettably, while guidelines get significance only when linking to political commitment, in today’s Haitian context the political will looks like something that still needs to grow up.

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Too Narrowly Defined: Resilience and Sustainability

 A critique of the concepts of resilience and sustainability as commonly used is presented. The discourse of ‘increasing resilience’ is simply not likely to prevent crises recurrences in the long-term as is claimed, because it does not carefully analyze the root causes of the development problems at hand. Ideas are explored of how resilience can be made to address equity, equality, fairness and human rights. It is further argued that the concept of sustainability has become too abstract since environmental problems cannot be analyzed independently from their effect on human rights and on people’s livelihoods. The root of the problem is that, to be sustainable, development actually is to be about processes of popular enrichment, empowerment and participation that our technocratic project-oriented view has simply failed to accommodate. Provided are some blueprints addressing the needed personal and institutional changes that will support a new vision of sustainability

By Claudio Schuftan*

 Ho Chi Minh City cschuftan@phmovement.org

Yes, Resilience and Sustainability Are Too Narrowly Defined

 

Resilience

Most of the proposed definitions have included the idea of a healthy, adaptive, or integrated positive functioning over the passage of time in the aftermath of adversity.

(Steven M. Southwick et al, “Resilience definitions, theory, and challenges: interdisciplinary perspectives”, Eur. J. of Psychotraumatology 4 (2014): 25338.  http://dx.doi.org/10.3402/ejpt.v5.25338)

In September 2008, the former UN Special Rapporteur on Food Olivier de Schutter used the concept of resilience confidently as a condition for coping with uncertainty and thus guaranteeing access to food for all when prices of food increase. He called on building longer-term resilience and contributing to global food and nutrition security, by expanding social protection systems; sustaining the growth of smallholder farmer food production; improving international food markets; and developing an international consensus on agro-fuels.

Olivier De Schutter, “Building resilience: a human rights framework for world food and nutrition security” (paper presented at the UN General Assembly, New York, September 8, 2008). Document A/HRC/9/23

In April 2016, seven years later, on the occasion of the Vancouver Health Systems Research Conference, things had changed. A group of colleagues presented a short and well justified critique of the concept of resilience. In general, their points were the following:

  • Resilience has become an emerging ‘hegemonic’ discourse in the field of development policy.
  • Resilience has been increasingly applied to refer to the need for distressed development conditions to ‘bounce back’ from shocks.
  • The gratuitous assumption is being made that such conditions were ‘there’ and were good in the first place, or at the very least, that with a concerted effort they can get back there.
  • What a resilient system to us thus addresses is a form of technocratic reductionism since resilience strategies and solutions are often divorced from meaningful assessment of the political economy and power dynamics that produced the development crises we face in the first place.
  • The communities seeking to regain access to chronically deficient social services delivery systems are more likely to have low levels of education, to have weak citizen engagement and to experience severe class discrimination.
  • Much of the technocratic discussion around ‘building resilience’ appears to bypass these issues, often focusing on tweaking inputs to the development process (frequently emphasizing self-reliance and behavioral changes). This technocratic approach to building resilience is at odds with the complex reality of the development process in each country.
  • Building resilience rarely seems to involve a direct examination of, or challenge to, the structural conditions that contribute to the overarching social services dysfunctionalities based on historical colonial legacies and current trade and aid structures.
  • The rise of the increasingly hegemonic resilience discourse has further effectively enabled duty bearers globally to replace the conversation about systemic failures at multiple levels seen from a long-term vision with an action-oriented discourse that is based on much shorter time frames and ignores myriad structural determinants.

The authors expressed the concern –that I fully share– that the discourse of ‘increasing resilience’ will lead to global development policy reforms that will be fueled by the perceived immediacy of a problem instead of by a careful analysis of the root causes and the strategies likely to prevent crises recurrences in the long-term.

Bottom line, a conscious discussion is needed to reframe what we mean when we use the term ‘resilience’. “Resilience only has value, as long as it is not divorced from the material changes that need to occur to support them and the requirement for a more balanced relation among national states (trade, flow of resources, and others). The use of the term is to rather build on the already reached consensus around the social determination of development outcomes, the use of the human rights framework and people-centered development. This means resilience must be situated within its relation with equity, equality, fairness and human rights.”[1]

(Stephanie Topp, Walter Flores et al, “Critiquing the Concept of Resilience in Health Systems”, Health Systems Global Blog, April 12, 2016.
http://www.healthsystemsglobal.org/blog/110/Critiquing-the-Concept-of-Resilience-in-Health-Systems.html)

Sustainability [2]

The 1987 Brundtland Report defined sustainable development as that which satisfies the needs of the present without compromising the needs of future generations. To many, this definition was too abstract since environmental problems cannot be analyzed independently from their effect on human rights, on human employment and on livelihoods.

The root of the problem is that, to be sustainable, development actually is to be about processes of popular enrichment, empowerment and participation that our technocratic project-oriented view has simply failed to accommodate.

Conversely, what we see among the most prominent newer development theories are all sorts of ‘multidisciplinary approaches’ to solve the problems of development.[3] There is nothing terribly wrong with this concept, only that it gratuitously assumes that looking at the problems at hand from a ‘wider’, ‘pluri-disciplinary’ perspective is going to automatically lead us to the better, more rational and equitable solutions… Just by putting together disciplines and putting together brains ‘sown’ differently –without considering where these individuals are coming from ethically, ideologically and politically– has not, is not and will not, by itself, make a significant difference in the outcome and in the options chosen. (For sure so if we do not, additionally, actively incorporate claim holders in the decision-making process).

As far as I am concerned, this has led us to an ice-age in our thinking on sustainability –on how, for instance, preventable ill-health and malnutrition are deeply linked to an overall unsustainable development model. Now, we need to think what ought to follow during the encouraging current thaw.

It is thus necessary to reformulate and revise the concept since, in the years since the Brundtland Report, it has been variously used as a ‘joker’ in all discussions about development and the environment. Taken to an extreme, some still argue that the privatization and commodification of the commons is the ideal roadmap to guarantee sustainability. This, notwithstanding that there is ample evidence that such an approach is eminently fallacious. For instance, Olivier De Schutter showed during UN hearings that ocean grabbing and overfishing had become a global phenomenon as deplorable as the exploits of colonialism. Moreover, in the name of sustainability, the right to work of millions of artisanal fisherfolks are actively being violated.

Much of what is done in the name of sustainability is not to be seen as a series of isolated cases the world over. Actually, Capitalism’s expansion does not stop seeking wealth accumulation by grabbing land (agroindustry and corporate extractivism) and water resources using ‘legal means’ –and doing so in the name of sustainability. Unfortunately also many international environmental NGOs have become part of this trend making this fallacy less visible in terms of both its human and environmental costs.

It is clear that as guardians-of-the-environment-claim-holders we have to go back to basics and put the needs of the future generations upfront and demand long-term policies that stop Capitalism’s unacceptable, insatiable and non-democratic predation of the environment, its human costs included. The political class that defends and administers the neoliberal status-quo needs to be brought to the negotiating table in a level playing field with claim holders’ representatives as the only way to guarantee structural changes in our dealing with the environment and with all aspects of human dignity.

What a crackdown on a narrow application of the sustainability concept would mean for activists

Not only do we need to come up with conceptual breakthroughs, but we also need to provide blueprints for the needed personal and institutional changes that will support the new vision and its arrangements.

At the risk of sounding panfletary, I think these elements could begin making our work yield more potentially sustainable and equitable outcomes. I can think of no other format than presenting the major (mostly normative) points in the form of bullets (in no real particular order here):

  • We need to de-professionalize our work.
  • This will mean seeking, re-valuing and incorporating popular knowledge and know-how into planned actions.
  • In the process, Third World local public interest civil society organizations have to take a more visible lead (even at the cost of making some possible mistakes).
  • All relevant knowledge has to be shared with the claim holders openly and upfront for them to fully participate in the decision-making process from the very start.
  • We need to move away from the project-oriented approach and move to long-term processes of popular enrichment and empowerment (using the consciousness raising of Paulo Freire).
  • Needed expertise now has to be drawn not from academicians, not even from professional practitioners, but much more from the ‘everyday sufferers of the effects of the prevalent inequitable system’.
  • Claim holders are to define what changes we will be looking for and let these guide the drawing of action plans.
  • Action plans are thus to be negotiated and finalized in the field, not in our offices.
  • As a matter of urgency, development and human rights education has to be carried out at a quite massive scale, carried out from the claim holders’ perspective with their choice of contents and priorities.
  • All this means we have to shed many of our biased values and be more open to the claim holders’ values.
  • Our analyses need to incorporate more the underlying structural causes of maldevelopment so as to see them as part of the ‘big picture’ (including those changes brought about by globalization).
  • Such analyses will force us to tackle not only the multidisciplinary aspects, but the complex social and political issues preventing people from improving their own livelihoods (mostly related to control processes in society).
  • We will have to confront face-on and expose the forces that oppose greater equity and equality so as to neutralize them (from the local level to the international arena).
  • This means that we will have to adopt a dialectical approach as a more effective means to lead us to the needed systemic changes at the base of the major contradictions shaping the present situation.
  • A conceptual framework of the causes of ill-health and malnutrition seen as outcomes –like the one UNICEF uses– is a needed intermediary step to assess and analyze the causes of maldevelopment at different levels and to come up with converging concomitant (necessary and sufficient) actions at the different causal levels.
  • We will have to intensify our efforts at using the internet to build networks of like-minded colleagues that can consolidate a strong worldwide solidarity movement.
  • We will have to become more active and vocal open critics of the type of (often tinkering) bilateral and multilateral aid that is perpetuating old non-empowering/non-equitable/non-sustainable approaches.
  • We will have to actively help forcing institutional changes in bilateral and multilateral aid agencies (the UN and EU system included) that make them more democratic, economically independent and transparent.
  • We will have to embark on a significant overhaul of the curricula of young development professionals that will prepare a new generation of more sustainable development-oriented professionals.

All the above –being desperately incomplete and a bit caricaturesque– sounds quite grandiose (and even romantic) and is packed with heavy-sounding, politically-charged action verbs. These action verbs probably define me (and many other) as a Gramscian ‘organic intellectual’. But what is here proposed should indeed help move the process from Gramsci’s orthodoxy to orthopraxis; otherwise, we might as well forget it.

But the processes that can lead to sustainability, equity, equality and human rights can (and should) start with small direct actions that we can help bring about more easily. Actions at grassroots level can take many forms, but should always reach a point in the discussion where who is losing and who is winning (and why) is thoroughly analyzed. At higher levels, most of us have more experience on how to start discussions leading to change. We just have to commit ourselves in a more militant way to get and/or keep the process going and, above all, challenge the status-quo that gives the impression that nobody cares.

Examples where some of the elements listed above have worked do exist. Some of them have become cliches (Kerala, Sri Lanka, Cuba, Iringa, Jamkhed and so many others). They all have in common bottom-centered, gender-sensitive, empowering approaches and a political choice to tackle the underlying deep roots of poverty, injustice and ignorance. Many organizations have championed causes such as the one proposed here (mentioning some would do injustice to the others), but evidently the effort has not been enough to the tenor needed to achieve global impact.

Note that the route suggested by this (clearly not) new vision requires we break with the old development paradigm; and this means stepping on many vested interests’ toes.

Yes, this will mean changing the terms of the discussion, because a vision is not much good if it simply stays in the air as something devoutly to be desired; a vision of that sort is a mirage: it recedes as you approach it. To be of use, the vision has to suggest a route, and this requires that it takes into account a lot of unpleasant realities.

But the role of an avant-garde is to cause fermentation. We cannot fall in the trap of believing someone else is going to take care of these things for us; we have to get active. A strategic overhaul of our actions requires nothing less than a crisis in our thinking and if by now there is no such a crisis in the horizon, we have to perhaps create one.

To do so, we see that old Marx was right. The political left must necessarily become international and solidary. What is happening everywhere is, not surprisingly, happening under the same legal and analytical frameworks Capitalism has set up. Problems are compartmentalized to hide its common determinants.[4] The time has come to work towards the definite unity of the progressive, environmentally conscious forces. With today’s reach of the social media it can be done. More than enough reasons justify this.

(Leonor Quinteros Ochoa, “Ocean grabbing o la depredacion internacional de los recursos pesqueros”, Politika Blog, June 1,2017 https://www.alainet.org/es/articulo/185865)

We are in for exciting new times. We need all the courage we can muster. Wouldn’t you rather become a protagonist than a bystander?

 

—————————————————

*Short Bio

Claudio Schuftan has worked extensively at global level (especially in Africa and Asia) in fields such as Public Health including, Strengthening Management of Health Systems and Health Policy Formulation, Public Health Nutrition, Primary Health Care; Maternal and Child Health Care, Health Management Information Systems, Human Resources for Health, Health Project Design, Health in SWAPs, District Health Management, Health and Human Rights Capacity Building, Community Health, Health Promotion, Health governance, Health Sector Reform and Gender Issues. Dr Schuftan has significant monitoring and evaluation experience in these fields. Apart from sector and joint evaluations for various donors,he has monitored EU projects mainly in the fields of health and nutrition especially since the establishment of the ROM initiative in 2001. 

Dr. Schuftan has worked on the drafting of national plans of action in Cameroon, Kenya and Vietnam and has carried out in-depth situation analyses including access to health and right to health issues. He has prepared health investment plans and facilitated numerous training workshops. He has also written numerous training manuals. As senior adviser in the MOHs in Nairobi and in Hanoi he was in charge of operational planning at both central and local levels and contributed to SWAP-related work in one province in Vietnam. The same was done in Bangladesh. He has closely worked with concerned government agencies including public finance institutions and human rights committees.

By training, Dr Schuftan is a Medical Doctor and Pediatrician with a degree of the Universidad de Chile in Santiago and holds a post-graduate diploma in Food and Nutrition Planning from the Massachusetts Institute of Technology (MIT) in the US. He is a US, Chilean and German national and resides in Vietnam since 1995 (first Hanoi and then in Ho Chi Min City since 2003). He is the author of over 85 scholarly papers published in refereed journals.

 LINKS

[1] Powerful international agencies under the influence of powerful nations promote programs that barely deal with human rights minima –if at all. These powers get away with bypassing the human rights commitments they do not like to recognize that they have made. They want to limit rights to the bare minima thus leaving aside all obligations to respect, protect and fulfill chronically violated rights that are at the base of ‘the lack of resilience’ as the authors so rightly point out. Governments depend on laying claim to being ‘rational and apolitical’ –in short, espousing the ‘ideology of the extreme center’. The space for Do Gooders belongs to the era of charity; we are now in the era of human rights. (The road to hell is paved with good intentions).

[2] Already in 2009, I had written two papers critiquing the sustainability concept. See Schuftan, C. http://claudioschuftan.com/37-a-the-emerging-sustainable-development-paradigm-a-global-forum-on-the-cutting-edge-of-progressive-thinking/ and  http://claudioschuftan.com/37-b-towards-operationalizing-a-sustainable-development-beyond-ethical-pronouncements-the-role-of-civil-society-and-networking/

[3] Unfortunately, difficult problems have the power of leading us to focus on their more manageable components thus totally avoiding the more complex, underlying and basic, structural questions. This is known as ‘the exclusion fallacy’ in which what we choose not to discuss is assumed to have no bearing on the issue. (Mc Dermott, World Bank, 1989)

[4] To make sense of current world problems, we too often fall back on a ‘shish-kebab mentality’. This much easier and convenient approach looks at the various problems affecting the world as if they were all separate events (morsels) skewed together by tragedy or destiny. So we set out to tackle the morsels…when the problem is in the skewer.

 

Health Breaking News 315

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 315

 

‘2018: a Year in Review through PEAH Contributors’ Takes’ by Daniele Dionisio 

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Neoliberalism has led to a crisis in care – and we urgently need to solve it 

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Smallholders’ global food production underestimated  

Human Rights Reader 468 

The Global Gender Gap Report 2018 

UNPO NEWSLETTER November-December 2018 

WHO launches technical guidance series on the health of refugees and migrants 

The Overwhelming Evidence in Favor of Harm Reduction  

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WHO Report Shows Global Progress On Influenza Preparedness Response 

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Spatially targeted screening to reduce tuberculosis transmission in high-incidence settings 

Eliminating financial and economic barriers to tuberculosis diagnosis and care 

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DRC Ebola: latest numbers as of 18 December 2018 

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DNDi: 2018 in Review 

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Murky climate deal lets down poor countries 

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Climate Change Is The Greatest Threat To Human Health In History 

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2018: a Year in Review through PEAH Contributors’ Takes

Authoritative insights by 2018 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

2018: a Year in Review through PEAH Contributors’ Takes

 

As  2018 draws to a close, 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 the relevant links:

Transitioning from Global Fund Grants to Domestic Funds: a New Opportunity for Strengthening Health Products’ Procurement and Supply Chain Systems in Middle Income Countries? by Barbara MilaniIndependent Consultant, Pharmaceuticals and Public Health – Programme & Policy Specialist

‘Lifestyle Drift’, Air Pollution and the World Health Organization by Ted SchreckerProfessor of Global Health Policy, Newcastle University

The UK is Finally Cracking Down on Unreported Clinical Trials. Now Other European Countries Must Take Action Too by Till BrucknerFounder of TranspariMED  

Social Capital Formation in the West African Ebola Pandemic: Tapping Faith-Community Trust Reserves is an Essential Tactical Strategy in Outbreak Control by Richard A. Nisbett, E Julu Swen, M. Scott GilpinUniversity of Liberia-PIRE Center Africa, Discipleship Resources International of the United Methodist Church, Liberia and Wesley College and Foundation, Tanzania 

Equity in Investments – a Need to Map the Research Landscape for Health by Michael HeadClinical Informatics Research Unit and Global Health Research Institute, Faculty of Medicine, University of Southampton, UK

Why Health in All Policies Is a Necessity? by Gisela AbbamDirector, Strategic Partnerships Abt Associates

Discrimination and Stereotype in the Global-North and -South Nation-States: the Major Interlope to Universal Health Coverage for Refugees and Other Vulnerable Immigrant Persons by Michael SsemakulaHealth Rights Researcher & Advocate, Human Rights Research Documentation Center (HURIC) & PHM-Network, Uganda

Private Players in the Growth Paradox of Health Service Provision and Advancement in Uganda by Michael Ssemakula, Health Rights Researcher & Advocate, Human Rights Research Documentation Center (HURIC) & PHM-Network, Uganda

The Global Implications of the Gag Rule and its Manifestations on Reproductive Health Rights in Uganda by Denis Bukenya and Michael SsemakulaHealth Rights Researchers & Advocates, Human Rights Research Documentation Center (HURIC), and PHM-Network, Uganda

Falsified and Substandard Medicines: Threat to the SDGs – but Who’s Watching, Caring or Acting? by David PattersonPrincipal Consultant, Health, Law and Development Consultants (HLDC), The Hague, Netherlands

Caning of LGBT Persons – Implications for Public Health and the Economy by Fifa RahmanPostgraduate Researcher (PhD) at University of Leeds, UK

The Untold Story About Counterfeit Medicines And Its Effects On The Right To Health In Uganda by Denis Bukenya and Michael SsemakulaHealth Rights Researchers & Advocates, Human Rights Research Documentation Center (HURIC), and PHM-Network, Uganda

The NHS Postcode Lottery: How the Decision-Making Power of Clinical Commissioning Groups is Preventing Standardised, Equal Access to the Abbott Freestyle Libre in England by Rebecca Barlow-NooneStudent of Medical Sciences at the School of Biological Sciences, University of Leeds (UK)

Accessibility to Medicines in Uganda by Denis Bukenya and Michael SsemakulaHealth Rights Researchers & Advocates, Human Rights Research Documentation Center (HURIC), and PHM-Network, Uganda

Public Finance and Public Health by Ted SchreckerProfessor of Global Health Policy, Newcastle University

Promoting Some Literacy on the Health Systems of Countries of Origin of Migrants in Europe by Yves CharpakMD, PhD, Consultant, Vice-president of the French Public-Health Association

Health and Climate Change: a Third World War with No Guns by Juan E Garay, David Chiriboga, Nefer Kelley, Adam GarayEquity Movement

New Hope for Conquering MDR-TB with Rapid Diagnostic Test and Short, Affordable Treatment Regimens by Subhash Hira, University of Washington-Seattle, USA-Brook Besor University, Lusaka, Zambia,  et al.

HIV and AIDS in Eastern Europe and Central Asia: Pragmatism and Human Rights Versus Taboos by Hans Houweling and Anke (J.J.) van Dam, AFEW International

Challenges and Solutions for the Latinx Population to Effectively Participate in Clinical Trials by Karen Mancera CuevasAssociate Director, Research Projects at Northwestern University, Feinberg School of Medicine, Chicago USA

International HPV Awareness Day by Corie LeiferGive Love Not HPV Campaign Coordinator, International Papillomavirus Society

Governments’ Failure to Curb Rampant Waste in Medical Research Threatens SDG Health Targets by Till BrucknerFounder of TranspariMED

Fair Research Partnerships in European Commission Funded Research by Carel IJsselmuiden and Kirsty KlippCouncil on Health Research for Development – COHRED

Who is Taking Responsibility for the Quality-Assurance of Medicines Supplied in Humanitarian and Development Programs? A Proposal from Belgium by Raffaella RavinettoPublic Health Department, Institute of Tropical Medicine Antwerp, Belgium

Policy Implications for Community-based Interventions to Strengthen Healthcare Delivery, Based Upon a Formative Study of Community Capacity in Urban Monrovia, Liberia Corresponding Author: Richard A. NisbettUniversity of Liberia-Pacific Institute of Research and Evaluation, Africa Center (UL-PIRE), WVS Tubman University, Harper Liberia                    

Corrupt Medical Practices in Germany by Christiane FisherMedical Director, No Free Lunch, Germany MEZISMember of the German Ethics Council

Bridging the Gaps in Clinical Guideline to Care in Pregnancy for Women Using Psychoactive Substances by Grana ZiiaAFEW-Kyrgyzstan

Opium and its Association with Cardio-Vascular Disease by Junior BazileProgram Director at New York Harm Reduction EducatorsResearch Consultant and Online Community Moderator at Global Health Delivery Project, Harvard University

Finally in the (Global Health) Spotlight, Nurses Now! by Clara Affun AdegbuluIntern and Researcher, Health Policy Unit, Institute of Tropical Medicine in Antwerp, Belgium; Masters (MPH) student, University of Vienna, Austria 

Global Health and Occupied Palestine by Angelo StefaniniCentre for International Health, University of Bologna (Italy)

Overcoming Public Health’s Perception Challenges by Lawrence C. LohAdjunct Professor, Dalla Lana School of Public Health, University of Toronto, and Director of Programs at The 53rd Week Ltd

The Strategic Functions of Nutrients in Preventing Tropical Diseases by Adrian BoruchProject Manager, ALVO Medical, Poland

What Public Health Policy Can Learn from the Murders of Nicole Brown Simpson and Ron Goldman by Ted SchreckerProfessor of Global Health Policy, Newcastle University

Understanding the Systems that Influence Distribution Channels for Drugs in Uganda by Denis Bukenya JosephHealth Rights Researcher & Advocate, Human Rights Research Documentation Center (HURIC) & PHM-Network, Uganda

On Health Inequalities, Davos, and the Deadly Neoliberalism by Ted SchreckerProfessor of Global Health Policy, Newcastle University

Challenges in Universal Health Coverage in Pakistan by Nighat KhanAffiliate at Global eHealth Academy University of Edinburgh

The contributions highlighted above add to PEAH internal articles published throughout the year. Find the links below:

The Contradictory Case of EU SPC Mechanism and Waiver by Daniele Dionisio

Will Ever WHO’s Roadmap for Medicines Move into Action? The Threat of Neoliberal Polices, Corporate Interests Collusion by Daniele Dionisio

Uganda: the Big Challenge of Maternal and Child Health by Pietro Dionisio

Interview to Saliou Diallo by Daniele Dionisio

La Salute Sostenibile (Pensiero Scientifico Ed. 2018) review by Daniele Dionisio

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

Moreover, as part of PEAH scope and aims, a new column titled ‘Focus on: Uganda’s Health Issues‘ has been set up. A space open to contribution articles from everywhere, this column aims to serve as an observatory of challenging health issues in Uganda from a comprehensive view encompassing the policies, strategies and practices of all involved actors. 

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.

——————————————————

*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

Health Breaking News 314

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 314

 

Why the Universal Declaration of Human Rights is still relevant, 70 years on 

How can the UN become a Thought Leader again? 

‘Transitioning from Global Fund Grants to Domestic Funds: a New Opportunity for Strengthening Health Products’ Procurement and Supply Chain Systems in Middle Income Countries?’ by Barbara Milani 

Tanzania is first African country to reach an important milestone in the regulation of medicines 

Could The Latest In Medical Treatment Be… A Roof? Medicaid Says Maybe 

Moving Work On Social Determinants Of Health From Health Funders To Health Funder Partnerships 

Journal of Public Health Volume 40, Issue suppl_2, December 2018 

Experts Call For Global Accountability Mechanism For Access To Essential Medicines 

A global accountability mechanism for access to essential medicines 

Pharma and medical device lobbies stonewall on transparency as doctors and patients call for fines on companies hiding clinical trial results 

OECD Report Presents Policies To Balance Innovation With Access To Medicines 

Latest numbers of DRC Ebola as of 12 December 2018 

Country-owned strategies to fight malaria 

So Close, Yet So Far: Why is HIV/AIDS Funding Decreasing? 

It is not our fault”: the plight of HIV positive adolescents in Cameroon – What difference can compassionate care make to HIV care for adolescents in LMICs? 

Vaccines in the fight against AMR and access by vulnerable groups 

Fostering synergies and strengthening joint efforts to fight AMR 

The role of specialist nurses in the fight against AMR 

Hospital pharmacists in the frontline against AMR 

EMSA’s View on Antimicrobial Resistance 

Medical students taking action on AMR 

How the new CAP can support the reduction in use of farm antibiotics 

Human rights in 2018 – ten issues that made headlines 

Rethinking global poverty reduction in 2019 

Associations between sex work laws and sex workers’ health: A systematic review and meta-analysis of quantitative and qualitative studies 

Nearly 30 million sick and premature newborns in dire need of treatment every year 

The Global Compact on Migration: Dead on arrival? 

163 states just approved the Global Compact for Migration. Now what? 

Indigenous IP And Climate Change Subject Of New Book 

No One Solution: A Climate Prize Hopes to Plant Many Seeds 

The most important country for the global climate no one is talking about 

Scientists decry lack of data on ocean pollution 

Two of 196 signatory countries to Paris Agreement have raised their climate ambitions

Transitioning from Global Fund Grants to Domestic Funds in Middle Income Countries

Preparing the transition of Middle Income Countries from Global Fund to domestic funds may provide new opportunities to strengthen procurement and supply chain management areas.  Reforming health products’ procurement procedures, price policies, domestic financial flows and national quality assurance procedures are likely to represent needed steps to capitalize on Global Fund supported health procurement. This will require renovated country ownership and a central role for WHO to implement efficiently collaborative regulatory projects

By Barbara Milani

Independent Consultant, Pharmaceuticals and Public Health – Programme & Policy Specialist

Transitioning from Global Fund Grants to Domestic Funds

A New Opportunity for Strengthening Health Products’ Procurement and Supply Chain Systems in Middle Income Countries?

 

The Global Fund financing model started off with unprecedented central ownership placed at national level for procuring quality assured health products at competitive prices. At the same time, by establishing clear procurement and supply chain management  (PSM) policies it has created a global market for quality assured medicines prequalified by WHO and/or registered by Stringent Regulatory Authorities. (1) Among the several requirements that the Global Fund placed on country systems, quality control of medicines has motivated several countries to strengthen national Quality Control laboratories to obtain WHO accreditation.

The Global Fund procurement policies embraced a much larger field of opportunities to strengthen health product management systems at the national level; either strategically building through disease specific grants or using Health System Strengthening dedicated grants. Many countries were supported to meet the most urgent needs such as central storage facilities and distribution systems meeting WHO Good Storage and Distribution Practices. Much of the potential to strengthen PSM remained underused due to weak proposal conceptualization. A 2017 Global Fund systematic analysis using a sample of 15 countries clearly recognized that supply chain management remains a major challenge. (2) Technical assistance is still required in several countries for quantification and procurement planning.  As reported by several organizations, risks of stock-outs and actual stock-outs are not unusual and technical assistance is often called in on an emergency level to solve or mitigate these risks.  (3) (4)

In the wider context of all Global Fund supported countries, the challenges raised for an unplanned transition are understandable. (3) (4) The positive element is that the Global Fund has set policy and guidance for co-financing and transition learning from the first experiences on transition. (5) (6) The policy reassures on the fact that the transition process has to be prepared and evaluated before enacting the actual transition.

There are countries for which the Global Fund contribution constitutes only a minimal fraction of the national programme operating budget (20% or less). However, this contribution can be vital for several reasons. In many cases the Global Fund contribution covers key activities that the national health system is currently unable to absorb. These activities range from community approaches addressing the epidemics in the most vulnerable and difficult to reach populations to the procurement of specific categories of health products.

De facto, the Global Fund systems have allowed countries to procure quality assured medicines even in small quantities through international procurement mechanisms bypassing price-related or government procedural limitations. In other instances, the Global Fund has mandated procurement of specific health products through certain channels. According to Global Fund policies, second line anti-tuberculosis medicines shall be procured through the Global Drug Facility, a United Nations-based  procurement agency which is pooling demand and consolidating a market for quality assured medicines for less than half a million patients per year globally.

In preparing the transition of Middle Income Countries, there are opportunities to strengthen PSM areas, which have been neglected during the rollout of grants. There is also an unprecedented possibility to prepare the transition in ways that support countries to reform their laws, regulations and procedures to procure and supply health products using modalities that meet WHO standards and obtain the “best value for money”. More specifically, domestic procurement of quality assured health products at competitive or internationally negotiated prices requires that government procurement procedures be reformed and adapted. These, among other aspects, shall enable timely procurement of health products, which are single/limited source or required in small quantities or for which internationally negotiated prices are available. These categories of products require distinct procurement methods beyond national tendering processes.  Assessing the current status of government procurement procedures for health products seems a starting point for preparing a step-wise transition. Reforming national procurement procedures for health products requires conceptualization and time.  Such processes are indeed framed within the legislative system of the country. (6)

Price policies should also be evaluated and reviewed. Especially in Middle Income Countries, price policies shall favour all measures to access quality assured health products at the most affordable price. These include among various interventions, mechanisms for procurement of health products at internationally negotiated prices as discussed above, but also training to enhance knowledge, reform and use of TRIPS flexibilities included in national laws. (6)

Another crucial aspect is the quality assurance of medicines and other health products. This requires major involvement and a renovated role of the World Health Organization to make use, expand and evaluate the WHO collaborative projects aimed at facilitating registration of quality assured medicines at the national level. (7) While the Global Fund has mandated quality standards for health products procured with its funds, the transition may result in procurement of locally registered medicines without recognition of the nearly two decades of work to expand access to generic affordable medicines through the WHO prequalification programme. (1) (3) (4) National disease programmes, through the implementation of Global Fund procurement procedures, have generally acquired the concept of quality assured medicines and its link with treatment’s efficacy and prevention of drug resistance. This may not be the case for unstructured and understaffed National Regulatory Agencies. Hence the need for WHO to offer, engage and measure participation in the WHO collaborative registration project seems the only way to interface with governments. Until now, the collaborative procedures for accelerated registration for medicines prequalified by WHO and registered by Stringent Regulatory Agencies (SRA) have been largely underused by the participating countries. Effective collaborative procedures to facilitate registration of quality assured medicines are very much needed. Countries preparing for a transition from Global Fund grant shall engage in such collaborative procedures.

Secondly, the Global Fund financing is often used to overcome limitations in procurement due to unreliable flow of domestic funds. In preparing for a transition, the domestic financial procedures need to be reviewed to enable reliable national procurement planning. Financial engagement and disbursement for health products shall be framed to allow the regular launch of national procurement processes and suppliers contracting.  Irregular availability of funds is detrimental to procurement planning, may discourage suppliers to apply for national tenders also for health products required in considerable quantities. Irregular financial flow makes any health products quantification and procurement planning exercise ineffective.

While several elements come into play to ensure an uninterrupted supply of essential health products to patients, it is important to highlight key elements that are likely to come up for any Middle Income Country transition.  Addressing the suitability of national health product procedures, price policies, quality assurance systems and domestic financial procedures shall be at the core of discussion. Moving in this direction requires renovated country ownership to make the best use of this opportunity to improve efficiency throughout the whole health system as well as a renovated role of WHO to address shortfalls in the functioning of National Regulatory Agencies.

 

References

1 -Guide to Global Fund Policies on Procurement and Supply Management of Health Products, July 2017 Geneva,  Switzerland

https://www.theglobalfund.org/media/5873/psm_procurementsupplymanagement_guidelines_en.pdf

2 -Audit Report :The Global Fund’s In-country Supply Chain Processes, GF-OIG-17-008, 28 April 2017, Geneva, Switzerland

https://www.theglobalfund.org/media/6363/oig_gf-oig-17-008_report_en.pdf?u=636727911240000000

3 -Article: Transitioning in the context of universal health coverage: Reflections from STOPAIDS and partners event at World Health Assembly 71, Jenny Vaughan, 11th June 2018

https://stopaids.org.uk/2018/06/11/transitioning-in-the-context-of-universal-health-coverage-reflections-from-stopaids-and-partners-event-at-world-health-assembly-71/

4 -MSF calls on Global Fund Board to make urgent changes to prevent drug stock-outs and quality issues, Geneva, 13 November 2018

https://msfaccess.org/hundreds-thousands-peoples-treatment-risk-countries-transition-global-fund-support?tid=3Transitioning and co-

5 -The Global Fund Sustainability, Transition and Co-financing Policy, 35th Board Meeting, GF/B35/04 – Revision 1 Board Decision

https://www.theglobalfund.org/media/4221/bm35_04-sustainabilitytransitionandcofinancing_policy_en.pdf

6 -Guidance Note: Sustainability, Transition and Co-financing of programs supported by the Global Fund, 13 January 2017

https://www.theglobalfund.org/media/5648/core_sustainabilityandtransition_guidancenote_en.pdf

7 -Website : Prequalification of medicines: Collaborative Procedure for Accelerated Registration

https://extranet.who.int/prequal/content/collaborative-procedure-accelerated-registration

 

 

 

 

 

Health Breaking News 313

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 313

 

Unhealthy conditions: IMF loan conditionality and its impact on health financing 

The problem with Public-Private Partnerships and the role of the EU 

CGD UPCOMING SEMINAR: Disrupting Health Product Distribution: The Emergence of Digital Innovators in Africa THURSDAY, DECEMBER 13, 2018 – 12:00PM TO 1:30PM 

International symposium on understanding the double burden of malnutrition for effective interventions 10 – 13 December 2018 IAEA Headquarters, Vienna, Austria 

WHO says spread of polio remains international health emergency 

The President’s Malaria Initiative and Other U.S. Government Global Malaria Efforts 

Congo Ebola outbreak is 2nd largest, 2nd deadliest 

DRC Ebola: Latest numbers as of 4 December 2018 

Are we on the cusp of a breakthrough in Ebola treatment? 

Measles cases spike globally due to gaps in vaccination coverage 

On World AIDS Day, a Moment for Celebration and Self-Reflection 

MPP: Accelerating access to treatment for children with HIV must be a public health priority 

The right to deworming: The case for girls and women of reproductive age 

‘Antimicrobial Resistance Knows No Boundaries’ 

First-ever UN report on disability and development, illustrates inclusion gaps 

The crisis of multilateralism and the future of humanitarian action 

Over 40 million people still victims of slavery 

Human Rights Reader 467 

Amit Sengupta (1958 to 2018) was a powerful voice for health equity 

UNPO Khmer-Krom Newsletter #2, November-December 2018 

No decline in discrimination against people of African descent in EU 

Ten harmful beliefs that perpetuate violence against women and girls 

Medicines Law & Policy: The TRIPS Flexibilities Database 

Putting People’s Health First: Improving Access to Medicines in Europe 

Amgen Cuts Repatha’s Price By 60 Percent. Will Value-Based Pricing Support Value-based Patient Access? 

Study Finds Arthritis Drug Enbrel Overpatented, Overpriced in US 

French health groups challenge public funders INSERM and CNRS over unreported clinical trials 

Research into medical devices needs to be made transparent – statement by TranspariMED  

In Yemen, Lavish Meals for Few, Starvation for Many and a Dilemma for Reporters 

The future of the sweetened beverages tax in Portugal 

World is woefully short of 2 degree goal for climate change, according to UN report 

World Bank Group to Raise $200 Billion to Fight Climate Change 

Pollution by the numbers 

Legal tweak could wreck Amazon forest 

Health Breaking News 312

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 312

In memory of the generous public health activist Dr Amit Sengupta, keen fighter of inequalities and humanitarian who always championed the weak and disadvantaged

 

An Irreparable Loss for the Broader Health Movement Globally and in India: People’s Health Movement’s tribute to Dr Amit Sengupta 

“One of the strongest pillars”: Dr Amit Sengupta, a leader of the public health movement, dies at 60 

The G20 Tango: What to Expect From the Buenos Aires Summit 

What to Watch at the UN Climate Talks 

Yes, climate change is a humanitarian issue 

China vows to improve action on climate change as it prepares for UN summit 

Making finance flows consistent with Paris objectives 6 December 2018 16:45 – 18:15 GMT +1 (CEST) Public event Bieszczady Room, COP24, Katowice 

In Nairobi, a landmark push for a global blue economy 

‘Lifestyle Drift’, Air Pollution and the World Health Organization by Ted Schrecker 

The European Alliance for Responsible R&D and Affordable Medicines: Manifesto European Elections 2019 /Nov 2018 ‘Putting People’s Health First: Improving Access to Medicines in Europe’ 

PHA4: Austerity measures are the biggest impediment to access to healthcare

Next Commission needs a vice-president for health, campaigners say 

WHO Africa’s Third Forum on health systems strengthening for UHC and the SDGs 

ROM TDR PARTNER, PROVIDED AS INFORMATION FOR SHARING: WHO Africa Innovation Challenge Promoting African Solutions for Africa’s Health. Deadline for submission: Monday 10 December 2018 at midnight (GMT+1) 

How Could Africa Be Affected by Product-specific Support for Farm Goods? 

‘No country is untouched’: Global Nutrition Report highlights compounding malnutrition 

Human Rights Reader 466 

UK pledges £50m to help end FGM in Africa 

UN Committee Adopts ‘Landmark’ Declaration Reinforcing Peasants’ Rights To Seeds 

Why the HIV epidemic is not over 

Pharmaceutical corporations failing children with HIV 

Silent Epidemic: a call to action against child tuberculosis 

Antibiotics resistance breaks global boundaries 

Malaria control campaign launched in Democratic Republic of the Congo to save lives and aid Ebola response 

Democratic Republic of the Congo begins first-ever multi-drug Ebola trial 

DRC Ebola: Latest numbers as of 27 November 2018 

From recognition to action: A strategic approach to foster sustainable collaborations for rabies elimination 

Relationships between intensity, duration, cumulative dose, and timing of smoking with age at menopause: A pooled analysis of individual data from 17 observational studies 

Are Other Countries to Blame for High US Drug Prices? 

Prescription for Change: The Pharma Giant Investing in Local Public School Students 

Thousands of European clinical trials are missing results. Here’s what advocacy groups can do to fix that 

‘Lifestyle Drift’, Air Pollution and the World Health Organization

The solution to pollution is to hold you children up out of the car exhausts?  Try exercising in less polluted areas?  (If you live in London, maybe drive to Somerset for your jog?)  One couldn’t make this stuff up

By Ted Schrecker

Professor of Global Health Policy, Newcastle University

‘Lifestyle Drift’, Air Pollution and the World Health Organization

 

In 2013 the International Association for Research on Cancer (IARC), WHO’s normally cautious cancer research arm, announced that it considers outdoor air pollution a Category 1 carcinogen – that is, the category for which evidence of cancer-causing properties is strongest.   (The full background monograph is available here.)  This turned out to be one of the most under-reported global health news stories of the new Millennium – like the estimate, the following year, that WHO considered air pollution responsible for shortening the lives of seven million people worldwide.

In 2016, a team of WHO researchers led by Annette Prüss-Ustün updated earlier estimates of the proportion of the global disease burden attributable to the environment, concluding that 23 percent of global deaths and 22 percent of global disability adjusted life years were attributable to environmental risks, although obviously only part of this toll reflects the impact of air pollution.  (I’m happy to say that we published a summary of this work in the Journal of Public Health.)  Importantly, the authors made the point that environmental risks are not primarily a problem of poor countries, or poor people: ‘The lower people’s socioeconomic status the more likely they are to be exposed to environmental risks, such as chemicals, air pollution and poor housing, water, sanitation and hygiene.’  This is certainly true of air pollution, with the highest annual mean concentrations of fine particulate matter occurring in low- and middle-income countries, and the highest urban concentrations of those particulates occurring in Indian cities, with high concentrations also observed in cities like Bamenda, Cameroon and Kampala, Uganda.

WHO now appears to be taking air pollution much more seriously.  Unfortunately, its approach reflects the individualized, behavioural approach taken by the organization to noncommunicable diseases as a whole, as this screenshot from its website shows:

The solution to pollution is to hold you children up out of the car exhausts?  Try exercising in less polluted areas?  (If you live in London, maybe drive to Somerset for your jog?)  One couldn’t make this stuff up.

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