Health Breaking News: Link 272

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

Health Breaking News: Link 272

The Top 5 Issues In EU Medicines Policy For 2018 (Including IP)

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Human Rights Reader 435

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About Ghana Health Service

A Beer With Bill Gates: Some Advice on How to Succeed in a Critical Funding Niche

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

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

By Ted Schrecker

Professor of Global Health Policy, Newcastle University, UK

Co-editor, Journal of Public Health

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

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

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

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

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

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

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

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

Understanding the Systems that Influence Distribution Channels for Drugs in Uganda

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

By Bukenya Denis Joseph*

Human Rights Research Documentation Centre (HURIC) Kampala, Uganda

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

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

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

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

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

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

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

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

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

Moving forward

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

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

References

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

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

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

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

Health Breaking News: Link 271

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

Health Breaking News: Link 271

World Economic Forum – live updates

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‘On Health Inequalities, Davos, and Deadly Neoliberalism’ by Ted Schrecker

A question for Dr. Tedros and other global health leaders ahead of Davos

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‘Challenges in Universal Health Coverage in Developing Countries like Pakistan’ by Nighat Khan

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On Health Inequalities, Davos, and Deadly Neoliberalism

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

By Ted Schrecker

Professor of Global Health Policy, Newcastle University, UK

Co-editor, Journal of Public Health

On Health Inequalities, Davos, and Deadly Neoliberalism

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

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

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

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

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

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

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

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

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

Challenges in UHC in Pakistan

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

By Nighat Khan

Affiliate at Global eHealth Academy University of Edinburgh

Challenges in Universal Health Coverage in Developing Countries like Pakistan

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

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

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

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

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

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

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

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

The case of Pakistan

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

http://www.un.org/en/universal-declaration-human-rights ( Accessed December 10th, 2017)
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Health Breaking News: Link 270

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

Health Breaking News: Link 270

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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

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

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

By Pietro Dionisio

EU health project manager at Medea SRL, Florence, Italy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Health Breaking News: Link 268

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