If you cross paths with Robert Zoellick's mother over the next few weeks, please remind her that applications to George Washington University's School of Public Health are due soon. Her son needs to hurry up and submit his paperwork. Mrs. Zoellick might be surprised at the suggestion that her son Robert, US Trade Representative, should go back to school. She might tell you that her dear Robbie already graduated magna cum laude from Harvard's Law School and received an MPP from the Kennedy School of Government. Mrs. Zoellick might say that her son's overqualified for his job. The only problem is that Robert Zoellick has been making a lot of decisions about public health lately - and in that realm, he is terribly uninformed.
Take, for instance, his actions last month at the WTO council. Trade representatives from the other 143 member countries of the WTO decided that the poorest of nations - those without any pharmaceutical manufacturing facilities - should be able to import cheap generic drugs, since they can't pay for the more expensive patented versions. But Mr. Zoellick became the only minister at the WTO to refuse to agree to the measure.
This isn't the first time that's happened. Back in December, Mr. Zoellick did the same thing just before Christmas. The issue was how to implement the WTO's "Doha Declaration" on public health, which the WTO (with Mr. Zoellick's vote) passed in November 2001. That agreement declared that the patent rights of drug companies should be secondary to public health concerns to "promote access to medicines for all." In the agreement, the WTO promised to determine how countries without manufacturing facilities were going to import generic drugs.
But Mr. Zoellick decided that he would "reinterpret" the Doha Declaration. He claimed that the Declaration was not really about promoting "access to medicines for all" (in spite of the wording in the Declaration itself) but it was really only intended to cover a short list of diseases. He came to the table with a list of 15 diseases he thought were suitable. The only problem was that major killers like cervical cancer and pneumonia were not included. Mr. Zoellick said those diseases not on the list were "lifestyle" disorders. So the three million kids who will die from pneumonia in Africa this year better whip themselves back into shape and learn to change their ways. Some of the other trade ministers thought this was a bit perverse, and refused to agree to that deal.
February was supposed to be a finalization of the delayed negotiation process, but Mr. Zoellick came to the table with a new set of rules, once again using his "alternative" theories of public health practice. This time, medicine access would not be restricted to just a short list of diseases, but countries would also be restricted to importing generics only after a "national emergency." So health ministers in Burkina Faso, which is currently in the beginning stages of a major meningitis epidemic, should sit tight and wait for a couple hundred thousand people to die - then they can begin the legislative process to get medicines. Other rules proposed by Mr. Zoellick would be extraordinarily cumbersome. Under the system proposed, if Pakistan wanted to get cheaper drugs from an Indian generic manufacturer, the Indian government would have to pass legislation for Pakistani citizens. How politically pragmatic!
No one mentions, of course, that the very measures Mr. Zoellick is pushing on the poorest of countries are far more stringent than those followed by the United States. Remember the anthrax scare? After only four deaths, Congress was threatening to import generics immediately if Bayer Corporation didn't produce its anti-anthrax drug quickly enough. But other countries, of course, aren't allowed to do the same when they have real public health crises.
I pity Mr. Zoellick's public relations officer, who will no doubt be working long hours to generate an entirely new system of logic justifying the nature of these deals. But, of course, there's plenty of support for Mr. Zoellick and his worker bees at the Washington trade office. It comes from the pharmaceutical industry, as was made explicit at the WTO council. Instead of negotiating with each other, the trade ministers declared they would just circumvent the whole process and start negotiating directly with Pfizer. Companies like Pfizer don't want a break in their global monopoly on prices. But if the most profitable industry in the world can't handle the fact that poor countries represent a tiny percentage of their pharmaceutical market, then our trade ministers need to be able to stand up to them and defend the Doha Declaration.
The industry, and the USTR, claims that generics would undermine their capacity to pay for research and development - that is, the research and development that American taxpayers actually foot most of the bill for. The industry doesn't bother to release it's own tax information, however, which reveals that Merck this year used 13% of its profits on marketing and only 5% on R&D, Pfizer spent 35% on marketing and only 15% on R&D, and the industry overall spent 27% on marketing and 11% on R&D according the Securities and Exchange Commission. That's not accounting for the fact that 52% of new drugs on the market aren't even the result of R&D, but are "me too" drugs that are simple reformulations of old products slapped with new stickers.
The industry still claims that generics will undermine its business, even as it continues to be ranked by Fortune Magazine as the world's most profitable industry for 11 years in a row (having profits as a percentage of revenue nearly three times the rest of the Fortune 500 industry). When confronted with the fact that Africa comprises only 1.3% of the industry's revenues (making its loss equivalent to "about three days fluctuation in exchange rates," according to an industry analyst quoted in The Washington Post), the industry claims that generic drugs will get diverted to the North to undermine its key markets, and cites GlaxoSmithKline's recent loss of AIDS drugs sent to Africa as a case in point. But a look at the GSK case shows that Glaxo failed to even track the shipments and only discovered after a year that its packages to Africa had been shipped improperly, allowing them to be smuggled to Europe. Tracking mechanisms, however, seem to be no trouble for neighbourhood flower shops. Indian generic manufacturers, meanwhile, have shipped medicines for over two decades without a single case of "diversion".
It's time for Mr. Zoellick to learn what it means when 24,000 people die a day from treatable diseases; otherwise, he should take a fraction of the $20 million in campaign contributions pharmaceutical companies donated last year and use it for his tuition at the School of Public Health.
* Read more about the WTO negotiations in the 'Equity and Health General' and 'WTO, Economic and Social Policy' sections of Equinet News.
1. Editorial
2. Equity in Health
The enthusiasm surrounding last month's proposal by US President George W Bush to triple government spending on HIV/AIDS in Africa has been tempered with calls from activists for more practical details. In his State of the Union address, Bush urged Congress to approve US $15 billion in funds to battle HIV/AIDS in the hardest-hit countries in Africa and the Caribbean over the next five years. But activists were cautiously optimistic. "The exact details of the president's plan for global AIDS are still unclear. We could be shipping AIDS medications to hospitals and clinics next month, not promising to treat two million people in five years," treatment lobby group, Act-Up Philadelphia said in a statement.
While the South African Treasury and Department of Health number-crunch to determine whether government can afford anti-retroviral (ARV) treatment in public health, a number of small ARV programmes are already up and running. Several others are in the pipeline, the most ambitious being the SA Medical Association pledge to raise R80-million to set up two ARV pilot projects in each province to treat 9 000 people.
"Let us not be mistaken that the resounding announcement by G.W. Bush, of a 10 billion dollars commitment to the fight against AIDS, serves essentially one objective: to renege on commitments made in November 2001, at the WTO conference in Doha, to allow access to generic drugs," says a statement from lobby group Act Up.
Women's rights advocates are condemning President George W. Bush for using his promised AIDS relief package to expand the so-called global gag rule. Calling the move the latest battle in the administration's war against women, many groups are mounting a campaign to draw attention to what they say are the Bush administration's plans to further restrict abortion rights.
Confusion is the only certain ingredient in government's approach to HIV/AIDS. President Mbeki, his lapel no longer sporting an AIDS ribbon, said government would continue to implement its "comprehensive HIV/AIDS strategy" when he opened Parliament last week. But his two dull sentences on the disease - as over 10 000 people massed outside to demand treatment for people with HIV - did little to convey the impression of a caring government committed to helping its 4,5 million citizens living with the disease.
The latest row about the use of state hospital beds by private medical schemes has raised again a contradiction between expressed constitutional aims on the one hand and government policy and practice on the other. The rights to "healthcare, food, water and social security" are contained in clause 27 of the Bill of Rights. This clause obliges the state to "take reasonable legislative and other measures within its available resources to achieve the progressive realisation of these rights". In essence, this means every effort should be made to ensure that all South Africans have equal access to quality healthcare.
Although a humanitarian crisis had been mitigated in Southern Africa through swift food aid deliveries, a horrifying new disaster was looming in Southern Africa in the form of HIV/AIDS, James Morris, the UN Secretary-General's special envoy for humanitarian needs in Southern Africa has warned. "The impact of HIV/AIDS on this part of the world is enormous and the impact on women and children is devastating," Morris told journalists after a visit to four of the six southern African countries battling critical food shortages affecting over 14 million people.
AIDS Healthcare Foundation, the largest AIDS organisation in the United States has filed a complaint with South Africa’s Competition Commission against GlaxoSmithKline. AHF filed the complaint over the company’s drug pricing and AIDS policies in South Africa, which it described as “having a stranglehold on key AIDS drug patents” and exercising “unfettered monopoly pricing on these life-saving medications.” AHF wants the commission, an independent body ensuring that companies compete fairly and do not abuse positions of power, to overturn GlaxoSmithKline’s sole right of manufacturing drugs in the country.
Although delegates from 22 World Trade Organization member nations failed to break gridlock on the issue of how to relax patent protection to give developing nations better access to drugs to fight public health epidemics, including HIV/AIDS, a proposal by Brazil may offer a "glimmer of hope" in the talks, Reuters reports. Under the new plan, introduced during a three-day meeting in Tokyo, the World Health Organisation would determine if low-income nations have the infrastructure to manufacture generic versions of drugs.
Thousands marched in Cape Town in February in a massive show of support for the demand that the South African government sign and implement a national HIV treatment programme. Estimates on the amount of marchers attending the march organised by AIDS-lobby group the Treatment Action Campaign (TAC) and taking place on the occasion of the opening of South Africa's Parliament for 2003 ranged from between 10 000 and 30 000. The material available through the link below includes a report on the march, a letter from TAC activist Zackie Achmat about the march, the memorandum presented to government and a memorandum to President Bush and Members of US Congress dealing with the Doha agreement.
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3. Human Resources
Private hospitals are pulling out all the stops to keep nurses from taking up lucrative offers overseas. Salary incentives and training programmes are just some of the carrots being dangled before staff to keep them loyal. Nursing Update, the journal of the Democratic Nursing Organisation of South Africa (Denosa), is overflowing with adverts for nursing positions in the UK (where the training background is similar), Canada, the US, Australia and New Zealand. Saudi Arabia also pays big money.
This publication is designed to guide government departments in South Africa on the minimum requirements to effectively manage HIV/AIDS in the workplace and ensure a coordinated public service response. It is expected to assist departments in planning, developing, implementing, monitoring and evaluating workplace HIV/AIDS policies and programs.
In a recent article in the South African Medical Journal, Nicki Fouché of the Division of Nursing and Midwifery at the Faculty of Health Sciences at the University of Cape Town warned that the haemorrhaging of professional nursing staff would have a catastrophic effect on the delivery of health care in South Africa over the next decade. She added that it was estimated that there are 2 300 registered nurses working overseas and that they receive about 200 applications per month for overseas registration. In 1999, 3 300 nurses left South Africa.
4. Public-Private Mix
This paper, Prepared and Presented at the 'Making Services Work for Poor People' World Development Report (WDR) 2003/04 Workshop, puts forward three arguments. First our understanding of the health sector is handicapped by trying to fit it into language and concepts which do not adequately capture its changing realities and the political economies within which health sectors are embedded. Second, this has disposed to putting forward decontextualised, and thus largely normative solutions, such as “regulation,” to the problem of improving service delivery in poorly performing environments. Third, approaches need to move beyond the dualism of public versus private and work creatively with messy and sometimes contradictory realities. It concludes with a discussion of how this analysis can be applied to a major international intervention set up to benefit the poor – the Global Fund for HIV/AIDS, TB and Malaria.
Many low and middle-income countries (LMICs) have experienced changes in the provision of healthcare services. Services are now provided by a variety of sources under market conditions. In response to this shift, how have the roles of healthcare providers changed? How have households adapted to these changes in order to meet their health needs? What should governments do to provide good healthcare in these conditions? Research by the UK's Institute of Development Studies highlights that over the last few decades there have been profound changes in the ways that health goods are produced and consumed in LMICs. This change is due to economic and political factors, such as crises in public sector financing and governance, that have reduced governments’ capacity to fund infrastructure, supplies and salaries and competently manage healthcare. The result in many countries is that it is difficult to maintain the distinction between public and private in the health sector.
This paper from Reproductive Health Matters looks at the implications of user fees for women's utilization of health care services, based on selected studies in Africa. Lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach. Even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions. If user fees and other out-of-pocket costs are to be retained in resource-poor settings, there is a need to demonstrate how they can be successfully and equitably implemented.
As the economic burden of HIV/AIDS increases in sub-Saharan Africa, allocation of the burden among levels and sectors of society is changing. The private sector has more scope to avoid the economic burden of AIDS than governments, households, or nongovernmental organisations, and the burden is being systematically shifted away from the private sector. The article suggests that the shift in the economic burden of AIDS is a predictable response by business to which a deliberate public policy response is needed. Countries should make explicit decisions about each sector's responsibilities if a socially desirable allocation is to be achieved.
This article produced by Social Watch analyses the impact of privatisation of health, education and basic infrastructure. It follows the United Nations Commission on Human Rights (UNCHR) report that urges WTO member nations to consider the human rights implications of liberalising trade in services, especially health, education and water. Social Watch is an international NGO watchdog network monitoring poverty eradication and gender equality.
5. Resource allocation and health financing
More energy, money and international attention is now being focused on HIV/AIDS than on any other global public health issue. A pandemic that was being quietly forgotten by the global community only three years ago has hurtled up national and international policy agendas. Equally, says this paper from Panos, there has never been a time when so much energy translates into so little hope. "We believe – and the feeling seems widely shared – that the energy and commitment currently focused on fighting HIV/AIDS is in grave danger of being wasted. If coherent, robust strategies are not directed at the root causes of the epidemic, rather than the symptoms, then the same level of energy and attention may never again be catalysed."
Officials at the Global Fund to Fight AIDS, Tuberculosis and Malaria have launched a "new round of arm-twisting" of its main donors -- the United States, Japan and European Union countries -- amid fears that the fund will "wither away" without new financing, the Financial Times reports. The need for increased contributions to the fund will be on the agenda of both the G7 finance ministers meeting in May and the G8 summit in June, before a scheduled meeting of the donor countries in July, according to Richard Feachem, executive director of the fund.
This paper - published in Health Policy and Planning - explores the policy-making process in the 1990s in two countries, South Africa and Zambia, in relation to health care financing reforms. The two countries’ experiences indicate the strong influence of political factors and actors over which health care financing policies were implemented, and which not, as well as over the details of policy design. Moments of political transition in both countries provided political leaders, specifically Ministers of Health, with windows of opportunity in which to introduce new policies. However, these transitions, and the changes in administrative structures introduced with them, also created environments that constrained the processes of reform design and implementation and limited the equity and sustainability gains achieved by the policies.
6. Governance and participation in health
Africa Malaria Day on 25 April 2003 is nearing, marking three years since African leaders met in Abuja, Nigeria and promised to help fight malaria by dropping taxes on treated mosquito nets. Research and experience prove beyond any doubt that Insect Treated Nets (ITNs) save lives by preventing new malarial infections. Recognizing their life-saving potential, African leaders pledged to drop all taxes and tariffs on ITNs. But despite this, many countries have yet to drop the malaria tax. At the website below there are a range of resources for finding out more about malaria and the campaign to drop the taxes on mosquito nets, information about the campaign to pressure African leaders to comply and a list of countries who have kept their promise about the tax and those who haven't.
7. Monitoring equity and research policy
Good public policy decisions require reliable information about the causal relationships among variables. Policymakers must understand the way the world works and the likely effects of manipulating the variables that are under their control. The purpose of this paper from The Robert Wood Johnson Foundation's Changes in Health Care Financing and Organisation (HCFO) is to assist policymakers by providing an introduction to some of the problems associated with causal inference from empirical data. The paper also will be helpful to researchers who are attempting to draw causal inferences from data, or explain their results to policymakers.
There has been a marked lack of dialogue on policymaking between the areas of reproductive health and reform of the health sector. Policies in each area have been developed by different actors, pursuing different objectives. Consequently, disjointed policy-making has tended to predominate. A framework is proposed for enhancing such dialogue and collaboration between the two fields, with reference to links between actors, an understanding of policy contexts, the development of compatible aims and the need for institutional strengthening.
8. Useful Resources
The Gender and Health Equity Network is a partnership of national and international institutions concerned with developing and implementing policies to improve gender and health equity, particularly in resource constrained environments.
Included in this issue:
* Jonathan D Quick
Essential medicines twenty-five years on: closing the access gap, Health Policy Plan. 2003 18: 1-3.
* Damian Walker
Cost and cost-effectiveness of HIV/AIDS prevention strategies in developing countries: is there an evidence base? Health Policy Plan. 2003 18: 4-17.
* David Ayuku, Wilson Odero, Charles Kaplan, Rene De Bruyn, and Marten De Vries
Social network analysis for health and social interventions among Kenyan scavenging street children, Health Policy Plan. 2003 18: 109-118.
PAHO has just launched a quick way for its readers to go straight to the source of what they are looking for in electronic format. They can now access one or more chapters of the organisation's most popular publications, such as Health in the Americas and Control of Communicable Diseases (Spanish version), among others, in a minimum of keystrokes. With this new service, readers can select only those chapters on the diseases that most interest them or select the chapter on a country for which they need the latest mortality or morbidity data.
POPLINE®(POPulation information onLINE) provides citations with abstracts of the worldwide literature on population, family planning, and related health issues. The world's largest bibliographic population database, POPLINE® brings together 300,000 records representing published and unpublished literature in the field.
SHARED started in 1996 as an EC concerted action. SHARED's objective is to share essential information on health research and development for developing countries. Everyone can contribute information to the database. A network of Focal Points has a proactive role in information dissemination on a local level. Visit their web site for more information.
Veteran Ugandan AIDS activist Noerine Kaleeba is an angry woman. Anger propelled her into the frontline of HIV/AIDS activism in her country after her husband's death from HIV/AIDS. Sixteen years later Kaleeba is still angry, but her anger is now directed at the stigma and discrimination surrounding the disease. Kaleeba was speaking during the launch of the second edition of her acclaimed book 'We Miss You All' in Johannesburg. The book tells the story of her husband's death from AIDS, and how this led her to form The AIDS Support Organisation (TASO). It also relates how her family coped with the pain and stigma that the disease brought into their lives.
The HealthLink Bulletin is a free weekly electronic news bulletin of interest to health workers, policy makers, journalists, researchers, donor organisations, medical insurance and pharmaceutical companies, civil society organisations and consultants. Information covered includes notice of new research findings, publications, conferences, events, news, job opportunities, resources (electronic and other), courses and news items relevant to health systems development, policy and practice in Southern Africa.
9. Jobs and Announcements
One of a series of International Policy Research Workshops held over the last eleven years in the UK, East Asia and Africa, the 6th HEARD HIV/AIDS workshop focuses on the need to anticipate the medium and long-term social and economic consequences of HIV/AIDS. We offer participants a unique opportunity over two weeks, to exchange ideas, review their experiences with strategies and tactics, and identify interventions appropriate to their local situation.
The organisation of Conferences on Community and Home based Care stems from the realisation that the issue is hardly dealt with in international meetings. This conference, initiated by PWAs, is convened every other year since 1993, in different countries, with different themes depending on PWA priority concerns.
TDR is inviting applications for the award of collaborative research grants to research institutions and scientists from least developed endemic countries (LDCs), and from high-burden countries for TDR target diseases on: Determinants of inequality of access to prevention, therapy and information; Implications of changing economic, social, political and civil structures (including health reforms) for disease persistence, emergence, resurgence and factors affecting them such as drug and insecticide resistance.
The Regional Training Programme for Reproductive Health with special emphasis on Family Planning is supported by the Government of Mauritius, the United Nations Population Fund (UNFPA), the World Health Organisation (WHO) and other international agencies. Its objective is to contribute to the health and socio-economic development in Africa and the region by improving the Reproductive Health (RH) status of the population through the provision of Training of Trainers programmes for Reproductive Health.
This conference stems from the need for HIV/AIDS interventions to be based on sound information about the medium and long-term demographic, social and economic consequences of HIV/AIDS. Towards that end, the organisers have invited 50 researchers to present papers derived from rigorous empirical research. The conference offers a unique opportunity for an additional 50 participants to hear what is actually known about the socio-economic and demographic impacts of HIV/AIDS, to compare evidence from different countries and to exchange ideas on research and management strategies.
The course aims to provide participants with an understanding of the most important strategies available for the control of pesticide related morbidity and mortality. After the completion of the course participants will be able to apply their knowledge to their own settings, be it research, teaching, or as health and safety managers, planners or practitioners. The course is intended to be adapted to the needs of different categories of participants, combining a mix of plenary sessions with working groups to address specific needs identified in a pre-course questionnaire.
HealthWrights - Workgroup for People's Health and Rights - is developing an online resource called 'Politics of Health Knowledge Network' (see www.politicsofhealth.org). This will be a user-friendly information-sharing tool providing solid facts and informative analysis so that concerned people can better respond to the most urgent health-related issues confronting humanity. They are inviting participation in various areas.
THE GLOBAL FUND, established in 2001, is an independent public-private partnership. It is the largest global fund in the health domain, with over USD 2.0 billion currently committed. The Fund is looking for staff with strong commitment, an open mind-set, entrepreneurial and flexible attitudes, proven emotional intelligence and the ability to work under pressure within tight deadlines.