Connecting global debates to local realities at the 2019 World Health Assembly
Michael Ssemakula, People’s Health Movement and Human Rights Research Documentation Center, Uganda

Global meetings and processes can seem very distant from the realities at local level, despite the fact that the policies being made in global meetings have profound influence on these local realities. The People’s Health Movement (PHM) has for several years implemented a ‘WHO watch programme’ to follow and provide information, analysis and critical commentary for people on the global health debates taking place at the World Health Organisation (WHO).

In its Global Health Watch activities, PHM follows range of WHO meetings, including the World Health Assembly (WHA) and the WHO Executive Board (EB) and at regional level in the WHO Regional Committees, such as the one for the AFRO region. The analysis that PHM does explores how far these global processes and resolutions respond to local, regional and global contexts and priorities and how far states and other relevant stakeholders’ implement, comply with and are publicly accountable for the resolutions made.

The recently ended ‘WHA72’ that took place in end May 2019 was one such global meeting.

There were many debates at the WHA72, but two merit attention. One was on improving the transparency of markets for medicines, vaccines and other health-related products and technologies. A second was on the Ebola epidemic in the Democratic Republic of Congo (DRC) and the public health emergency response. Both were critical debates for African countries. Both issues need strong intervention from states, by galvanizing comprehensive workforces and capacities for both health systems and emergency responses, to address disease burdens and respond to disease outbreaks.

After the scrutiny and criticism of its response to the Ebola epidemic in West-Africa in 2014, WHO restructured its health emergencies program in 2016 to provide a more effective response. However, the virtual freeze in member state contributions has meant that the core funding for the program has not improved. The current Ebola outbreak in the DRC thus provided an opportunity to assess how successful the measures and resources are for such emergency responses. The DRC outbreak provided a tough test: it has been termed a complex emergency due to its occurrence in a highly volatile and extremely insecure conflict zone, politicizing the epidemic and raising the challenge of dealing with an outbreak in a war zone. At the recent WHA, WHO reported that its use of vaccination strategies enabled it to achieve unprecedented survival rates. It also pointed to other factors that enabled the response and improved survival, including significant investment in planning and capacities for epidemic preparedness, sustained testing for Ebola, improved screening, vaccination of frontline healthcare-workers and training of multidisciplinary teams for a rapid response mechanism.

While this work has been a significant contribution to addressing the Ebola emergency in DRC, there are still issues to address. PHM observe that WHO should mobilise member states and other relevant-stakeholders to find ethical and valid ways of more rapidly testing interventions to combat diseases like Ebola. A rapidly spreading emergency like Ebola calls for an urgent response, including quick advice on the most effective treatments to use. The concern is that the pace of development of new vaccines, drugs and diagnostics is not meeting the pace of rapid spread of health emergencies, such as that faced in the DRC. The time consuming nature and wide population enrolment of current medicine trials doesn’t match the urgency needed for responding to such rapidly spreading epidemics. This raises debate on what flexibilities can be introduced that do not compromise the quality and safety of trials.

At the same time, there is also a more general demand for improved access to medicines. Accessing medicines would have been critical for the approximately 1.6 million Africans who died of malaria, tuberculosis and HIV-related illnesses in 2015. While many of the diseases in Africa can be prevented or treated with timely access to appropriate and affordable medicines, vaccines and other health interventions, less than two percent of medicines consumed in Africa are produced on the continent. Many people cannot access locally produced drugs and many may not afford imported medicines.

The WHA discussed a draft roadmap on access to medicines, vaccines and other health products for 2019-2023. The roadmap proposes strategies to support quality, safety, efficacy and equitable access of health-products. The strategies include strengthening regulation, assessing the quality, safety and efficacy or performance of health products, including through market surveillance and investing in research and development (R&D) that meets public health needs. The strategies also include managing intellectual property so that it contributes to innovation and promotes public health, and ensuring evidence-based selection, fair and affordable pricing, procurement and supply chain management and appropriate prescribing, dispensing and rational use of health products.

The resolution on transparency of markets for medicines, vaccines, and other health-related products and technologies adopted at this year’s WHA is a substantial stride towards improving the affordability of and access to medicines and other technologies. For example, there is currently an information gap on what different countries pay for medicines and on the actual cost of R&D and manufacture of medicines. The lack of transparency on this gives pharmaceutical corporations a significant advantage and allows them to charge extortionate prices, maximizing profit over human life.

Despite the obvious benefit of improved transparency in these issues, the resolution received mixed reactions. Germany, Hungary and the United Kingdom dissociated themselves from the resolution, using a range of procedural reasons. They claimed that the roadmap was “rushed through” and breached procedure, with inadequate consultation with all experts. The dissociation raised governance concerns. However the resolution was approved by a majority of states and will support the space for governments in Africa to negotiate medicine prices. Given the current crisis of unaffordable pricing of many medical technologies, the resolution, if implemented, will support greater public disclosure of prices of medicines and other health-related products. This information should help to reduce the prices of these products, now needed also for rising levels of chronic conditions such as cancers, hepatitis and diabetes, many of which are too costly for universal access in low and middle income countries.
The resolution was thus welcomed by African countries. It needs to be further monitored for its implementation to assess if it achieves its purpose and goal in relation to universal health coverage (UHC). At the same time, as raised by PHM during a debate at the WHA on UHC, accessing medicines also depends on investing in comprehensive primary health care. Further, as was the original intention of Alma Ata, we need to apply human rights-based and comprehensive approaches not just to treating disease, but also to ensuring health. As we address issues of transparency and of responsiveness to emergencies, that also depends on a deeper redistribution of power and wealth.

You can read more about PHM ‘watch’ activities and findings in the Global Health Watch at https://www.ghwatch.org/wha72 . Commentaries, statements and policy briefs can be found on the WHO Tracker at https://who-track.phmovement.org/.

Consolidating progress: what have we done to use the flexibilities in the TRIPS agreement won at Doha in 2001?
Elijah Munyuki, Rangarirai Machemedze, SEATINI, Rene Loewenson, TARSC

The Trade Related Aspects of Intellectual Property Rights (TRIPs) Agreement of the World Trade Organisation came into effect on 1 January 1995 and set standards for intellectual property systems. Least Developed Countries (LDCs) have until 2016 to bring their systems into line with TRIPS for pharmaceutical patents. Five years may seem a long time. But how far have we come in the 15 years since the agreement was passed?

One of the most important steps taken after the agreement was the successful advocacy at the WTO Ministerial conference in Doha in 2001 to include flexibilities in the TRIPs agreement so poorer countries could address their public health crises, especially given the AIDS epidemic. Paragraph 17 of the Doha Declaration provided that the TRIPS Agreement be interpreted in a manner supportive of public health by promoting access to existing medicines. The flexibilities provided for compulsory licensing or the right to grant a license, without permission from the license holder; for parallel importation or the right to import products patented in one country from another country where the price is less; for exceptions from patentability and limits on data protection and for early working, known as the Bolar Provision, allowing generic producers to conduct tests and obtain health authority approvals before a patent expires, making cheaper generic drugs available more quickly at that time. The World Health Organisation (WHO) in its 2008 Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property, urged for these flexibilities to be implemented in national laws and international agreements, including facilitating, through export, access to pharmaceutical products in countries with insufficient or no manufacturing capacity.

Nine years after Doha, a review of legislation shows that the intellectual property regimes in place in many east and southern African (ESA) countries have not been significantly changed. Patenting laws in many countries (eg Botswana and DRC) were passed before the TRIPS agreement or Doha round. Some (such as Zimbabwe and Zambia) already provided for the flexibilities, but some still have gaps, such as in South Africa, where flexibilities enabling production and export of medicines to the region are still to be enacted. Some countries, such as Kenya, have enacted new laws providing for flexibilities, while in others (such as Uganda and Namibia), these proposals still remain in draft form. While WTO provides for countries to provide the TRIPS Council with "as much information as possible on their individual priority needs for technical and financial cooperation in order to assist them in taking steps necessary to implement the TRIPS Agreement, " so far in ESA only Uganda has taken this step. LDCs in ESA do not have to give exclusive marketing rights to pharmaceuticals that are subject of a patent application until 1 January 2016, but it is unclear how many countries have yet conducted self-assessments to prepare negotiating positions for possible extension of this waiver.

Even those ESA countries that have the flexibilities in their laws are not fully implementing them. They face a number of constraints. Most ESA countries lack domestic pharmaceutical research and manufacturing capacities and have insufficient technical and infrastructural capacities to effectively regulate medicines. Countries have weaknesses in their pharmaceutical management and procurement systems, and in accessing pricing and patent status information. Countries also face economic and political pressures. Stronger property rights (including of intellectual property) is urged as necessary for foreign direct investment and countries face trade and investment pressures not to use the TRIPS flexibilities.

African configurations are at various stages of negotiating comprehensive Economic Partnership Agreements with the European Union, for example. While the underlying 2000 Cotonou Agreement does not oblige ESA countries to negotiate IPR rules and aims for “co-operation” in the field of IPRs, the overall intention of the agreement is to protect intellectual property rights. EU business seeks to open new markets for its exports and this includes protecting intellectual property, given the heavy involvement of EU companies in research and development. The African Growth and Opportunities Act (AGOA (2000) has unilaterally extended market access to ESA countries, with one of the requirements for eligibility being that the country should commit itself to eliminating barriers to US trade and investment by “protecting intellectual property rights,” and desist from interfering in the economy through measures such as price controls, subsidies and government ownership of economic assets. Most recently, anti-counterfeit laws, such as those passed in Kenya, under debate in Uganda and effected through amendments to existing law in Tanzania, while seeking to prevent the damage caused by fake medicines, have the potential to limit the legal production and distribution of generic medicines. When Anti-Counterfeit Laws define a counterfeit as a good that is identical or substantially similar to a good protected under an intellectual property right, they appear in effect to include legal generic products. It seems these states have not designed their anti-counterfeit laws to adequately take into account the protection of TRIPS flexibilities.

A lack of vigilance to protecting the ground won at Doha is now apparent in a new problem. The 2001 public health related aspects of the TRIPS flexibilities now have to be formally adopted at the World Trade Organisation. For this two thirds of countries need to propose the formal adoption. By December 2009, according to the WTO (http://www.wto.org/english/tratop_e/trips_e/amendment_e.htm), only Mauritius and Zambia in ESA had added their names to this proposal. In other words the ESA countries have not added their names to the critical mass needed to enable a formal adoption of the protocol amending the TRIPS agreement at the WTO. This formal adoption should have been implemented by December 2007. The deadline was extended to December 2009, and on 17th December 2009, WTO members agreed to a second extension to December 2011. It is important for ESA countries to now formally propose adoption to avoid the unnecessary renegotiation of these critical amendments to the TRIPs agreement.

Advances can never be taken for granted in a rapidly changing world, and neither can the five year period we have left before TRIPS is fully enforced, for us to put in place a self determined legal, institutional and investment environment for drug manufacture and procurement in ESA countries. For now there is an urgent need for all ESA countries to endorse the protocol on the TRIPS amendments that the flexibilities are entrenched. In the next five years we still appear to have much to do to take advantage of the flexibilities through our laws, policies and capacities, including with respect to the production and export of medicines within the region, and to set the terms for discussions on intellectual property regimes (IPRs) with trade and development partners in a manner that puts us in a stronger position to produce and procure medicines and to protect public health. Our national health strategic plans in ESA should all include clear roadmaps of how we will effectively use the next five years to achieve this.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the SEATINI website at http://seatini.org/ and the EQUINET website at www.equinetafrica.org.

Critiquing the Concept of Resilience in Health Systems
Stephanie Topp, Walter Flores, Veena Sriram and Kerry Scott

In social theory, the dominant state is known as the hegemon. In the 19th century, hegemony came to denote the ‘Social or cultural predominance or ascendancy; predominance by one group within a society or milieu’. However, commentators on power have also used the term to describe the power of discourse - particularly in the field of governance. In this note we wish to draw attention to, and challenge, what we fear is an emerging hegemonic discourse in the field of health policy and systems work - the discourse of resilience.

In the past five years ‘resilience’ has been increasingly applied in health policy and systems research (HPSR) to refer to the need for distressed health systems (micro or macro) to ‘bounce back’ from shocks. Often implicit in this discourse, is the assumption that such systems were ‘there’ in the first place, or at the very least, that with a concerted effort they can get there. What a resilient health system means in this context is not clear - but we contend that, in a form of technocratic reductionism, resilience strategies and solutions are often divorced from meaningful assessment of the political economy and power dynamics that produced the health system crises in the first place.

Health systems in crises suffer from chronic deficiencies in many things - material and human resources central-level planning and coordination capacity and domestic financing to name but a few. The populations and communities seeking services from these deficient systems are more likely to have low levels of education, weak citizen engagement and to experience deep class inequity. Much of the technocratic discussion around ‘building resilience’ appears to bypass these issues, however, often focusing on tweaking inputs or health system components, and frequently emphasising self-reliance and behaviour change. This technocratic and formulaic approach to building resilience is at odds with the complex reality of health systems in each country.

‘Building resilience’ rarely seems to involve a direct examination of, or challenge to, the structural conditions that contribute to overarching health system dysfunction, including historical colonial legacies, current trade and aid structures, tax and health insurance structures. We are concerned that the discourse of resilience will follow the trend of global health policy reforms being fuelled by the perceived immediacy of a problem instead of careful analysis of root causes and strategies likely to prevent recurrence in the long-term. Recent examples include the Ebola epidemic and now Zika, in which resilience discourse is getting close to that of the global health security agenda in which the main concern is transnational epidemics from the south to the north. The rise of hegemonic resilience discourse has effectively enabled global health stakeholders to replace the conversation about systemic failures at multiple levels which supports a far more long term vision, with an action-oriented discourse that implies much shorter time-frames.

A conscious discussion is needed to reframe what the health system community means when we use the term ‘resilience’. Resilience and the linked concept of sustainability of health programming have value, as long as they are not divorced from the material changes that need to occur to support them and the requirement for a more balanced relationship among national states (trade, flow of resources, and others). Use of these terms should build on previous work and consensus around social determinants of health, right to health and people-centered health systems. This means resilience should be situated on a continuum rather than replacing important advances around health systems and its relation with equity, fairness and human rights.

Ultimately, we contend that a more ambitious and nuanced application of the term ‘resilience’ is required if the term is to contribute to improving LMIC health systems’ capacity to withstand political, financial, epidemiological and environmental shocks. We must also do everything possible to prevent such shocks in the first place. But at the very least, we in the health policy and systems community need to start acknowledging the dangers of using ‘resilience’ as part of a de-politicised and technocratic discourse.

This piece was first posted as a blog for Health Systems Global (HSG) http://tinyurl.com/j968dqc. The authors are thematic leads of the cluster on Power in Health Systems in the SHaPeS Technical working group of HSG. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.

Delhi Communique of the Second BRICS Health Ministers’ Meeting
Ministers of Health of the Federative Republic of Brazil, the Russian Federation, India, People’s Republic of China and Republic of South Africa, New Delhi, 11 January 2013

The BRICS countries, represented by the Ministers of Health of the Federative Republic of Brazil, the Russian Federation, India, People’s Republic of China and Republic of South Africa, met in New Delhi on 11 January 2013 at the Second BRICS Health Ministers’ Meeting.

The meeting recalled the Delhi Declaration of 29 March 2012 during the BRICS leaders summit and the Joint Communiqué of the BRICS Health Ministers at Geneva of 22 May 2012 including specific areas of work under the BRICS Health Platform for each Member State, focussed on the theme “BRICS Partnership for Global Stability, Security and Prosperity” to address emerging health threats.

The Ministers recalled that BRICS is a platform for dialogue and cooperation amongst countries representing 43% of the world’s population. The Ministers reiterated their commitment to the Beijing Declaration of July 2011 for strengthened collaboration in the area of access to public health and services in BRICS States including implementation of affordable, equitable and sustainable solutions for common health challenges. The Ministers committed to strengthen intra-BRICS cooperation for promoting health of the BRICS population. The BRICS Health Ministers resolved to continue cooperation in the sphere of health through the Technical Working Group.

The Ministers drew attention to the current global threat of non-communicable diseases and noted that in 2008, around 80% of all NCD deaths occurred in low and middle income countries. The Ministers recognized the significant role of BRICS countries in the global process of prevention and control of NCDs including the Moscow Declaration of April 2011, the WHA Resolution 64.11 of May 2011 and the Political Declaration of the UN General Assembly of September 2011.The Ministers recognized the need for more research into the social and economic determinants leading to occurrence of non-communicable diseases, amongst the BRICS countries. They resolved to collaborate and cooperate to promote access to comprehensive and cost-effective prevention, treatment and care for the integrated management of non-communicable diseases, including access to medicines and diagnostics and other technologies.

The Ministers also recognized the need to combat mental disorders through a multi-pronged approach including the World Health Assembly Resolution 65.4, consideration of a Comprehensive Mental Health Action Plan through sharing of innovations in the field of Mental Health Promotion, diagnosis and management, exchange of best practices and experiences amongst BRICS countries.

The Ministers renewed their commitment to the WHO Framework Convention on Tobacco Control and stressed the importance of research and study by WHO and other stakeholders into the social and economic determinants of tobacco use and its control.

The Ministers recognized that multi-drug resistant tuberculosis is a major public health problem for the BRICS countries due to its high prevalence and incidence mostly on the marginalized and vulnerable sections of society. They resolved to collaborate and cooperate for development of capacity and infrastructure to reduce the prevalence and incidence of tuberculosis through innovation for new drugs/vaccines, diagnostics and promotion of consortia of tuberculosis researchers to collaborate on clinical trials of drugs and vaccines, strengthening access to affordable medicines and delivery of quality care. The Ministers also recognized the need to cooperate for adopting and improving systems for notification of tuberculosis patients, availability of anti-tuberculosis drugs at facilities by improving supplier performance, procurement systems and logistics and management of HIV-associated tuberculosis in the primary health care system.

The Ministers called for renewed efforts to face the continued challenge posed by HIV. They committed to focus on cooperation in combating HIV/AIDS through approaches such as innovative ways to reach out with prevention services, efficacious drugs and diagnostics, exchange of information on newer treatment regimens, determination of recent infections and HIV-TB co-infections. The Ministers agreed to share experience and expertise in the areas of surveillance, existing and new strategies to prevent the spread of HIV, and in rapid scale up of affordable treatment. They reiterated their commitment to ensure that bilateral and regional trade agreements do not undermine TRIPS flexibilities so as to assure availability of affordable generic ARV drugs to developing countries.

The Ministers committed to strengthen cooperation to combat malaria through enhanced diagnostics, research and development and committed to facilitate common access to the technologies developed or under development in the BRICS countries.

The Ministers renewed their commitment for effective control of both communicable and non-communicable diseases through cooperation in sharing of existing resource information, development of risk assessment tools, risk mitigation methods, referral systems, life course approaches, community empowerment, monitoring health impact assessments of all public policies at national and international levels.

Recognizing that an effective health surveillance, including injury surveillance, is the key strategy for controlling both communicable and non-communicable diseases, that surveillance is also the cornerstone around which the implementation of the International Health Regulations (2005) is based and further recognizing that the countries may be using different models for surveillance based on different realities and best practices, the Ministers committed to strengthen cooperation in the mechanisms for planning, monitoring and evaluating disease prevention and control activities and capacity-building for effective health surveillance systems.

The Ministers urged focus on the unique strength of BRICS countries such as capacity for R & D and manufacturing of affordable health products, and capability to conduct clinical trials. The Ministers called for strengthened cooperation in application of bio-technology for health benefits for the population of BRICS countries.

The Ministers emphasized the importance of child survival through progressive reduction in the maternal mortality, infant mortality, neo-natal mortality and under-5 mortality, with the aim of achieving the Millennium Development Goals. They confirmed their commitment to a renewed effort in this area and to enhance collaboration through exchange of best practices.

The Ministers discussed the recommendations of the Consultative Expert Working Group on Health on coordination and financing of R & D for medical products and welcomed the proposal to establish a Global Health R&D observatory as well as the move on holding regional consultations to set up R&D demonstration projects. The Ministers urged that the entire process, including priority setting, should be driven by WHO Member States and should be based on public health needs, in particular those of developing countries, with the cost of R & D delinked from the final products.

The Ministers reiterated their support to the continued discussions on the process of reform of WHO, to better respond to global challenges in programmatic, organizational and operational terms, including the future financing of WHO, and welcomed the proposal to establish a financing dialogue based on priorities collectively set by WHO Member States in a structured and transparent process.

The Ministers acknowledged the value and importance of traditional medicine and need of experience and knowledge-sharing for securing public health needs. They urged for cooperation amongst the BRICS countries through visits of experts, organization of symposia to encourage the use of traditional medicine, in all spheres of health.

The Ministers confirmed their support for the United Nations General Assembly Resolution on universal health coverage and committed to work nationally, regionally and globally to ensure that universal health coverage is achieved.

The Ministers recalled the Beijing Declaration of the 1st BRICS Health Ministers’ Meeting in 2011, emphasizing the importance and need of technology transfer as a means to empower developing countries. In this context, they underlined the important role of generic medicines in the realization of the right to health. The Ministers renewed their commitment to strengthening international cooperation in health, in particular South-South cooperation, with a view to supporting efforts in developing countries to promote health for all and resolve to establish the BRICS network of technological cooperation. The Ministers acknowledged the need of use of ICT in Health services to promote cost-effective treatment in remote areas. They encouraged strengthened cooperation amongst the BRICS countries to share their experiences in e-Health including tele-medicine. The Ministers agreed to cooperate in all international fora regarding matters relating to TRIPS flexibilities with a public health perspective.

The Ministers agreed to establish platforms for collaboration within BRICS framework and with other countries with a view to realizing the goals and objectives outlined in this Declaration.

This statement is drawn from the Government of India communique on the BRICS Health Ministers meeting at http://pib.nic.in/newsite/erelease.aspx?relid=91533. Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.

Delivering on aspirations for equity

This newsletter includes the Istanbul Declaration, adopted by delegates to the first Global Human Development Forum in Istanbul in March 2012. The Declaration calls on the world community, gathering soon at the United Nations Conference on Sustainable Development (Rio+20) in June 2012, to set and implement global and national development strategies that emphasise social inclusion, social protection, and equity. This is in recognition of the fact that economic development has too often gone hand in hand with environmental degradation and increased inequality. Who sets those development strategies matters. One paper in this newsletter points, for example, to the disproportionate power over the global economy of just over 100 transnational corporations. Another questions the influence of private wealth in the underfunded global 'protector' of public health, the World Health Organisation. Within such asymmetries of power and influence the work at Rio+20 cannot end with aspirations. It also needs to tackle how institutions and processes need to change to deliver on these aspirations.

Dentistry in crisis: time to change
Lois Cohen, Gunnar Dahlen, Alfonso Escobar, Ole Fejerskov, Newell Johnson, Firoze Manji, La Cascada, Colombia

A group of senior scientists—researchers, academics and intellectuals—from various parts of the world, with over 250 years’ combined experience of working to improve the oral health of communities, independent of any institution, government body or corporate entity, met in Colombia in March 2017 and prepared a statement on their analysis of the problem and recommendations about what should be done. This editorial presents paragraphs extracted from the statement. The full statement, referred to as La Cascada Declaration, together with associated papers, is available at https://lacascada.pressbooks.com/front-matter/introduction/.

We are concerned that the dental profession, worldwide, has lost its way.

Despite current knowledge of the causes of oral diseases, globally most people continue to experience significant levels of disease and disability. Although technological and scientific developments over the last 50 years have contributed to improvements in the quality of life for some, oral diseases continue to cause pain, infection, tooth-loss and misery for a vast number of people. While in many middle and high income countries, there have been marked overall improvements in oral health, oral health inequalities both between and within countries are now a major problem. The overall improvements in oral health have been the result of general improvements in living standards and conditions, changing social norms in society (improvements in personal hygiene and reduction in smoking) and the widespread use of fluoride toothpastes, rather than due to the clinical interventions of dentists.

Globally the profession has had little direct impact on the scale of the problem. Clinical interventions account for only a small proportion of improvements in the health of populations. This is as true of oral health as of general health.

The world has witnessed significant growth in social inequalities between the rich and the poor. …Austerity policies worldwide (commonly referred to as ‘structural adjustment programs’ in the global South) have diverted social and welfare spending away from the public to the private sector in the belief that ‘the market’ can meet social needs, despite evidence to the contrary. This has led to the creation of a two-tier health service—one for the rich, and the other, limited and often of poorer quality, for the majority.

Corporations and insurance companies are increasingly taking over the provision of health services, including dental services, in many countries. The treatment regimens that they promote are designed more to ensure adequate returns on investment for their shareholders than to improve the health status of the community, resulting in a tendency for the provision of excessive and sometimes inappropriate treatments.

Major food and beverage companies continue to promote the consumption of refined carbohydrates, free sugars in drinks, confectionary and in processed foods, even though these are major contributory factors for dental decay, not to mention obesity and diabetes. Advertisements of these products frequently and unjustifiably imply health benefits.

We believe that the dental profession, as presently constituted, is inappropriately educated for dealing adequately with oral health problems faced by the public. In many countries, there is an overproduction of dentists, most of whom provide services only in the main urban centers where private practice is more lucrative and services often fail to reach those in more remote areas of the country. In some cases, overproduction results in unemployment.

While there is no doubt that the intention of the profession is to improve health, commonly used treatment regimens for tooth decay (drillings and fillings) and gum diseases (scaling and polishing) do not by themselves arrest or control their progression. Furthermore, filling teeth inevitably leads to a cycle of replacements of increasing size, ultimately shortening the life of the dentition.

Dentistry is drifting, it seems, away from its task of prevention and control of the progression of disease and of maintaining health. The mouth has become dissociated from the body, just as oral health care has become separated from general medicine.

We believe dentistry is in crisis. Things must change.

Since clinical interventions account for only a small proportion of health improvements, the dental professions should be in the forefront of efforts that call for a reduction in income disparities and for a more just world in which everyone has access to resources and conditions for good health and well-being. Those industries whose products are harmful to health, especially producers of free sugars in foods, drinks, and producers of foods containing refined carbohydrates, should be required to label their products as harmful (just as has been done in many parts of the world in relation to tobacco and alcohol). The decline in government spending on the social sector cannot be justified in the light of excessive expenditures on war, the military, arms and other destructive initiatives. Corporations and industry should not be permitted to unduly influence research or clinical practice.

The dental profession is over-trained for what they do and under-trained for what they should be doing. Control of the most common oral diseases requires relatively little training and could and should be performed in most cases by community healthcare workers. Demonstration projects on the effectiveness of such approaches are needed.

Dentistry should become a specialism of medicine, just as ENT (ear, nose & throat), ophthalmology, dermatology, etc. are specialisms of medicine. As such, oral health physicians would be responsible for providing leadership of the oral health team, in the management of advanced disease and the provision of emergency care, relief and management of pain, infections and sepsis, management of trauma, diagnosis and management of soft-tissue pathologies and, where justifiable from the point of view of the maintenance of health, interventions to re-establish a functional dentition and orofacial reconstruction. Since the management and control of most common diseases could be undertaken by primary healthcare workers, a relatively small number of such oral health physicians would need to be trained. In addition, a relatively small number of public health dentists would be needed to coordinate oral health needs assessments, implement and evaluate community-based oral health improvement strategies and to act as oral health advocates to ensure the closer integration of oral health into wider policies.

The implications of the above recommendations are obvious: changing dentists into oral health physicians necessitates thorough revision of the education profiles of dental schools: an overhaul of the current curriculum for training of dentists; a reduction in the number of dentists trained; and an improvement in the quality of courses, especially ensuring that training is linked to the needs of the population.

The current state of dentistry worldwide is dire. It requires radical solutions. This short declaration has been produced to stimulate discussion about what needs to be done in the interest of the health of the majority of humankind. We recognise that the changes may take time to implement. Each country will need to assess how best to bring these about.

Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org.

Developing country trade and health issues demand attention at 59th World Health Assembly
Riaz K. Tayob, SEATINI

Developing countries took several initiatives at the World Health Organisation's (WHO's) 59th World Health Assembly (WHA) in May 2006 to raise the need for WHO more strongly assert its global role in protecting health in the global economy.

A resolution was passed to increase coordination between WHO and the World Trade Organisation (WTO) on Trade and Health. It mandated the WHO to assist countries that are negotiating trade agreements that have an impact on their health sectors. Ministers at the East, Central and Southern African Health Community 42nd Regional Health Minister’s Conference in February 2006 called for such training for government and civil society to facilitate better understanding of the TRIPs agreement. Towards this EQUINET has developed a training toolkit on trade and health and carried out pilot workshops in Malawi, Zimbabwe and Tanzania. These confirm the call for greater support to country teams in negotiating new issues on trade and health. Countries are currently dealing with the General Agreement on Trade in Services (GATS) and the implementation of flexibilities under the WTO's Trade Related Intellectual Property Rights (TRIPs) agreement. TRIPs flexibilities relate to access to patented medicines or legally produced generics. The GATS deals with the liberalisation of health and health related services and has implications for cost recovery, cross subsidisation, health insurance, the regulation of commercial or competitive health services and indirectly related sectors like distribution.

Critics of the GATS have, for example, pointed out that it can and has limited the ability of governments to regulate health services towards the necessary cross subsidies and equity measures needed to promote universal access. EQUINET has resolved in its past forums that in a situation of high inequality in access to services, governments should enjoy full flexibility to regulate their health sectors in the public interest, unconstrained by WTO disciplines. The WTO Secretariat countered such criticisms in a publication “GATS - Fact and Fiction”, responding that countries were free to make commitments only in sectors they choose and could therefore limit liberalisation. This poses a problem for countries like Zambia who have already committed their health services in GATS, and may now want to regulate areas of health service provision. A ruling in April 2004 of the WTO's dispute settlement body in a case between the US and Mexico raises even greater concerns for countries like Zambia, as the dispute settlement body decided that the right of a country to promote development was not as important as its commitments to trade in services under the GATS.

In the TRIPs negotiations, flexibilities for developing countries for local production or import of pharmaceuticals under compulsory licenses have also led to relatively stiff resistance to proposals for improved flexibilities. Countries have also had to deal with bilateral trade agreements that erode these flexibilities. Some Latin American ministers at the WHA made a separate statement saying that TRIPs obligations should not be increased under bilateral/regional agreements. At the same time, the ECSA Regional Health Ministers noted that countries in the region still need to fully utilize these flexibilities and embed them in their national laws.

WHO clearly has significant challenges to address to promote health under WTO agreements. The mandate of the Trade and Health resolution is broad and will need to be closely monitored to ensure that the co-ordination promotes public health priorities and challenges the WTO's stronghold in health, particularly for developing countries.

One area of ground work for this has been in the WHO Commission for Intellectual Property Rights and Innovation in Public Health. The commission report was tabled at the WHA and made a number of recommendations on the IPR system for health, including that needs-driven health research should follow public health and development priorities; and promote innovation to develop solutions to health problems.

Parallel to this report an Intergovernmental Working Group was established by a resolution of the WHA, proposed by Kenya and Brazil. The proposal responded to the limitations of the current risk-reward innovation system of IPRs. This profit driven model fails to provide incentives for research into diseases affecting developing countries. Because the expectation of profit is limited in these “neglected diseases,” drugs are not researched and developed. The Working Group was mandated to produce a strategy and action plan on ways of promoting research for the prevention and management of these diseases and to examine the impact of this research on public health. This too will be an area where inputs from Africa will be important, given the extreme inequities that exist between public health burden and access to the technologies, diagnostics and drugs to prevent and manage disease.

African countries again raised the issue of the “brain drain” at the WHA, and the effect it has on their ability to cope with health demands. They requested compensation and ethical recruitment practices in sometimes tense debates. The African proposals were contested by the some developed countries, including those recruiting and receiving health personnel from Africa. The debates were not resolved, and the WHA resolution adopted committed rich countries to increase funding for health worker education in developing countries, inadequately addressing the wider demand for mechanisms that fairly and sustainably address perverse subsidies and enable African health sectors to value and retain their own health workers. At the same time, countries in the region need to be aware of the implications of the commitments they make under the GATS agreement on the movement of persons. Countries that make commitments that include liberalising the movement of people in the health sector may weaken their claims to compensation for that movement. Given the significant impact the shortfall in health workers is having in access to health care in east and southern Africa, we need bolder, more challenging global arrangements to manage issues of migration and resource transfers than have been the case to date.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat at TARSC, email admin@equinetafrica.org and to SEATINI (www.seatini.org). EQUINET work on health equity in economic and trade policy is available at the EQUINET website at www.equinetafrica.org.

Economic Partnership Agreements: negotiators must not compromise on health
Aulline Mabika, Percy Makombe, Ludwig Chizarura, SEATINI, Rene Loewenson, TARSC

Amekwi Lokana, a mother of six from Kenya, said some years ago 'These days, if you are without money, they leave you to die. If my children are ill, and I have money from selling sisal and firewood, I take them to the nearest town. If there's no money, I use herbs … if God takes them, we have done our best.'

It should never be the case that those without money cannot access health care. The most basic obligations that governments have are to respect and protect the survival and health rights of citizens. For governments in east and southern Africa, this is done in a context of the greatest intensity of AIDS globally, high levels of poverty and many other health challenges.

Meeting this obligation is not simply a matter for Ministries of Health. Increasingly finance and trade sectors are having a powerful bearing on health through the agreements they make. Most recently this issue has emerged in the Economic Partnership Agreement (EPA) currently being negotiated between east and southern Africa (ESA) and the European Union (EU), with the aim of signing a final agreement in December 2007.

The "Cotonou Agreement", signed between the EU and African and Caribbean countries in June 2000 makes clear the two central objectives of EPAs: to eradicate poverty and to enhance global integration. The challenge ESA countries face however is that the “global integration” pursued is through liberalisation and commercialisation measures that threaten poor communities' access to the goods and services essential for their health. In past experience this has increased - not reduced - poverty and poor health outcomes, particularly in an international trading system heavily stacked against African countries.

An EQUINET / SEATINI report released earlier this year points to a number of areas in which the EPA currently under negotiation can affect health and health care, unless specifically dealt with.

Firstly the EPA can affect access to essential medicines. It does not yet clearly make a commitment to give ESA countries rights to make maximum use of flexibilities in the WTO TRIPS agreement. These are essential to ensure access to medicines and medical technologies. Although this commitment has been verbally stated by the EU, it is not yet reflected in the EPA. Prior experience of EU free trade agreement (FTAs) with South Africa on this issue suggests that ESA countries and their parliaments and civil societies need be vigilant. The draft text put forward by ESA countries to provide full TRIPS flexibilities and capacity support for their implementation needs to be written into the EPA before it is concluded.

The EPA has not yet specified provisions for trade in health related services. Although most EU countries rightly protect their own public sector as the major provider of health services, there is pressure for service liberalisation in the EPA. ESA countries may thus be put be under pressure to make commitments to liberalise their health services. However for countries in the region to ensure that the poorest draw an equitable share of resources to meet health needs, governments need to regulate health service provisioning and to redistribute funds for health through public sector services. This contradicts commitments to liberalisation of health services. The EPA should exclude any such commitments to liberalise health care services, and should further include health impact assessments in other sectors prior to commitments being made, where these may have an impact on health.

The EPA promotes market access and reduced tariffs and subsidies in agriculture. In a region where undernutrition is high and increasing, all trade policies in agriculture need to be scrutinised for their health impact. In the context of the extreme and longstanding inequalities between EU and ESA agricultural production systems, it is likely that local and smallholder producers will not benefit from the current proposed measures, unless they are deliberately recognised and invested in under the EPA. Until all subsidies on agriculture in the EU are removed, it would not make sense for African countries to lift their own protective subsidies, particularly if this will lead to a further increase in food imports, further undermine local producers and further increase undernutrition.

The EPA raises a more fundamental issue. In the trade agreement, health and health care are put in the context of tradeable goods and services and treated under the aim of enhancing global integration, rather than as key contributors to the stated priority of poverty eradication. We argue that:
• the health implications of the EPAs need to be explicitly recognised
• health officials should be included in negotiations
• health impact assessments should be carried out where relevant, such as in any areas where service liberalisation may impact on health; and
• EU and ESA countries ensure that the EPA is fully compliant with all regional and international health protocols and conventions before it is concluded.

These calls were also made by Zimbabwe civil society in April this year as part of a wider process of Africa and Europe wide activities on the EPAs on April 19. One recurring point of these events was that EPAs as currently constituted would disadvantage developing countries. The EU negotiates as a bloc, with a powerful functioning bureaucracy and a team of skilled negotiators who will speed the pace of the negotiations. However at stake for ESA countries is a deeper bottom line – the health and survival of their people. ESA states thus have an obligation to apply the “precautionary principle” in the EPA negotiations where potential health impacts exist: countries need to be satisfied through evidence produced that the measure negotiated provides greatest possibility, authority and policy flexibility for protecting health and access to health services, and does not lead to negative health outcomes.

Addressing these issues will surely begin to meet the stated joint commitment to poverty eradication. Alternatively, with people's health at stake, the precautionary rule surely applies: No deal is better than a bad deal!

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat admin@equinetafrica.org. For further information on this issue or the full report referred to please visit SEATINI (www.seatini.org) or EQUINET www.equinetafrica.org.

Effective health centre committees can bring life into our health systems
Delegates to the EQUINET Regional Meeting on Health Centre Committees February 2014

Post-independent governments in east and Southern African (ESA) countries have all recognised that social participation is central to the success of primary health care (PHC) oriented health systems. There are, however, wide differences in how far they are implementing this policy view. The 2012 EQUINET Equity Watch report found many shortfalls in meaningful levels of social participation in health systems. Health Centre Committees (HCCs) are known by a range of names in different countries but are joint community- health worker structures at primary care level. They offer one way for systems to facilitate social participation and shared decision making between communities and health personnel. There is evidence that they can contribute to quality of and equity in access to health care and improved health outcomes. At a recent EQUINET regional meeting delegates identified ways to better tap into and support this valuable resource for health.

Building on prior work in EQUINET, twenty delegates from seven ESA countries and three international organisations, all working with HCCs, gathered at a regional meeting in February 2014 hosted by Training and Research Support Centre in association with Community Working Group on Health and Medico International in February 2014 to exchange experience on and learning from work to train and strengthen the role of HCCs (The report of the meeting and background paper are available at www.equinetafrica.org).

Dr Portia Manangazira from Zimbabwe’s Ministry of Health and Child Care opening the meeting concurred that HCCs provide a key mechanism for communities to participate in revitalising PHC and for strengthening and monitoring service delivery.

Despite this, while HCCs exist in some form in most countries, they often have no formal legal status or are not trained, resourced or active. In Zambia, the 1995 National Health Services Act provided in law for the District Health Boards and Neighbourhood Health Committees (NHCs). When this was repealed in 2006, it removed the legal mandate for HCCs. Yet in Zimbabwe it has been raised that expecting HCCs to manage public funds from government or external funders without a clear legal mandate is a problem. Even where government guidelines provide for HCCs, they vary in detail. For Zambia, an NHC working group has prepared explicit operational guidelines on establishment, composition, functions and monitoring mechanisms for NHCs. In South Africa, on the other hand, the provisions are more vague and left for the provincial authorities to decide. Generally while guidelines often set HCC composition and duties, they are less clear on how they are funded or on their role in towards social accountability. Despite their role in bringing community voice to service planning and the requirement that they represent communities, HCC members are not always elected by communities, have variable levels of community involvement and influence and may be liable to political control.

To some extent this reflects ambivalence towards whether HCCs are more a voice for the community to influence health services, or an outreach for services to reach and influence communities. Both roles are important, but where do HCCs focus their time and energies? In the Western Cape, South Africa for example, a baseline assessment in two districts found that HCC members spent limited time engaging the community and were spending more time as service volunteers - in security or as queue monitors for example. Similar concerns existed in Uganda. There was concern that in some countries HCC roles have become ‘commodified,’ with the resources available to them based less on community interests or needs than on what is paid for, often by international organisations.

Hence rather than the common practice of a long list of apparently delinked and equally weighted roles, the meeting identified roles of an HCC in a more systemic way, linking these to processes in health systems. The process starts with building an informed health literate community, obtaining community views and drawing on this to bring community voice and experience into the interaction with health service personnel, to jointly design and implement plans and budgets for the health system at primary care and community level. This joint role in governance gives the HCC the information, authority and motivation to go back to communities to facilitate dialogue and social action on health plans; to make sure that the agreed plans have been implemented, and that the duty bearers are capacitated, supported and resourced to deliver on plans and that they do so in a manner that is responsive to the community. HCC members should thus bring the direct experience and views of communities into the system, supporting understanding and reflection within communities on how to improve health, and advocating for improvements, with other sectors or at higher levels of the health system. This means that HCCs are more likely to thrive where health systems are themselves PHC oriented, facilitate action on the social determinants of health and support participatory planning and practice, than where they are organised largely around individual medical care with top down power.

HCC members need to have resources and skills across all these areas of functioning to complement their inherent social capacities and to enable them to overcome power imbalances in the relationships between themselves and health authorities. While there is a lot of training activity taking place, this may be limited to specific disease problems or interventions, may not address the general community health literacy or spectrum of HCC abilities needed and may lack follow up to evaluate its effectiveness or to sustain it. Training may not include some key areas such as budget tracking or assessment of community benefit. Further those providing training for HCCs may themselves lack competencies to build skills in areas such as budget planning or tracking.

Delegates also recognised that for HCCs to be effective in PHC oriented roles, communities themselves need to be health literate and empowered. Social rights to health care, to information and meaningful participation can provide a foundation for this and should be included in all constitutions of the region and in updated national or public health law. Regulations should more clearly define the duties, powers, roles and constitution of HCCs, and guidelines set these in a more systematic manner. However all this is likely to remain on paper unless it is accompanied by processes for capacitating systems and for supporting social activism and information.

The meeting thus proposed a number of areas for follow up attention and action by national authorities and organisations working in health, in relation to legal provisions, guidance, election, composition, functioning and capacity building of HCCs. While the specific cultural contexts differ, it was proposed that the ESA region set minimum guidance for these areas, such as on the core content of and processes for comprehensive HCC training, and that countries budget for the capacity building and functioning of HCCs. As for all other areas of health system performance, it was proposed that the health information system and communities monitor and collect information on the functioning, performance and impact of HCCs. Selected indicators were proposed for this, for further dialogue and development.

The organisations attending the meeting made a commitment as a network of practitioners working with HCCs to continue to link regionally, including to document, to share and make their work more visible. At a time of increasing attention to domestic resources for health, delegates drew attention to the most critical resources in the region- the people. The challenge was raised for policy actors in the region to turn commitments into action and to give systematic attention to the effective functioning of HCCs, as key social assets for health.

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised please visit www.equinetafrica.org. The report of the Regional meeting referred to can be found at

Engaging in global health: who sets the agenda?
Bente Molenaar Neufeld, The Centre for Trade Policy and Law, Canada

The World Health Organization (WHO) states in its constitution that it aims to achieve "the attainment by all people of the highest possible level of health.” The World Health Assemblies (WHAs) provide a key opportunity to engage on the achievement of this aim. Yet in an interesting study by Kitamura et al. in May 2013 in Health Policy reviewing the agendas of the WHAs between 1970 and 2012, the authors concluded that “agenda items of the WHA do not always reflect international health issues in terms of burdens of mortality and illness.”

So how are countries and stakeholders shaping the WHA agenda?

One way is through the WHO Executive Board (EB), particularly as it plays a role in setting the provisional agenda for the WHA. EB members are individuals nominated by countries with technical expertise in health. Of the 34 members of the Executive Board, seven are from the African region. Currently these are from Cameroon (2011-2014), Chad (2012-2015), Namibia (2013-2016), Nigeria (2011-2014), Senegal (2011-2014), Sierra Leone (2011-2014) and South Africa (2013-2016). As EB members, they are well-positioned to be heard and to bring concerns from their regions to the table. They can also block issues being discussed. The WHO secretariat also plays a role in agenda setting. Procedurally, the provisional EB agenda is proposed by the WHO Director-General. Getting issues on the agenda for the WHA is, however, not difficult. According to the rules of procedure, every proposal brought by a member state and any proposals submitted by the DG should be included in the provisional WHA agenda. So how are these policy levers being used?

Take the 2014 EB agenda for example. Many agenda items were not controversial as they are carried over from previous years, after broad agreement around their importance. This included non-communicable diseases (NCDs), neglected tropical diseases and reform of the WHO. Other agenda items may be more controversial. For example, when in 2012 the United States of America and Thailand successfully petitioned to include lesbian, gay, bisexual and transgender (LGBT) access to health in the WHO EB agenda for consideration it provoked debate, with Egypt and Nigeria, on behalf of their regions, asking for the item to be deleted.

This issue exemplified how health concerns can reflect and raise political division. Bringing health into diplomacy platforms, including that of the WHO, poses a challenge for how to avoid foreign policy concerns overshadowing health issues. The US delegate, Nils Daulaire, speaking about the demands for deletion of the LGBT item in 2012 said that it was “unprecedented for WHO member states to come together to attempt to remove an item legitimately placed on the Executive Board agenda by another member state. We believe it is important to afford each other the courtesy to discuss these important health items, even those with which not everyone agrees. Changing this deeply-established precedent risks politicizing all EB agenda items moving forward.” At the same time, countries are sensitive about health platforms being used to advance wider foreign policy agendas.

On the specific agenda item, a compromise position was reached to delete it and to ask the DG to consult with members on how to address the public health issues for future discussion. African diplomats in Geneva noted that the issue could continue to cause a stalemate unless the DG brings compromise solutions from her consultations within the regions. In the 2014 EB the item thus appeared as ‘[deleted]’ on the final agenda, and there was no discussion of it, as Member States had not agreed on a title or content of accompanying documentation for it. Until they do, the item will not be discussed.

Agenda setting can and does thus fall victim to politics and requires diplomacy to reach solutions that are acceptable to the membership. However African countries have successfully brought items to the WHA agenda, such as that of ethical recruitment of health workers. What may restrict both the inclusion and action on agenda item may be the limits set by the General Program of Work (GPW). The GPW is set for the organization every 5 years. Unless a suggested item falls within the GPW and has funding allocated to it, it is unlikely to make it onto the formal agenda. The Organization is currently working on its 2014-2019 GPW and bases its’ plans on a set of distinct categories in the GPW that have been agreed to by Member States - that is communicable diseases, non-communicable diseases, promoting health through the life course, health systems, and preparedness, surveillance and response. One reform of the WHO underway, according to the WHO website, is to “allow greater flexibility in allocating resources to priorities within these categories”, which may then give flexibility for new agenda items not yet covered in the GPW.

Even when issues make it to the WHA agenda, will they receive adequate attention?

The agenda of both the EB and the WHA have become longer and longer over the years. In May 2013, for example, the WHA agenda included numerous weighty issues, including health post 2015, NCDs, communicable diseases (including malaria and neglected tropical diseases), WHO reform, substandard/spurious/falsely-labelled/falsified/counterfeit medical products and a range of other issues. With such packed agendas, smaller delegations to the WHA face challenges in participating when equally important issues are being discussed at the same time. Dr. Emmanuel Makasa, health attache at the Zambia high commission in Geneva noted in one 2013 meeting in the region that African delegations have responded to this by working as a group: “We work together as the African Group of Health Experts in Geneva to tackle issues and engage as a group, which helps with our individual member state staff shortages and different professionals present at the meetings.”

A lengthening agenda may also reflect the widening reach of global factors and policies in health, or the widening range of concerns claiming for attention. Either way, countries need proactive strategies to get their health concerns onto the global agenda, to ensure that they obtain attention and are addressed. It implies long term thinking, preparing and collaborating with partners in advance to develop positions and organizing the evidence, expertise and alliances to raise and advance agenda items. As Chigas et al. highlighted in 2007 those who can early on “frame the definition of the problem and the terms of the collective debate, can have enormous influence on the subsequent negotiations and their outcomes.”

Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. The Centre for Trade Policy and Law is working with EQUINET on a research programme on GHD in association with the ECSA HC Strategic Initiative on Global Health Diplomacy. For more information on the issues raised please visit www.equinetafrica.org