The 56th World Health Assembly - the annual health meeting at which the World Health Organisation's (WHO) directives are set for the year - ended last week in Geneva after a long round of discussions on the continuing SARS saga. Press coverage of the Assembly also focused on the completion of a tobacco control resolution, which the U.S. delegation agreed to sign in exchange for deals that will secure a future pact on sugar imports. But the resolution receiving the longest debate among the delegates of the 192 member governments attending the WHO's Assembly received little attention outside of the business press.
The controversy was over a resolution mandating the WHO to advise governments about patent rules and access to medicines. Patent laws in many developing countries are now set through a combination of World Trade Organisation (WTO) directives, World Intellectual Property Organization (WIPO) advice, and U.S. bilateral trade pressure. But because the WTO's Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement requires developing countries to pass national legislation guaranteeing patent terms of two decades for pharmaceuticals, the prices of new drugs for both common and rare conditions is expected to double soon after January 2005. The TRIPS Agreement, passed more than a decade ago under the aegis of the WTO, was described as a "free trade" measure by its key architect, Pfizer CEO (and Ronald Reagan trade advisor) Edmund Pratt. By definition, it is the complete opposite of competition-based trade: it grants pharmaceutical companies a monopoly on any new product they produce, and therefore allows drug prices to be set to the purchasing standards of the elite, to the obvious detriment of the poor.
1. Editorial
2. Equity in Health
The best way to improve the health and nutrition of the poor still is to have them move out of poverty. For equity to be achieved, economic growth in the development process needs to be deliberately geared towards the needs of the poor. Focusing on sustainable poverty alleviation is inseparable from bringing about greater equity. A focus on both tasks is necessary to achieve the indispensable reduction in the existing rich-poor gap. Focusing on poverty alleviation alone can end up as charity in disguise. Focusing on equity is a step towards social justice. Equity and social justice in health and nutrition are one and the same thing: in health and nutrition, social inequities are always unfair. This is an extract from an article in the International Journal for Equity in Health 2003.
U.N. Special Envoy for HIV/AIDS in Africa Stephen Lewis, during a speech at the Global Health Council's annual conference in Washington, D.C., said that he was "aghast" at the way in which "AIDS was deepening hunger and hunger was deepening AIDS" in Southern Africa. According to Lewis, Africa "reaps what the world sows, and with a vengeance."
Dr. Jong-Wook Lee, the newly elected director general of the World Health Organisation, said that he would make combating HIV/AIDS in the developing world a major priority, the Boston Globe reports. Lee said that he would fulfill the WHO's promise to provide three million HIV-positive people in resource-poor countries with antiretroviral drugs by 2005.
The southern African country of Zambia has set a new record - one which no country would wish to hold. The average life expectancy in the country is 33 years - by far the lowest in the world - and it is all due to Aids.
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3. Human Resources
One in three countries in Africa and South East Asia has only one medical school for every 10 million people or more, a rate poorer than anywhere in Europe or the Americas, says a new report by researchers from the World Health Organisation. Nine out of 10 countries in the same two regions have fewer than 50 doctors per 100000 inhabitants, and about half of the countries have a similar density of nurses and midwives. The report outlines a series of major new WHO initiatives, which aim to provide better information to allow more meaningful international comparisons. "Despite the undoubted importance of human resources to the functions of health systems, there is little consistency between countries in how human resource strategies are monitored and evaluated," say the authors, from WHO's department of health service provision. "In many countries there is no regular recording of the numbers and activities of all health personnel, and some emphasize only the public sector or can have variable accuracy for rural areas."
4. Public-Private Mix
The use of private health care providers in low- and middle-income countries is widespread and is the subject of considerable debate. This article, produced by the Bulletin of the World Health Organisation, reviews a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardised primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In addition, implications for public health policy of the emergence of this new model of private provider are discussed. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. It is concluded that encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened.
Equity is a frequently stated justification for government involvement in the health care market. This is often taken to mean directly providing all segments of the population with a wide range of government-operated health services at no cost: free universal care. Yet a look at the record suggests that this goal all too often remains elusive, especially in poor countries; that governments in fact serve only some of the population; and that the people served are disproportionately concentrated among the better-off. When this happens, government health services, far from promoting equity, work against it. The purpose of this chapter is to illustrate that there are many ways for governments to pursue the goal of ensuring that the poor receive adequate, affordable services through alternative approaches to resource allocation and purchasing. The first section summarizes the information known about the distribution of benefits from government health services across social groups in order to document the regressive pattern that now frequently exists and the need for significant changes in approach if the poor are to benefit. The second and third sections illustrate the kinds of changes that might be considered.
This backgrounder to a session of the WHO 56th World Health Assembly looks at issues surrounding innovation in public health particularly focusing on biotechnology, including genomics, pharmaceuticals, medical devices and other diagnostics. The report argues that innovation to address conditions which particularly affect the poor are often held back by market failure and/or under investment by the public sector. The report highlights a number of mechanisms to stimulate innovation. These include: Investment in basic science in developing countries; Public / private partnerships to address neglected diseases; IP mechanisms to promote private sector investment such as advance-purchase funds; Flexibility in the application of TRIPS as advocated in the Doha Declaration particularly with regard to licensing and exemptions; Improved technology transfer from North to South; Increased capacity building in developing countries; Greater international cooperation; Clear, co-ordinated setting of research priorities; and A sound regulatory environment.
Neo-liberal economic policies and World Bank/IMF inspired 'health reforms' being pushed through in developing countries have resulted in: Privatisation of public health services; The introduction of user fees for patients; Lack of public investment in state-run primary health care systems; and Lack of attention to leadership and management development for PHC. "All this has obviously also resulted in the overall deterioration in quality and equitable delivery of public health services and had a devastating effect on the ability of the poor to access health care," says a recent press release from the People's Health Movement (PHM). PHM has called for wider consultation between the World Health Organisation and civil society mem-
bers.
Global health problems require global solutions, and public-private partnerships are increasingly called upon to provide these solutions. Such partnerships involve private corporations in collaboration with governments, international agencies, and non-governmental organizations. They can be very productive, but they also bring their own problems. This volume examines the organizational and ethical challenges of partnerships and suggests ways to address them. How do organisations with different values, interests, and worldviews come together to resolve critical public health issues? How are shared objectives and shared values created within a partnership? How are relationships of trust fostered and sustained in the face of the inevitable conflicts, uncertainties, and risks of partnership? This book focuses on public-private partnerships that seek to expand the use of specific products to improve health conditions in poor countries. The volume includes case studies of partnerships involving specific diseases such as trachoma and river blindness, international organizations such as the World Health Organization, multinational pharmaceutical companies, and products such as medicines and vaccines. Individual chapters draw lessons from successful partnerships as well as troubled ones in order to help guide efforts to reduce global health disparities.
5. Resource allocation and health financing
Although a grossly disproportionate burden of disease from HIV/AIDS, TB and malaria remains in the Global South, these infectious diseases have finally risen to the top of the international agenda in recent years. Ideal strategies for combating these diseases must balance the advantages and disadvantages of 'vertical' disease control programs and 'horizontal' capacity-building approaches. Nevertheless, it is clear that significant structural changes are required in such domains as global spending priorities, debt relief, trade policy, and corporate responsibility. HIV/AIDS, tuberculosis and malaria are global problems borne of gross socio-economic inequality, and their solutions require correspondingly geopolitical solutions.
Fewer than one in five people at risk of HIV infection today have access to prevention programs, and annual global spending on prevention falls $3.8 billion short of what will be needed by 2005, according to a new report released by the Global HIV Prevention Working Group. The report, Access to HIV Prevention: Closing the Gap, is the first-ever analysis of the gap between HIV prevention needs and current efforts, and provides recommendations for expanding access to information and services that could help save lives and reverse the global epidemic.
In an informal address to the 4th International Conference on Priorities in Health (Oslo, 23 September 2002), Professor Jeffrey Sachs – Chairperson of the WHO Commission on Macroeconomics and Health – maintained that the real causes of the inability of the world's poorest people to receive help for the lethal diseases that burden them did not include the "usual suspects" (corruption, mismanagement, and wrong priorities). Rather, the root cause was argued to be an inherent lack of money, indicating that the burden of disease would be lifted only if rich countries gave more money to poor ones. Without taking exception to anything that Sachs said in his address, there nevertheless remain a number of justifications for efforts to improve priority setting in the face of severe shortages of resources, including the following three defences: prioritisation is needed if we are to know that prioritisation is insufficient; prioritisation is most important when there is little money; prioritisation can itself increase resources.
6. Governance and participation in health
Fund the Fund have produced an advocacy kit aimed at civil society organisations (including nongovernmental, community-based, people living with the diseases, faith-based, and trade unions) to promote their advocacy for increased investment in the Global Fund.
Civil society actors have become more visible, active and influential within health and health systems. Understanding their role, the factors influencing them and the health outcomes they produce is important to anyone wishing to improve public health. This website presents an annotated bibliography of research on civil society and health prepared as a collaboration between the World Health Organisation's Civil Society Initiative and Training and Research Support Centre. The research focused on three theme areas: Civil society - state interactions in national health systems; Civil society contributions to pro-poor, health equity policies; Civil society influence on global health policy.
7. Monitoring equity and research policy
Health policy and systems research (HPSR) is increasing in prominence in low and middle income countries, stimulated by social and political pressure towards health system equity and efficiency. Yet the institutional capacity to fund and produce quality research and to have a positive impact on health system development has been little examined and touches mainly on specific areas such as malaria research or the impact of research on health reforms. In general, however, there is increasing pressure to direct research investments on the basis of evidence of policy relevance and impact. Indeed, in this decade of efforts to link development, health and research world-wide, there is little enquiry into the role of scientific capacity in general. This paper seeks to develop an empirical basis for assisting decisions on what are likely to be good investments to increase capacity in health policy and systems research (HPSR) in developing countries. It presents the results of a survey undertaken by the Alliance for Health Policy and Systems Research (Alliance-HPSR) in 2000 and 2001 to analyse institutional structure and characteristics, engagement with stakeholders, institutional capacity, level of attainment of critical mass and the process of knowledge production by institutions in low and middle income countries.
8. Useful Resources
The Directory of Open Access Journals service covers free, full text, quality controlled scientific and scholarly journals.
The Centre for HIV Information (CHI) at the University of California, San Francisco has launched an internationally oriented, HIV/AIDS Internet resource. The pages feature detailed global and regional overviews of the HIV/AIDS pandemic, as well as 194 individual country profiles containing key documents and links. This information is complemented by the Database of Country and Regional Indicators, which allows users to create customized, comparative tables of epidemiological and socio-economic data. Through this continuously updated, "one-stop" resource, visitors can access the best online information on the international AIDS pandemic.
For an overview of what ejournals are accessible in developing and transitional countries, go to the Fulltext Journals page of INASP Health. The page contains numerous annotated links. Of particular interest are: BMJ Journals: Countries with Free Access; FreeMedicalJournals.com; Health InterNetwork Access to Research Initiative (HINARI); Highwire: Free Access to Developing Countries sites; and INASP: Programme for the Enhancement of Research Information (PERI).
The World Bank has launched a website containing technical notes on quantitative techniques for health equity analysis. The site will eventually contain 20 notes covering: The measurement of key variables in health equity analysis; Generic tools in health equity analysis; and Applications to the health sector.
9. Jobs and Announcements
People living in developing nations continue to face significant barriers in access to essential medicines and health commodities. Concerned members of the global health community will meet this June in Dar es Salaam to share ideas, experience, and plans for moving forward, with a focus on recent and ongoing efforts to confront this crisis.
The Centre for African Family Studies (CAFS) is pleased to announce the next offering of our popular regional advocacy course entitled "Advocacy for Reproductive Health". This course was developed in collaboration with the Support for Analysis and Research in Africa Project (SARA) of the Academy for Education Development (AED), with financial support from USAID. CAFS has adjusted the course to the African region situation.
Established by the Canadian HIV/AIDS Legal Network and Human Rights Watch, the Awards for Action on HIV/AIDS and Human Rights recognize individuals or organisations for excellence and long-term commitment to defending the human rights of those most vulnerable to and affected by HIV/AIDS. An award will be presented annually to a person or organisation in each of two categories: A person residing in Canada or a non-profit organisation based in Canada; A person or non-profit organisation from another country.
The Rockefeller Foundation is currently seeking an Associate Director for its office in Nairobi who will have overall responsibility for providing thematic leadership for grant activities in the AIDS area of work in the development of programs related to the Health Equity (HE) theme and the Africa Regional Program (ARP) in Eastern and Southern Africa.
A new book entitled “Letting them die – why HIV/AIDS intervention programmes fail”, written by social psychologist Dr Catherine Campbell, addresses the questions of why people knowingly engage in sexual behaviour that could lead to a slow and painful premature death?; and why the best-intentioned HIV-prevention programmes often have little impact? Dr Campbell is a Reader at the London School of Economics and a Research Fellow at HIVAN, (the Centre for HIV/AIDS Networking, based at the University of Natal in Durban). The book's title is derived from South African satirist Pieter-Dirk Uys's comment that: "In the old South Africa we killed people. Now we're just letting them die."
The Alliance and the Governance, Equity and Health Program Initiative of the International Development Research Centre, Canada (GEH) invite letters of intent for strategic research in governance, equity and health for Eastern and Southern Africa. Health systems in Africa face special challenges given their development situation, their epidemiological profile and the opportunities to scale up disease control programmes. It is important that the new and larger policy and programme efforts currently being implemented improve the equity and responsiveness of health systems through approaches that strengthen and integrate actions at national and local levels.
ZARAN is a non-governmental organisation that was established in December 2001. ZARAN believes that successful HIV/AIDS interventions are those that protect and promote the rights of People Living With Aids (PLWA). It is therefore committed to the implementation of the International Guidelines on HIV/AIDS and Human Rights.