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


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The Reasons Behind the Flop of Alma-Ata Principles

The Alma-Ata Declaration was endorsed by the 32nd World Health Assembly held in Geneva in 1979, which approved a resolution acknowledging the key role of primary health care (PHC) for the attainment of  acceptable health levels for all. However, despite the initial enthusiasm, it was difficult to implement healthcare in accordance with Alma-Ata principles.This article turns the spotlight on the relevant reasons


by Pietro Dionisio

Degree in Political Science, International Relations

Cesare Alfieri School, University of Florence, Italy

The Reasons Behind the Flop of Alma-Ata Principles

 Universal Health Coverage: Really a Long Way Off


“The main goal of universal health coverage is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them in order to avoid any poverty trap” [1].

For a country to achieve universal health coverage (UHC), several factors must be in place, including:

1) A strongly efficient, well-run system meeting health priority needs through a people-centred, integrated approach based on:

-proper information and tutorial strategies for health keeping and disease prevention;

-early detection of conditions negatively affecting health;

-appropriate disease treating capacity; and

-adequate care and rehabilitation frameworks.

2) Affordability, by effective public health financing services that give up out-of-pocket expenses by the users.

3) Equity, including by securing non-discriminatory access to essential medicines, care  and technologies for health and to services for communicable/non-communicable diseases and maternal/child health.

4) Well-trained, motivated and skilled health workers to meet the needs of patients through high quality, best available evidence services.

The points above are without prejudice to the critical role in assuring human health played by sectors including transport, urban planning and overall education services.

UHC has a direct impact on people’s health. Universal access to health services enables people to become more productive and active contributors to their families and communities. It also ensures that children can go to school and learn. At the same time, financial risk protection prevents people from being pushed into poverty when they have to pay for health services out of their own pockets. UHC is thus a critical component of sustainable development and poverty reduction, and a key element of any effort to reduce social inequities and inequalities. In essence, UHC is the hallmark of a government’s commitment to improve the well-being of all its citizens.

UHC is firmly based on the WHO constitution of 1948, declaring health a fundamental human right, and on the Health for All agenda set up by the Alma-Ata Declaration in 1978. In such a context, equity is a paramount, meaning that countries need to track progress not just across a vague “national population” term but within different groups including by income level, sex, age, place of residence, civil engagement, social attitudes and behaviors, migrant status and ethnic origin.

The Origins of Primary Health Care

The concept of primary health care (PHC), in the last decades, has had a noteworthy influence upon health workers, especially in less-developed countries.

Since the late 1960s and early 1970s, the US was involved in a crisis of its world hegemony. It was in this political context that the concept of PHC emerged. Since this moment, the vertical health approach[2] used in the fight against malaria by US agencies and WHO was being criticized. New proposals for health and development appeared. For instance, Kenneth W. Newell, a WHO staff member since 1967, who collected and studied the experiences of medical auxiliaries in developing countries, argued that “ a strict health sectoral approach is ineffective”[3]. In addition, the 1974 Canadian Lalonde Report[4] deemphasized the importance attributed to the quantity of medical institutions and proposed four determinants for health: biology, health services, environment and lifestyles[5].

An important role for the PHC concept formation was played by the Christian Medical Commission. As a specialized branch of the World Council of Churches and the Lutheran World Federation, this organization was created in the late 1960s with the mission to emphasize the training of grassroots village workers equipped with very essential drugs and simple methods. In 1970, it created the successful journal “Contact”, which adopted the expression “primary health care” (one of the first times this term was used). Noticeably, from 1974 a collaboration between the Commission and WHO was formalized.

A further element to be taken into account to understand the inspiration for PHC, was the widespread attention worldwide to the massive expansion of rural medical services experienced in communist China. In this process a notable role was played by the so called “ barefoot doctors” whose number increased between early 1960s and the cultural revolution. They were a different group of village health workers who lived in the community they served by actively stressing rural rather than urban healthcare, preventive rather than curative services and combining Western and traditional medicines[6].

The emergence of PHC was also backed by the new international context characterized by the presence of decolonized African nations and the propagation of national, anti-imperialist and leftist movements in many less-developed countries. These changes led to new proposals by some industrialized countries.

The main event towards the achievement of PHC model was the  international conference taking place at Alma-Ata (Soviet Union) on 6-12 September 1978.

The idea of an international conference on PHC emerged from the Chinese delegation to the WHO. At the beginning, the Soviet Union opposed the proposal by upholding a more medically oriented approach for less-developed countries. Subsequently, based on awareness that PHC  movement was growing, they started supporting the meeting  and offered a location too[7].

Nearly 3000 delegates from 134 countries and 67 international organizations took part in the conference which was also attended by UN and international agencies like the International Labor Organization, the Food and Agriculture Organization and the Agency for International Development. NGOs, religious movements (including the Christian Medical Commission), the Red Cross, Medicus Mundi and political movements including the Palestine Liberation Organization and the South West Africa People’s Organization, were also present, whereas, for political reasons, the Chinese Government was absent[8].

The fact that this conference represented a cornerstone event in the history of international healthcare, is demonstrated by the Declaration it released as an universal and bold statement  mainly focusing on three points:

  • appropriate technology;
  • opposition to medical elitism;
  • health as a means to achieve social-economic development.

Regarding the first point, the used expression “disease oriented technology” incurred the criticism of envisaging too much sophisticated, expensive or irrelevant technologies to the common needs of the poor. Critics also stressed that the creation of urban hospitals in less-developed countries would forge a culture running contrary to the independency of consumers, while only benefiting a minority through a poor share of available funds and human capital. In order to solve these issues, it was emphasized the need of using equipped medical technology to link in with people needs, while being scientifically sound and financially feasible. Relevantly, a decentralized approach based on setting up health units in rural areas, in lieu of city hospitals, was seen as a more cost-effective policy.

The second point emphasized the opposition against medical elitism including health personnel overspecialization and top-down health policies in developing countries. In this connection, the Declaration focused on the need to appropriately train health staffs and increase the participation of communities in sanitary matters. The need for working together with traditional healers, such as shamans and midwives, was also emphasized.

The third point of Declaration linked health to development. Health was seen not as an isolated element but as an intrinsic tool to achieve improvements of life conditions by an inter-sector approach whereby public and private institutions should work together on health education, adequate housing, safe water and basic sanitation, among other things. This vision echoed in the words of WHO Director H.T. Mahler supporting the idea that health, far from being a mere byproduct of economic progress should be a key engine for development “we could. . . become the avant-garde of an international conscience for social development”[9].

The Alma-Ata Declaration was endorsed by the 32nd World Health Assembly held in Geneva in 1979, which approved a resolution acknowledging the key role of  PHC for the attainment of  acceptable health levels for all.

However, despite the initial enthusiasm, it was difficult to implement healthcare in accordance with the Alma-Ata principles.

Criticism to Alma-Ata and New Proposals for PHC

The Alma-Ata Declaration was criticized for being too wide and for having an unrealistic timetable (the slogan “health for all by the years 2000” was considered not feasible by a great portion of scholars).

In this regard, the Rockfeller Foundation in 1979 held a conference in order to identify the most cost-effective strategies and examine the status of interrelation between health and population programs. The meeting was inspired and based on a paper by Julia Walsh and Kenneth S. Warren entitled: “Selective primary healthcare, an interim strategy for disease control in developing countries”[10]. The paper, which did not represent criticism against the Alma-Ata Declaration, focused on specific causes of death, largely on the most common children’s threats in developing countries, including diarrhea and diseases following the lack of vaccination programs. The authors highlighted an entry point strategy through which basic health services targeted to achievable objectives could feasibly be developed both in financial and temporal terms. This new perspective was named “selective primary healthcare”, meaning  a set of low-cost technical interventions to address some crucial health problems in less-developed countries.

In essence, the selective primary healthcare (SPHC)  mainly focused on four interventions:

  • growth monitoring;
  • oral rehydration techniques;
  • breast-feeding;
  • immunization

Growth monitoring was considered an important instrument to identify, at an early stage, children who were not growing as they should.

Oral rehydration aimed at controlling diarrheal disease outbreaks by electrolyte water solution packets.

Breast-feeding emphasized the protective and nutritional value of giving breast milk alone to children for the first six months of their life.

The last intervention, immunization, underpinned vaccination campaigns against communicable diseases, especially in the early childhood.

These four interventions have indeed several positive effects: they are easy to control and evaluate, are measurable, have clear targets and, due to the fact that indicators of success and reporting can rapidly be produced,  earmarked funding appears quite easy to obtain.

Relevantly, a debate came out soon between PHC and SPHC approach backers.

The backers of comprehensive PHC accused SPHC of being an approach diverting attention away from basic health and social development while not taking into proper consideration, and so not addressing, the social causes of diseases. Another point  under the fire of criticism  was the fact that monitoring was difficult to undertake since it required the use of charts by illiterate mothers.

And Newell, one of the architects of PHC idea, stated that “[SPHC] is a threat and can be thought of as a counter-revolution. Rather than an alternative, it . . .can be destructive . . . Its attractions to the professionals and to funding agencies and governments looking for short-term goals are very apparent. It has to be rejected”[11].

In the face of this, US agencies, the World Bank, and UNICEF started to focus on some aspects of SPHC. As a result, there was mounting friction between the WHO and UNICEF during the early 1980s, with debate centred around three main questions:

-What is the meaning of PHC?

-How is PHC to be financed?

-How is it to be implemented?

PHC has several meanings, so it was not easy to define. In its more radical version, it was seen as an adjunct of social revolution. This perspective was considered as something undesirable and drew a lot of criticism against Mahler and WHO that began to be seen as a politicized organization. Others considered this point of view simply unrealistic and thought it was impossible to expect those changes from the conservative governments of developing countries. Firstly, they stated that the political power of rural people was overestimated and that, consequently, the thrust of some health experts was misplaced. Another bone of contention was the vision of communities in the developing countries as a pyramid willing to participate in health programs should its leaders be given the necessary information. This vision was judged quite idealistic on the grounds that those communities and their learning processes were often diverse and complex.

Critics also considered the PHC target of extending health services to rural areas as an addition to preexisting medical services. As such, they saw PHC as a second quality care,  something like “primitive” and a means to keep poor people under social control.

The second point of debate referred to the financing procedure in order to make the Alma-Ata Declaration a sustainable one. Admittedly, when compared with other international campaigns (such as the global malaria eradication program of the 1950s, where bilateral funding assistance was provided by UNICEF and the US), no clear funding resources were quoted in the Declaration as regards health workers training, nutrition and safe water programs or new hospitals building. As a result, it comes as no surprise that many international agencies did prefer to engage in short-term, clear budget initiatives rather than in too broad programs [12].

This links in with the fact that, during the 1980s, several less-developed countries faced an economic slump and burdensome foreign debt that negatively impacted on the availability of public resources for  health. Moreover, a drastic restriction in the available funding for healthcare in developing countries arose from the emergence of neo-liberal policies by governments in the most affluent countries.

This changing political context fostered deeply rooted conservative attitudes among health professionals. For instance, several high-income physicians, based in city hospitals and trained in prestigious medical schools (like US universities), used to consider PHC as a professional step-down in monetary and social prestige terms. The resistance of medical doctors worsened at the time when, coupling with awareness of the lack of any effort to reorganize medical education around PHC and enhance the prestige of personnel, they feared they were going to lose their privileges and power.

An additional problem, as mentioned above, referred to  the implementation of the Declaration. In the post Alma-Ata period, different strategies were adopted by the signatory countries:

  1. Negation: no concrete steps were undertaken to put the Declaration into practice.
  2. Legislation: the Alma-Ata Declaration was copied into a lot of National Legislations. Sometimes this was a starting point for action, other times it was the start of a continuous process of “lip-service” to PHC ideas, without concrete political commitment.

When action was undertaken, four strategies emerged:

  • Implementation: for some countries (Cuba and the rural areas of China) the implementation of the Declaration was in continuity with already existing developments.
  • Adaptation of existing health systems: many countries opted for healthcare reforms, trying to implement the Alma-Ata Declaration by a process of change of the existing healthcare structures.
  • Innovation: countries opting for starting a primary healthcare structure, apart from the existing system.
  • Importation: the primary healthcare system was “imported” into the framework of bilateral cooperation, multilateral agencies or non- governmental organizations.

Due to the fact that a great majority of international agencies favored SPHC, many less- developed country governments decided to create underfunded PHC programs by concentrating efforts mainly on one or two selective interventions. As a result, the friction between those who advocated vertical, disease oriented programs and those who advocated community oriented programs was accepted as a natural state of affairs, irrespective of  the situation of confusion and inefficiencies bound up with this context.

During the 1980s, Mahler continued his fight for a comprehensive PHC, but he was quite often alone because of the inadequate support by WHO’s bureaucracy and his allies outside WHO. When, in 1988, Mahler ended his third mandate as WHO Director General, none of the candidates to succeed him seemed to have the right energy to bring off the battle for comprehensive PHC.

The Japanese Hiroshi Nakajima was elected as the new WHO Director General, and it was immediately evident that the communicativeness and the charismatic personality of his predecessor were lacking.

In the last decade of the 20th century, it became clear that the goal of  “health for all by the years 2000” would not be reached. Part of the reasons can be summed up as follows:

– The focus on SPHC and on “vertical programs” was disruptive for the development of an horizontal PHC approach taking care of individuals, their families and communities. Relevantly, the HIV/AIDS pandemic played a key role by shifting budgets towards “vertical programs”, instead of PHC investment programs.

– Moreover, the PHC strategy underestimated the power of pharma industry and hospitals in the healthcare system, and failed to take doctors into proper consideration. This coupled with the lack of a clear strategy to adequately train doctors and health worker staffs, even if the idea of multidisciplinary PHC teams was present in all documents. Taken together, these circumstances brought about a slowdown in the development of PHC project[13].

– Additionally, a point of weakness referred to donor agencies’ requirements of results to be achieved by the funding cycle period or the agency’s mandate. While encouraging short-term planning and readily measured program objectives, these requirements ruled out the engagement in PHC[14] and civil society involving projects looking at bottom-up approaches and participatory frameworks including relevant to health infrastructures building.

– Another bar to the achievement of  UHC was the feeling that the PHC idea strictly linked  in with the concept of solidarity. This value came under pressure in the 1980s and the 1990s. The disappearance of the “Iron Curtain”, the “war on terror”, the growing individualization and globalization, with increasing flows of migrants, all eroded the idea of solidarity as the basic engine for comprehensive PHC regimens.

– Many problems also arose from the fact that the Declaration was filled with ideology. It clearly stated, indeed, what to do but not how to reach the goals laid down in its statements. As such, many professionals and decision makers regarded its principles only as  program indicators to directly translate into operational resolutions and policy directions of each country. Relevantly, even WHO stated that: “in their post Alma-Ata enthusiasm many decision makers assume that, since primary healthcare is supposed to use simple methods, it would be simple to implement”[15].

– What’s more, obstacles even arose from the fact that the need for contextual adaptation of the Alma-Ata principles was underestimated. The PHC approach was expected to act as a flexible model prone, at least in principle, to readapt to local needs and situations. In reality, because of its conceptual appeal, because of its heavy international promotion by WHO and other international bodies and because of deep gaps in many countries needing immediate action, it was often adopted without first exploring and defining the socio-cultural environment on to which it had to be implanted. Health planners from WHO and national governments failed to grasp the complexity of social organization within rural settings, and even failed “to construct resource foundation adequate for describing health and illness as processes constituted as much by forces of languages, socio-cultural structure, political and economic organization as biological and psycho-physical events”[16].  This lack of contextual organization brought about problems to international agencies, national governments, ministries of health, local authorities who were defining their central objectives by the theoretical framework of PHC. As an example, while rural inhabitants generally wanted the attainment of as much care and treatments as their urban counterparts,  PHC advocates often ignored this reality, labelling instead the villagers for not quickly perceiving the true advantages of preventive healthcare, something that took international healthcare professionals decades to grasp. As such, there was a perpetration of illusion that PHC could deliver new, valuable messages into a social vacuum[17].

– The circumstances highlighted above linked in with evidence that the problems faced by the PHC proponents were really huge. As such, grounding on awareness that no miracle solution would be able to quickly transform global social and economic inequalities into something better, the PHC proponents understood that the completion of PHC project would take a very long time while hinging on the policy directions by governments and their impact on health, society, equity, politics and world order outcomes.

Overall, as a result of the facts stressed so far, the PHC  model was introduced at very variable levels in the countries worldwide.  Irrespective of the lot of gaps and inefficiencies bound up with these circumstances, especially in Africa and less-developed countries, some results from PHC implementation even in those countries with incredible social and economic problems are being documented. As in the case of Kenya where the political will of  government and international aid resources have been producing significant improvements in the UHC issue.

Unfortunately, despite isolated examples, there is still  hard work to do now that the impact of governments’ policies on public health and access to care and appropriate, affordable, high-quality treatments is an issue of global concern in the international agenda.

And this occurs at a time when free trade agreements and choices by the administrations in wealthy countries are turning policies into decisions which protect monopolistic interests at the expense of non-discriminatory, equitable access to health.

Admittedly, the struggle against economic and governmental interests is long and hard. But this is another story.



[1]WHO, “What is Universal Coverage?”, World Health Organization. Web source:

[2]The vertical approach focuses on fighting one disease at time. The horizzontal one, as defined by WHO, focuses on “ all the activities whose primary porpuse is to promote, restore or maintain health”.

[3]K.W. Newell. “Health by the people”, Geneva, Worl Health Organization, 1975,xi.

[4]The Lalonde Report is a 1974 report produced in Canada. It proposed the concept of “health field”, identifying two main health-related objectives: the healthcare system; and prevention of health problems and promotion of good health. The report is considered the first modern government document in the Western world to acknowledge that our emphasis upon a biomedical health care system is wrong, and that we need to look beyond the traditional health care (sick care) system if we wish to improve the health of the public.

[5]Canadian Department of National Health and Welfare, A New Perspective on the Health of Canadians. ( Ottawa, 1974)

[6]V. W. Sidel, “The Barefoot Doctors of the People’s Republic of China”, New England Journal of Medicine 286 (1972): 1292-1300.

[7]The offer, also, resulted from a growing competition between the traditional communist parties and the new pro-chinese organizations that emerged in several developing countries.

[8]The Sino-Soviet conflict had been worsening since the 1960s.

[9]H. T. Mahler, “WHO’s mission revisited: Address in presenting his report for 1974 to the 28th World Health Assembly, 15 May 1975”, 10, Mahler Speeches/Lectures, box 1, WHO Library, Geneva.

[10]Walsh J. A., Warren K. S., “Selective primary healthcare, an interim strategy for disease control in developing countries”, N. Engl. J. Med., 301, 967-974, 1979.

[11]K. W. Newell, “Selective Primary Healthcare: the Counter-Revolution”, Social Science and Medicine 26 (1988): quote from p. 906.

[12]S. B. Rifkin, F. Muller and V. Bich-mann, “Primary Healthcare: On Measuring Partecipation”, Social Science and Medicine 26 (1988), 931-940.

[13] The openness of the public towards interventions from public health (campaigns for prevention, health promotion) is influenced positively by the presence of efficient clinical curative services because they contribute to the creation of “trust” towards the health system. The primary health care-services were relying to a large extent on nurses for the clinical work, but very often they were faced with diagnostic responsibilities that they were not prepared for.

[14]PHC: Primary Healt Care.

[15]WHO: National Health Development Networks in Support of Primary Healthcare. Geneva, World Health Organization, 1986.

[16]LH. Connor, N. Higgenbothon: A sociocultural perspective on rural health development: a proposal for educating health professionals in Asia and the Pacific. Honolulu, East-West Center, 1983.

[17]L. Stone: Primary healthcare for whom? Village perspectives from Nepal, Social Science and Medicine 1986; 22 (3), pp. 293-302.

Why ’Big Pharma’ Alone Cannot End the AIDS Pandemic

The major focus in both national and international responses to HIV  pandemic is now on ensuring that as many positive people as possible have sustainable access to the specific drugs. But, whatever their medical efficacy they can only ever provide a partial solution to what has become a ‘post modern plague’ in so many of the poorest parts of the world. The coming decades are likely to be ones of increasing need and declining resources. Hence optimistic suggestions that drugs alone will soon bring an end to the pandemic will need to be treated with the greatest caution


by Lesley Doyal*

Emeritus Professor, School for Policy Studies

University of Bristol, UK

Why ’Big Pharma’ Alone Cannot End the AIDS Pandemic


Debates about the pharmaceutical industry have received new impetus over the past decade with the introduction of antiretroviral therapy (ART) for many of the millions diagnosed as HIV positive. Though these drugs do not offer a cure they do hold out the possibility of major improvements in wellbeing and life expectancy for those who are able to access them.

The major focus in both national and international responses to the pandemic is now on ensuring that as many positive people as possible have sustainable access to these drugs. But as we shall see, whatever their medical efficacy they can only ever provide a partial solution to what has become a ‘post modern plague’ in so many of the poorest parts of the world.

When ART first became available in the mid 1990’s, it was confined to high income countries with sophisticated health care systems. Some commentators argued against attempts to extend access to the poorer parts of the world on the grounds that lack of adherence would cause what they called ‘antiretroviral anarchy’. However many others campaigned against such a ‘double standard’, demanding a more equitable distribution of drugs (Chan 2015 ch3).

Early attempts to achieve more widespread dissemination were, of course, limited by the high cost of the drugs themselves. This led inevitably to lengthy battles with pharmaceutical firms over pricing as well as issues of intellectual property (Chan 2015). But aided by the production of substantial quantities of generic drugs in countries such as India and Brazil the wholesale price of first line drugs fell markedly after 2001. This made possible a dramatic increase in the number of people receiving treatment. By 2011 this figure had risen to a record 9.7 million compared to just over 8.1 million in 2011 – an increase of 1.6 million in one year alone (WHO,UNICEF& UNAIDS 2011). But many problems still remain.

First, there are still marked inequalities in access to ART. The most obvious of these are differences between rich and poor countries. Currently treatment in the US and Western Europe is accessed by more than 50% of all those known to be in clinical need. In Eastern Europe however the figure is only 21% and in the Middle East and North Africa it falls to only 11% (UNAIDS Fact Sheet 2014).

These inequalities partly reflect the wealth or poverty of individual countries and the strength or weakness of their national care systems. But lack of fairness is also evident within countries with members of marginalised groups being disadvantaged compared with their HIV positive counterparts. Studies from different parts of Africa, for example, have shown that men who have sex with men (MSM) are significantly disadvantaged while in the USA and Europe, injecting drug users (IDU’s) will also face additional challenges. In many settings, similar obstacles face male, female and transgender sex workers (Global Commission on HIV and the Law 2012).

If these inequalities are to be tackled, more attention will have to be paid to the social, cultural and economic obstacles facing disadvantaged groups or positive individuals who cannot make their way successfully through what has been called the ‘treatment cascade’ or care continuum.

Who tests and who does not?

The first stage of accessing care is of course testing, and many fall at this early hurdle. A recent estimate suggests that in the most affected African countries, only about 10-12% of people have been tested for HIV and know the result (Obermeyer and Osborn 2007). Worldwide, it is estimated that only about 40% of positive people are aware of their status. This reflects in part the lack of testing facilities. Though the number has increased significantly in recent years they are unevenly distributed with only around 5.5 per 100,000 people in low and middle income countries (WHO, UNICEF & UNAIDS 2011).

But even when facilities are available a wide range of factors may prevent individuals from testing. Of course many will simply be afraid of discovering that they have a serious and potentially fatal illness. But both women and men also report that they are afraid to test on the grounds that if they are found to be positive they may be treated badly by partners, family members and the wider community (Frank 2009).

In most settings women are more willing to be tested than their heterosexual partners. This is partly because they are offered (or required) to test in the context of their use of reproductive services. But it also reflects the reluctance of many men to threaten their masculine identity through appearing weak and vulnerable. As a result many are tested at a later stage than their female counterparts and hence will frequently have a worse prognosis (Skovdal 2011).

A number of studies have also shown that many are reluctant to test because the centres are perceived to be stressful. Most are overcrowded, with staff themselves under huge pressure and too often insensitive to the needs of those they are testing. Service users in many settings have reported a lack of respect as well as a marked lack of confidentiality especially if they test positive (Angotti 2010; Butt 2011).This will of course , be especially problematic in the small close-knit communities where many of the poorest people who are positive struggle to survive. This reluctance to test clearly presents a major obstacle to the success of any drugs based strategy.

What happens after testing?

Even if they are tested there will often be difficulties accessing treatment for those who are found to be positive. While some will have a CD4 count low enough to necessitate the immediate prescription of drugs others may have to wait until their condition worsens. As a result they may be lost to care in the intervening period. And even if treatment is successfully initiated there can be no guarantee that individuals will be willing and/or able to follow medical protocols.

When individuals do drop out of treatment this lack of ‘adherence’ is too often blamed on the individual’s irrationality or lack of will .However recent research has shown that a wide range of economic and social obstacles may face those who have both the need for the drugs and (at least theoretically) the access (Russell et al 2010; Nguyen et al 2007).

Recent US studies have identified the young, the less educated, the poorest, those who are black or Latino and those who do not have medical insurance as being least likely to continue their treatment (Horstmann et al 2010) Injecting drug users too are likely to drop out more frequently. While discrimination may be an important factor, it appears that in most parts of the world it is material and social deprivation that present the single most important obstacle to successful treatment.

Depending on the financial arrangements in place, antiretroviral drugs may be unaffordable for individuals. And even when they are free there may be charges for blood tests or any other treatments needed for opportunistic infections. There have also been a number of reports of corruption in settings where patients are forced to pay bribes (Zimbabwe Lawyers for Human Rights 2010).

As well as the cost of treatment itself the expenses of transportation to the clinic are frequently mentioned as obstacles to sustainability of therapy. Many studies from rural African settings in particular have highlighted the struggles faced by women in their attempts to balance the competing demands of transport, housing and school fees (Tuller et al 2010).

The cost or unavailability of food is also frequently mentioned as an obstacle to appropriate drug use across a range of settings. Lack of food is likely to exacerbate the side effects of ART as well as increasing the patient’s appetite and making them feel hungrier. Thus the medical requirement that the drugs be taken with meals may be impossible to fulfil in situations where food itself is short to come by (Hardon et al 2007).

Managing insecurity

The complexity of these obstacles in what are often very poor subsistence economies may well be exacerbated by the irregular supply of drugs and the lack of choice for service users. Being HIV positive is itself a major cause of insecurity with individuals having little knowledge of if and when their health is likely to deteriorate.

This will frequently be worsened in situations where drug supplies are intermittent as a result of inefficiency in distribution, corruption, social conflict or the natural disasters such as floods or earthquakes that are more common in resource poor settings. Not surprisingly, access to ART is often given little or no attention in the context of such crises yet for individuals it is of critical importance to their survival (Veenstra et al 2010).

A number of studies have shown that harm caused by institutionalised insecurity can be very severe and will often lead individuals to drop out of treatment. While they may begin with hope, this will often be dispelled in the case of drug shortages and lack of appropriate testing and monitoring equipment (Bernays et al 2010).

For many this will be highly stressful with increasing levels of insecurity and uncertainty. Not surprisingly patients find it especially difficult to deal with gaps in treatment or with unexplained changes of drug that appear to have no medical rationale. New combinations are often difficult to get used to and may produce side effects that individuals find unacceptable.

Many service users in situations of dependence also report feeling pressured to change their lifestyle as ‘positive living’ is increasingly stressed by heath workers, policy makers and funders (Nguyen et al 2007). A major requirement will be public disclosure of their status which many will be reluctant to do, having spent much of their time and energy trying to maintain secrecy.

Telling partners can be difficult especially for women who may be afraid of a violent response. For men on the other hand the requirement to ‘live positively’ by avoiding alcohol, cigarettes and unsafe sex may mean the loss of what they perceive as central to their masculinity (Mfecane 2007). For both women and men the requirement to always engage in safe sex may also place major constraints on plans they may have for creating a family (Richey 2006).

It is clear then, that while ART may be effective in ideal circumstances this does not apply to the situation of the majority of HIV positive people in low and middle income countries. As we have seen many have no access at all while others are unable to optimise the potential effects of the therapy as a result of economic and social circumstances as well as the duties, responsibilities and attachments they have to others.

What of the future?

Despite these problems, universalising access to ART remains the central theme of the global response to HIV and AIDS. The notion of ‘Treatment as Prevention’, or TASP, is intended to end the pandemic by ensuring universal access to drugs at an early stage for those diagnosed as positive. It is assumed that this in turn will reduce their infectivity and hence limit the spread to others. But how effective is this likely to be in the wider context of economic recession and growing inequality?

Increased access to treatment will mean a huge increase in the number of people living with HIV who will continue to be in need of drugs throughout their lives. Many will eventually need the much more expensive second and third level drugs. Hence much more investment will be required not just in the production and distribution of drugs themselves but also in the strengthening of health systems and the training and employment of health workers.

However the last few years have seen a continuing decline in available funding. Over the past two decades multilateral, bilateral and philanthropic organisations including The Global Fund, PEPFAR and the Gates Foundation have provided about 60% of all external HIV and AIDS funding to sub-Saharan Africa (Ravishankar et al 2009). The Global Fund has been especially important providing one fifth of all resources for HIV .

The percentage of countries where antiretroviral treatment programmes were adversely affected by reduced external funding rose markedly between 2008 and 2009. Eastern Europe and Central Asia have been particularly vulnerable to the effects of reduced external funding and the economic crisis. Less than a quarter of people in need of treatment in the region are now receiving it with drug stock-outs common and government health expenditure on HIV and AIDS treatment programmes falling sharply.

Not surprisingly the burden of funding is now falling increasingly on individual countries. Domestic spending on HIV care in low- and middle-income countries is already increasing, going from USS$ 3.9 billion in 2005 to nearly $8.6 billion in 2011. Over the next decade the growth rate of a number of the middle income or BRIC countries (Brazil, Russia, India and China) should enable them to meet the needs of their own positive citizens, provided they have the political will to do so.

But the fact remains that for millions of people in the poorest settings, domestic funds will simply not be available. High levels of indebtedness, disadvantageous international trade policies and structural adjustment have limited the volume of national expenditures on health care (AIDS2031 2010). A recent UNAIDS document estimated that the cost of funding HIV treatment will have peaked by 2030 (UNAIDS Fact Sheet 2014). However the coming decades are likely to be ones of increasing need and declining resources.

In the context of growing global inequalities there will inevitably be major questions over the funding of treatment. And even more importantly there is little sign that the lives of those in the greatest poverty will be improved to the point where they can take optimal advantage of available services. Even with improvements in the availability and affordability of antiretroviral drugs, many of those who are HIV positive will not be able to optimise their wellbeing without radical economic and social change (Doyal with Doyal 2013 pp 169-172 and 183-185). Hence optimistic suggestions from New York and Geneva that drugs alone will soon bring an end to the pandemic will need to be treated with the greatest caution.



-AIDS2031 (2010) Taking a Long Term View. London: Financial Times Press
-Angotti N (2010) Working outside the box : How HIV counsellors in sub-Saharan Africa adapt HIV western testing norms. Social Science and Medicine 71 (5) 986-993
-Bernays S & Rhodes T (2009) Experiencing uncertain HIV treatment delivery in a transitional setting: a qualitative study. Aids Care (3) 315- 21
-Butt L (2011) Can you keep a secret? Pretences of confidentiality in HIV/AIDS counselling and treatment in Eastern Indonesia. Medical Anthropology 30 (3) 319-38
-Chan J (2015) Politics in the Corridor of Dying: AIDS activism and global health governance. Baltimore: Johns Hopkins Press
-Frank E (2009) The relation of HIV testing and treatment to identity formation in Zambia. African Journal of AIDS Research 8 (4) 515-524
-Global Commission on HIV and the Law (2012) Rights, Risks and Health. New York: UNDP HIV/AIDS Working Group
-Hardon A et al (2007) Hunger, waiting time and transport costs: time to confront challenges to ART adherence in Africa. Aids Care 19 (5) 658-65
-Horstmann E et al (2010) Retaining HIV infected patients in care: where are we ? where do we go from here? Clinical Infectious Diseases 150 (5) 752-6
-Mfecane S (2011) Negotiating therapeutic citizenship and notions of citizenship in a South African village. African Journal of AIDS Research 10 (2) 129-138
-Nguyen V-K et al (2007) Adherence as therapeutic citizenship: impact of the history of access to anti-retroviral drugs on adherence to treatment. AIDS 21 (supp 5) S31-5
-Obermeyer C & Osborn M (2007) The utilisation of testing and counselling for HIV: a review of social and behavioural evidence. American Journal of Public Health 97 (10) 1762-72
-Ravishankar N et al (2009) Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet 373 (9681) 2113-24
-Richey L (2006) Gendering the Therapeutic Citizen: ARV’s and Reproductive Health. CSSR Working paper no 175 Cape Town: UCT Press
-Russell S et al (2010) Expanding anti-retroviral therapy provision in resource-constrained settings: social processes and their policy challenges. AIDS Care 22 (Supp 1) 1-5
-Skovdal M (et al) 2011 masculinity as a barrier to men’s use of HIV services in Zimbabwe. Globalisation and Health 15 7
-Tuller D et al (2010) Transportation costs impede sustained adherence and access to HAART in a clinic population in southwestern Uganda: a qualitative study. AIDS and Behaviour 14 (4)
-UNAIDS Fact Sheet: Global Statistics 2014
-Veenstra N et al (2010) Unplanned anti-retroviral treatment interruptions in Southern Africa: how should we be treating these? Globalization and Health 6 4
-WHO,UNICEF and UNAIDS (2011) Progress Report : Global HIV/AIDS Response. Epidemic Update and Health Sector Progress Towards Universal Access Geneva: UNAIDS
-Zimbabwe Lawyers for Human Rights (2010) Corruption Burns: Universal access to treatment. Harare ZLHR

For further elaboration of these ideas as well as a broader commentary on the pandemic see Doyal L with Doyal L (2013) Living with HIV and Dying with AIDS: Diversity, Inequality and Human Rights in the Global Pandemic Ashgate


* Lesley Doyal is Emeritus Professor of Health and Social Care at the School for Policy Studies, Bristol University, and has just completed six years as a Visiting Professor at the University of Cape Town. She has published widely in the field of international health and health care with a particular focus on gender. In this capacity she has acted as a consultant for a number of organisations including WHO,UNDAW,Global Forum for Health Research and the British Council.In recent years she has worked extensively in the area of HIV and AIDS using a combination of political economy, ethnographic and intersectional perspectives. Her latest book has been widely acclaimed as the first attempt to provide a global and interdisciplinary approach to life with HIV. Entitled ‘Living with HIV and Dying with AIDS:inequality, diversity and human rights in the global pandemic’ it is published by Ashgate. 

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Global Surveillance of Resistance to Anti-Tuberculosis Drugs

Surveillance of resistance to anti-TB drugs remains a cornerstone of any effective TB control programme worldwide. With the availability of new technologies and new drugs, and the prospect of new regimens for the treatment of TB and MDR-TB, surveillance of drug resistance is evolving and adapting to continue being a critical tool to inform public health actions to fight TB

matteo zignol

by Matteo Zignol

Raviglione Mario

and Mario Raviglione

Global Tuberculosis Programme
World Health Organization

Global Surveillance of Resistance to Anti-Tuberculosis Drugs


“Surveillance” is the systematic ongoing collection, collation and analysis of data for public health purposes and their timely dissemination for assessment and response as necessary (from the International Health Regulations, 2005, adopted by the 58th World Health Assembly).

The basis for global surveillance of drug resistance in tuberculosis (TB) was set during internal discussions within the World Health Organization (WHO) in 1993. A global project on anti-TB drug resistance surveillance was initiated in 1994 with the aim of collecting and evaluating data on drug resistance in TB in a systematic way around the world. Surveillance is needed to measure the frequency of drug resistance as an indicator of the effectiveness of prevention and control activities; to accurately forecast the need for drugs and plan accordingly; to design standardized regimens for the treatment of drug-resistant TB; to assess epidemiological trends; and to identify local outbreaks of drug-resistant TB for a timely response.

Within the standardized methodological framework designed by WHO, two main mechanisms of surveillance are used to collect data on drug resistance that are representative of a geographically-defined population allowing comparison across and within settings over time: surveillance based on routine drug susceptibility testing of all TB patients and periodic surveys of sampled TB patients.
A network of 33 WHO Supranational TB Reference Laboratories covering all six WHO regions supports global surveillance of drug resistance in TB.

Since 1994, therefore, data on drug resistance have been systematically collected and analysed from 144 countries worldwide (74% of 194 WHO Member States). Half of them (72 countries) have established continuous surveillance systems based on routine diagnostic drug susceptibility testing (DST) of all TB patients. The remaining 72 countries rely on ad-hoc epidemiological surveys of representative samples of patients. All countries with high burden of TB and/or multidrug-resistant (MDR*) TB (a total of 36 countries) have either established a continuous surveillance system or conducted at least one survey over the past two decades to monitor drug resistance.

* defined as a form of tuberculosis that is resistant to at least isoniazid and rifampicin

Continuous surveillance for MDR-TB, based on routine DST of TB patients and systematic collection, collation and analysis of data, is the most effective approach to monitor trends in drug resistance over time. The number of countries that can rely on data generated by continuous surveillance systems is increasing, due to efforts invested in scaling up the availability of culture and DST services. Among the 36 countries classified by WHO as suffering from a high TB and/or MDR-TB burden, 10 have put in place high quality surveillance systems to monitor drug resistance. All these countries are in Eastern Europe and Central Asia where the burden of MDR among TB cases is the highest world-wide.

Ad-hoc surveys still represent the most common approach to investigating the burden of drug resistance in resource-limited settings where routine DST is not accessible to all TB patients due to lack of laboratory capacity or resources. Of the 36 countries with high TB and/or MDR-TB burden, 26 have generated drug resistance data through special surveys. Half of them (13 countries) have conducted surveys in the most recent years between 2010 and 2013.
Central and Francophone Africa remain the regions of the world where drug resistance surveillance data are the scarcest, largely as a result of the current weak laboratory infrastructure.

Globally, 3.5% (95% CI: 2.2–4.7%) of new TB cases and 20.5% (95% CI: 13.6–27.5%) of previously treated cases are estimated to have MDR-TB. These estimates are essentially unchanged compared with recent years. The highest proportions of MDR-TB are found in countries of Eastern Europe and Central Asia where in some settings up to 50% of all TB cases have MDR-TB.
Globally in 2013, an estimated 480 000 (range: 350 000‒610 000) new cases of MDR-TB emerged worldwide and 210 000 (range: 130 000‒290 000) died from MDR-TB.

Extensively drug-resistant (XDR**) TB had been reported by 100 countries globally by the end of 2013. A total of 80 countries and territories reported representative data from continuous surveillance or ad-hoc surveys regarding the proportion of MDR-TB cases that had XDR-TB. Combining their data, the average proportion of MDR-TB cases with XDR-TB was 9.6% (95% CI: 8.1%–11%). The proportion of MDR-TB cases with resistance to fluoroquinolones was 17.0% (95% CI: 12.0–22.0). A total of 29.8% (24.3%–35.3%) of patients with MDR-TB have resistance to a fluoroquinolone, a second-line injectable agent, or both. These patients would likely be eligible to receive bedaquiline and/or delamanid, the new bactericidal drugs recently approved for use in patients with MDR-TB.

** defined as a form of tuberculosis which is resistant to at least four of the core anti-TB drugs. XDR-TB involves resistance to the two most powerful anti-TB drugs, isoniazid and rifampicin, also known as multidrug-resistance (MDR-TB), in addition to resistance to any of the fluoroquinolones (such as ofloxacin or moxifloxacin) and to at least one of three injectable second-line drugs (amikacin, capreomycin or kanamycin)

Surveillance of drug resistance is gradually expanding from the main first-line anti-TB drugs, rifampicin and isoniazid, to cover novel and repurposed drugs. For example, fluoroquinolones and pyrazinamide are now considered key drugs for future new regimens for the treatment of TB and MDR-TB. In this context, understanding the background prevalence of resistance to fluoroquinolones and pyrazinamide at the population level is critical to assessing the feasibility of the introduction of new drugs and shorter regimens. A new project to measure levels of resistance to fluoroquinolones and pyrazinamide among TB patients is being implemented in 7 countries (Azerbaijan, Belarus, Bangladesh, Pakistan, Philippines, South Africa and Ukraine). Correlation between phenotypic testing and genetic mutations, and levels of cross-resistance between fluoroquinolones are also being assessed. Results of this project will inform laboratory practices for surveillance and diagnosis of drug resistance and provide guidance to the development of diagnostic algorithms and to the introduction of new treatment regimens.

Molecular technologies are being increasingly incorporated into drug resistance surveys to simplify logistics. GenoType® MTBDRplus (Hain Lifescience, Germany) was used in the national survey completed in 2012 in Nigeria and is currently being used in the national survey in Sudan. In Pakistan, Xpert® MTB/RIF (Cepheid, USA) identified additional cases missed by culture in the national survey completed in 2014. In ongoing surveys in Papua New Guinea and Senegal, Xpert MTB/RIF is being used to screen specimens for rifampicin resistance and identify those requiring further testing at national or supranational TB reference laboratories. This approach greatly reduces the workload for laboratories and decreases the cost of national surveys.
In addition, high-throughput sequencing technologies are now increasingly being used for surveillance purposes. In a few years these technologies will likely completely revolutionize the way in which surveillance of drug resistance in TB is currently conducted.

Surveillance of resistance to anti-TB drugs remains a cornerstone of any effective TB control programme worldwide. With the availability of new technologies and new drugs, and the prospect of new regimens for the treatment of TB and MDR-TB, surveillance of drug resistance is evolving and adapting to continue being a critical tool to inform public health actions to fight TB.