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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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Human Rights Reader 374 

Family Planning Commitments: Much Achieved, But Short of Goal 

Ending violence against women: 3 ways to innovate 

South Africa’s NHI, a Spark of Hope for Health

South Africa's achievements towards a National Health Insurance (NHI) whole country system implementation need strengthening now that only 17 per cent of the population can access well sourced private health services, whereas most people have to rely on understaffed and overstretched public facilities. A refined NHI-related white paper, reportedly close to presentation to Cabinet for approval could be a milestone for all South Africans’ non-discriminatory access to health


by Pietro Dionisio

Degree in Political Science, International Relations

Cesare Alfieri School, University of Florence, Italy

South Africa’s NHI, a Spark of Hope for Health


The path towards a National Health Insurance (NHI) is fundamental to South Africa’s people. Indeed, South Africa’s history of reforming health care financing system dates back to the year 1928 when a “Commission on Old Age Pension and National Insurance” was established aiming at the constitution of an insurance scheme covering medical, maternity and funeral benefits for all low- income formal sector employees in urban areas.

Unfortunately, while the country is home to 53.4 million people with a 0,78 per cent annual growth rate in 2015, the achievement of Universal Health Coverage (UHC) remains a difficult task for three main reasons at least:

  1. At a time when the expenditures in either the private or public health sector are roughly the same (about R100 billion each, 9 per cent GDP overall), inequity is in the coverage since apartheid institutionalized social distortions are not easy to root out and the health system is divided too. Only a minority of the population (nearly 17 per cent) can access well sourced private health services, whereas who cannot (approximately 83 per cent) are forced to rely on understaffed and overstretched public facilities.
  2. Health scourges place a burdensome pressure on the health system since HIV/AIDS and tuberculosis are still leading causes of death now that maternal, neonatal and child mortality rates are high and Non Communicable Diseases (NCDs) are rising.
  3. South Africa is a middle-income country but after years of economic roller coaster (GDP contracted an annualized 1.3 per cent in the second quarter of 2015 over the previous quarter), doubts emerge as to the Government capacity to finance a health system reform requiring amazing infrastructural transformation and not only.

Since recent years the Government has been lavishing efforts aimed at the establishment of a national health insurance scheme. In this regard, a “Green Paper”, published in 2011, mapped out a two-phase strategy to move towards UHC over a 15-year period.

The first phase emphasized on how to make headway in improving the management and quality of (and access to) public, particularly primary care level, health services.

The second phase was intended to introduce a strategic purchasing mechanism by establishing a semi-autonomous National Health Insurance Fund (NHIF) whose sources would be pooled through general tax revenues and additional earmarked, pay-roll and pre-payment taxes.

In the Government’s vision, the introduction of a “National Health Insurance” (NHI) would help  improve access to quality health care services and provide financial risk protection against health-related catastrophic expenditures for the whole population.

What’s more, the “Green Paper” encourages the creation of a system whereby public and private providers would collaborate in supplying health services, health promotion and illness prevention.

Coherently, South Africa’s health Minister Aaron Motsoaledi steadfastly insisted on the implementation of NHI. In a related speech, delivered on 31 May 2011, he showed strong political will by stating that:

“The problem is that many believe that NHI is just the release of a document. For us in health, we know that it also involves an extensive preparation of the health care system while at the same time preparing a policy document and in this case, the reengineering of the Health Care System is very vital.”

Since then, NHI was introduced in 10 pilot districts which are still making headway in improving primary health care  through three kinds of working teams:

  1. School health teams including nurses at schools and mobile vans to check pupils’ eyes, ears and teeth;
  2. Ward-based outreach teams staffed by door-to-door nurses and community health workers aimed at safeguarding the health of pregnant women and children under five while educating people on healthy living;
  3. District medical specialist teams, made up of health experts tasked with supporting health workers, particularly clinic nurses.

These teams collaborate with each other to prevent hospitalization by finding out most vulnerable people to sickness and decentralizing the delivery of medicines for chronic illnesses from hospital pharmacies to more convenient places, including schools and private pharmacies.

Despite efforts, one of the problems South Africa still faces as regards implementation of the pilot projects above is drawing general practitioners-GPs (whose services will be essential for making public health facilities scale up performances) into actively working for public clinics. Fewer than 200 of the 8,000 GPs working in private practice have agreed to work in public clinics since the NHI pilot program was launched.

In the face of this, Dr. Motsoaledi recently declared that the Government would supply 180,000 hours to clinics in 10 pilot districts during the 2015/16 financial year so as to encourage private sector doctors to work in public clinics.

According to South Africa’s making law process, the 2011 “Green Paper” stands as a discussion document. Hence, while giving an idea of the general thinking that informs health policy, it was published for comment, suggestions or additional ideas. Hereinafter, a more refined document, a white paper, had to be drafted. This is what the South African people are waiting for.

As per Dr. Motsoaledi’s recent words, the long awaited white paper is finished now and will be presented to Cabinet for approval soon:

“We have completed with it, we have discussed with treasury , the next nearest space I get which cabinet says you are ready you can come in, I go there and present it chairperson and after presenting it to cabinet the very next day I will present it to the nation”.

The patience of South Africans will probably be rewarded shortly.

Concerns remain about the sustainability of the whole project, but Dr. Motsoaledi’s policy has to be considered positively. Definitely,  the efforts spent are producing results and the path taken might be the right one.

A little more persistence, a little more effort, and what seemed hopeless failure may turn to glorious success, in the words of Elbert Hubbard.

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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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European Civil Society Organisations Call for EU Leadership on HIV/AIDS, TB and Hepatitis C


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UNAIDS Strategy 2016-2021 

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TPP: Up with Corporate Profits Outweighing Equity in Health!

The TPP case just represents the tip of the iceberg for the underhanded tactics to ensure that countries accept IP clauses that go beyond the full extension they have a right to under the WTO’s TRIPS. This context entails that TPP involved governments should, as per MSF words, “….carefully consider before they sign on the dotted line whether this is the direction they want to take on access to affordable medicines and the promotion of biomedical innovation...”


by Daniele Dionisio*

Policies for Equitable Access to Health – PEAH

TPP: Up with Corporate Profits Outweighing Equity in Health!


On 5 October 2015, ministers from Pacific countries clinched hard-fought, five-year Trans-Pacific Partnership, or TPP, trade agreement negotiations as the largest pact of its kind outside the World Trade Organization (WTO). The 12 countries involved – Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, the United States (US), and Vietnam – are home, indeed, to almost 800 million people and represent nearly 40 percent of the global economy.

The talks were promoted by the US to enhancing free trade in the Pacific realm by addressing global trade issues (including piracy and counterfeiting) and raising standards by taking into account the implications for the multilateral trade system and the different economic levels and needs of participating countries.

Disappointingly, the negotiations were shrouded in unprecedented lack of transparency and unbalanced secrecy level, whereby, as reported [here] and [here], the public was frozen out, US Congress members were severely limited in their access to treaty-related documents at a time when pharmaceutical and content industries sat on the IP advisory committee as corporate representatives, while smaller innovators and generics companies did not.

As such, it is unexpected news that, under recent decision by the federal district court in Manhattan, the Office of the United States Trade Representative (USTR) has been ordered to provide justification for withholding from a Freedom of Information Act request the communications with its industry advisors as confidential commercial or financial information in the lead-up to TPP agreement completion.

On 5 November 2015, the full text of the agreement was released by TPP Parties. Now it will have to be public for several weeks or months before being considered by the domestic parliaments of participating economies for ratification, implementation and, finally, entry into force.

Yet, the road ahead remains an arduous one given allegations that the agreement serves the interest of the wealthiest, caters to the needs of big industry rather than the citizens of member nations, and protects monopolistic interests now that, on a world scale, corporate profits outweigh any commitment to the global human rights  and equitable access to health [here] [here] and [here].

As argued, … The Obama Administration’s most important objective in this [TPP] negotiation was to raise the prices for drugs, vaccines and medical devices, worldwide, and they have no doubt achieved that objective, albeit not to the degree that meets every single one of the pharmaceuticals and medical device company asks….

A case in point, the minimum period for exclusivity data protection on biologic drugs was an harsh contention area in the final TPP negotiation days owing to the profit  interests of a number of corporations (e.g., Pfizer Inc, Roche Group’s Genentech and Japan’s Takeda Pharmaceutical Co, among others) relevant to state-of-the-art vaccines, anti-toxins, blood or blood products for transfusion, gene therapies, and cellular therapies.

As contended …..the real truth to the matter is that biologics are in the TPP because they represent big money for pharmaceutical companies as new chemically synthesized drugs offer less of a chance for “blockbuster” drugs than biologics. The global biopharmaceuticals market was valued at US$161,851.6 billion in 2014 and is expected to expand at  rate of 9.4 per cent to reach US$278,232.9 billion by 2020. Other studies believe the global market biologics will reach $386.7-billion by the end of 2019. Further, biologics are expected to account for approximately 17 per cent of total global spending on medicines by 2016 and reach an overall market value of $200 billion to $210 billion in 2016, up from $157 billion in 2011. Biologics provided roughly 22 per cent of the Big Pharma companies’ sales in 2013, will likely rise to 32 per cent by 2023. While promising in their potential to treat diseases ranging from cancer to rheumatoid arthritis, such drugs are significantly costly, with the Brookings Institution finding that these can cost up to 22 times the price of chemical drugs.

Unfortunately, though developing “biosimilars” (as “follow-ons” to an original biologic) would dramatically knock prices down, the US 12- year exclusivity data protection law currently makes that biosimilars cannot be approved during the period if they rely on the data used for the original biologic.

Relevantly, though the standing power of their counterparts has forced the US negotiators to fall short of demand and accept TPP rules that allow for a minimum five-year standard to eight years of data protection, regrettably, as stated,.… this is still the longest term of data protection ever enshrined by treaty, and will unquestionably hurt developing countries.

No surprise, the Big Pharma lobby and its Congressional supporters were unhappy with the TPP terms above. Does unhappiness explain why the US  has opposed a LDC Group’s request for an indefinite exemption from trade rules on pharmaceuticals?

The TPP deal has been dubbed as being transformational not just for the Asia-Pacific region, but also for the global economy at a time when, with new membership requests seemingly in the offing, the TPP terms are feared to influence still underway trade deals such as, among others, the EU-US Transatlantic Trade and Investment Partnership (or TTIP), and the EU-Japan, EU-India FTA negotiations.

As for India case, the concerns definitely outweigh optimism now that an ongoing breakthrough of multinational drug corporations in the country couples with protectionist US and EU policies, with India’s obligations as a WTO member, and with pressures on India’s government towards adopting IPRs beyond the Trade-Related Aspects of Intellectual Property Rights Agreement (or TRIPS) and strengthened enforcement mechanisms as the keys to foreign investments and innovation.

Overall, these circumstances put India’s freedom in jeopardy  as an independent  provider of affordable medicines for domestic and resource-limited countries’ needs

Relevantly, the chapter 18 (Intellectual Property) in the agreement confirms that, in spite of some lip service, the US has been pursuing a TRIPS-plus, corporations friendly policy over TPP negotiators  even though, just in the aftermath of the clinched pact, the USTR office stated that the IP chapter “reaffirms Parties’ commitment to the WTO’s 2001 Declaration on the TRIPS Agreement and Public Health, and in particular confirms that Parties are not prevented from taking measures to protect public health, including in the case of epidemics such as HIV/AIDS” .

Admittedly, the chapter largely grounds on TRIPS-plus measures including patents for new uses (the so-called ever-greening), granting of patents on medicines even in the absence of improved therapeutic effects, data/regulatory monopolies on clinical trial data (data exclusivity), patent term extensions (supposedly to compensate patent holders for delays in getting regulatory  approval), as well as enhanced mandatory injunctions for patent infringement and strong border measures.

As such, IP protection enforcement provisions, which make up a broad section of IP chapter, not only re-present but even exacerbate the provisions from the shelved ACTA treaty.

As would be the case for counterfeit trademark goods that are meant to be, for IP chapter purposes, .. any goods, including packaging, bearing without authorization a trademark that is identical to the trademark validly registered in respect of such goods, or that cannot be distinguished in its essential aspects from such a trademark;….

As regards the sectors to packaging and labelling of medicines, the impending threat of the definition above binds up with its potential to affect the patent holders’ access to the market at a time when the legislation against counterfeit and substandard medicines too often does not address quality issues, but instead is aimed at protecting the commercial interests of brand-name manufacturers.

Under these circumstances, it would make it easier for a claim to be lodged by the right holder against an infringer or alleged infringer for nullifying or eroding benefits by applying packaging and labelling models that, despite fair trading and full alignment with TRIPS requirements, are deemed to be insufficiently distinguishable or fraudulent.

The IP chapter enforcement provisions also contend that…. each Party shall provide that, in civil judicial proceedings concerning the enforcement of an intellectual property right, its judicial authorities have the authority, on a justified request of the right holder, to order the infringer or, in the alternative, the alleged infringer, to provide to the right holder or to the judicial authorities, at least for the purpose of collecting evidence, relevant information…. regarding any person involved in any aspect of the infringement or alleged infringement and the means of production or the channels of distribution of the infringing or allegedly infringing goods or services, including the identification of third persons alleged to be involved in the production and distribution of the goods or services and of their channels of distribution.

As such, TPP targets third parties by exposing them to the risk of punitive action also in trademark and patent infringement allegations.  As regards non-discriminatory access to medicines, this could play as an unfair deterrent to anyone engaged in the production, sale and distribution of affordable, high quality generic medicines including treatment providers like MSF, suppliers of active pharmaceutical ingredients used for rolling out generic medicines, as well as distributors and retailers who stock generic medicines.

Moreover, as regards border measures and criminal procedures and penalties relevant to products under infringement allegations, IP chapter terms appear unreliably vague or extortionate when stating that:

-Each Party shall provide that its competent authorities may initiate border measures ex officio [i.e., without the need of a formal complaint from a third party or right holder] with respect to goods under customs control that are: (a) imported; (b) destined for export; or (c) in-transit and that are suspected of being counterfeit trademark goods…

– Each Party shall adopt or maintain a procedure by which its competent authorities may determine within a reasonable period of time after the initiation of the procedures…whether the suspect goods infringe an intellectual property right.

– If a Party requires identification of items subject to seizure….., that Party shall not require the items to be described in greater detail than necessary to identify them for the purpose of seizure….

Furthermore, the Damocles’ sword of an investor state system enforcement as regards access to medicines cannot be underestimated since USTR office terms clearly state that “the dispute settlement mechanism created in chapter 28 [of the agreement] applies across the TPP, with few specific exceptions”.

Consequently, being not explicitly excused from, the chapter 18 (Intellectual Property) is undoubtedly subject, as just argued, to the dispute settlement mechanism whereby private companies located in the territory of any TPP disputing Party are allowed to sue governments directly for policies the governments take.

In this regard, many forms of government regulations, including price cuts of medicines, could be argued not to conflict with the TRIPS agreement, yet to make pointless or erode the expectations of the patent owners.  Relevant risk sectors also include tariffs on medicines, as would be the case should a country that has agreed to reduce tariffs on an imported product later subsidize home manufacturing of the same medicine. A complaint against this country under an investor state system would be allowed to re-establish the conditions of competition in the original transaction.

These prospects appear ominously alarming  and compound fear that the afterglow from the TPP’s completion could lead other trade initiatives on a world scale to adopt “investor-state mechanism” friendly terms.

Last but not least, while TPP focuses on expanding IPRs and defends market-driven rather than needs-driven rules, it, as reported, …also fails to give attention to innovative approaches to stimulating R&D for new drugs, vaccines and medical devices that delink R&D costs from product prices. Such new approaches would ensure the development of needed new treatments at affordable prices.

Taken together, all insights here suggest that the TPP case just represents the tip of the iceberg for the underhanded tactics to ensure that countries accept IP clauses that go beyond the full extension they have a right to under the WTO’s TRIPS.

On these grounds, what expectations now that US pressure  will certainly force through its position to allow the TPP to be ratified by the national parliaments, hence undermining access to  care and lifesaving medicines for millions of people in resource-constrained settings?

This context entails that TPP involved governments should, as per MSF words, “….carefully consider before they sign on the dotted line whether this is the direction they want to take on access to affordable medicines and the promotion of biomedical innovation. The negative impact of the TPP on public health will be enormous, be felt for years to come and it will not be limited to the current 12 TPP countries, as it is a dangerous blueprint for future agreements.”



*Daniele Dionisio is a member of the European Parliament Working Group on Innovation, Access to Medicines and Poverty-Related Diseases. He is an advisor for “Medicines for the Developing Countries” for the Italian Society for Infectious and Tropical Diseases (SIMIT), and former director of the Infectious Disease Division at the Pistoia City Hospital (Italy). Dionisio is Head of the research project PEAH – Policies for Equitable Access to Health. He may be reached at



Acqua e Servizi Igienici: in Kenya un Miraggio per Molti

Il libero accesso a fonti di acqua potabile e ad idonei servizi igienici è un diritto universale. Sfortunatamente, la realtà che riscontriamo ci racconta una storia diversa. Milioni di persone muoiono ogni anno per le difficoltà che alcuni Governi riscontrano nel garantire tale diritto. Il Kenya è fra questi. Molto è stato fatto da questo Governo, ma maggiori sforzi devono essere profusi


by Pietro Dionisio

Degree in Political Science, International Relations

Cesare Alfieri School, University of Florence, Italy

Acqua e Servizi Igienici: in Kenya un Miraggio per Molti


Una questione internazionale

La disponibilità adeguata di acqua potabile e di servizi igienici rappresenta un elemento basico per potere garantire un livello di salute dignitoso ad una popolazione. La mancanza di tale fornitura di servizi è alla base delle ricorrenze infettive che affliggono milioni di persone nei Paesi poveri. A farne maggiormente le spese è la fascia infantile spesso colpita da forme gravi di diarrea dovuta a mancanza di igiene o di acqua potabile; le stime parlano di circa 1,5 milioni di minori che ogni anno muoiono per infezioni correlate.

Tale questione è sentita come di vitale importanza dalla comunità internazionale. Negli ultimi anni i governi, anche dei Paesi in via di sviluppo, hanno cercato di promuovere politiche atte alla risoluzione del problema. E le Nazioni Unite, prima con gli MDGs (Millennium Development Goals), e poi con gli SDGs (Sustainable Development Goals), hanno posto un forte accento sull’argomento dimostrando come il garantire un facile accesso ad acqua potabile e opportuni servizi igienici non sia un mero esercizio retorico ma una volontà pratica e concreta.

L’interesse su tale argomento è ovvio solo prendendo in considerazione gli effetti positivi che conseguirebbero ad un impegno coerente per colmare il gap. Se i governi afflitti da questa piaga investissero nel settore, avrebbero la possibilità di recuperare l’investimento ottenendo una popolazione più sana e quindi più produttiva. Inoltre, il capitale umano a disposizione ne risentirebbe positivamente poiché i minori avrebbero la possibilità di accedere allo studio e alla frequenza scolastica, mentre la conseguente riduzione dei livelli di povertà in una popolazione più sana comporterebbe la flessione della spesa sanitaria pubblica.

Ne risulterebbero volumi di risparmio che potrebbero essere spesi in consumi interni così da produrre un ulteriore beneficio economico.

Sfortunatamente, queste prospettive non sono alla portata di tutti. Oggi, sebbene a livello mondiale il target MDG relativo all’accesso a fonti di acqua potabile sia stato raggiunto, ancora alcune regioni faticano a garantire tale diritto.

Il caso Kenya

La regione Sub-Sahariana è una di queste. In essa, solo il 68% della popolazione ha accesso ad acqua potabile, e molti Stati stentano a garantire questo diritto.

Il Kenya non è da meno. Su una popolazione complessiva di circa 47 milioni di persone, il 38% non ha accesso ad acqua potabile e il 5,3% delle morti totali è riconducibile ad infezioni contratte tramite l’assunzione di acqua contaminata o  per mancanza di consoni servizi igienici. Per decenni, la scarsità di acqua è stato uno dei principali problemi del Paese. Frequenti siccità, un sistema idrico insufficiente, una deforestazione indiscriminata, la contaminazione dell’acqua a disposizione, il tutto unito ad un aumento della domanda dovuto all’incremento della popolazione, hanno fatto sì che il problema assumesse proporzioni considerevoli.

Negli ultimi quindici anni il governo Keniota ha cercato di superare il deficit ma ad oggi, sebbene qualche miglioramento sia stato ottenuto, ancora molto deve essere fatto.

Come accennato, gli sforzi promossi sono stati notevoli: ne sono esempi il “Water Act 2002” e la “Costituzione del Kenya del 2010” dove all’Art. 43.1 e all’Art. 56 si fa esplicito riferimento alla volontà di garantire a tutti l’accesso a quantità adeguate di acqua potabile e servizi igienici e sanitari.

Le politiche implementate hanno portato ad un miglioramento della situazione. I dati riferiti dal Governo Keniota affermano come dal 2008 al 2013 la proporzione di popolazione che ha accesso a fonti di acqua potabile sia cresciuta dal 59% al 62% e, sempre nel 2013, è il 55% della popolazione rurale che riesce ad approvvigionarsi a fonti di acqua sicura.

L’impegno del Governo è considerevole. Gli obiettivi che le varie strategie si propongono di raggiungere riguardano l’ottimizzazione della gestione dei lavori e dei piani di investimento, l’aumento dei fondi da destinare al settore, la promozione di interventi volti a garantire fonti idriche e igieniche per i gruppi più svantaggiati (soprattutto nelle zone rurali), e l’aumento di lavoratori formati per potere sviluppare il settore stesso e rendere le riforme sostenibili nel lungo periodo.

Oltre a questo, il Governo Keniota è impegnato nella costruzione di un serie di dighe così da incrementare l’approvvigionamento idrico mediante progetti quali, ad esempio, il “Background-Badasa Dam Project”, il “Maruba Dam Project”, il “Chemususu Dam Project” e il “Umaa Dam Project”.

Questi progetti fanno seguito al “Mwache Multipurpose Dam Project” del 2014 le cui finalità sono molteplici. L’obiettivo principale è la costruzione della diga, quale prerequisito per la realizzazione  di infrastrutture idonee a migliorare la fornitura di acqua e servizi igienici nelle contee di Mombasa e Kwale, e per l’ottimizzazione dell’intero sistema di irrigazione locale.

Una agenda da ampliare

Nonostante tutti gli sforzi profusi, non è ipotizzabile che un Governo possa considerarsi soddisfatto se il 38% della sua popolazione ancora non ha accesso ad acqua potabile e ad appropriati servizi igienici. Purtroppo la realtà del Paese ci racconta una storia dove gli investimenti nel settore non possono assolutamente ritenersi sufficienti e dove il gap tra offerta di fondi e la domanda fa sì che ci sia più di un dubbio circa il mantenimento dei servizi esistenti. Tali presupposti ci possono solo fare immaginare le problematiche che il Governo incontra  per l’implementazione di nuovi progetti!

Al fine di garantire un miglioramento del persistente deficit attuale alcune misure sarebbero richieste. Un maggiore coinvolgimento della comunità internazionale potrebbe garantire fondi più consistenti.  L’apporto congiunto di politiche più chiare e di una strategia più definita, renderebbe il miglioramento del settore un obiettivo realmente conseguibile.

In aggiunta, il sistema di valutazione e monitoraggio dovrebbe essere rafforzato al fine di realizzare efficaci politiche di intervento ad hoc.

Nel contempo dovrebbero essere poste in atto permanenti campagne informative per la popolazione al fine di infondere consapevolezza sui rischi connessi alla assunzione di acqua non potabile.

In conclusione, se i progressi conseguiti ad oggi dal governo Keniota, certamente considerevoli,  fanno ben sperare per il futuro, è chiaro che ulteriori energie devono essere profuse affinché il libero accesso ad acqua potabile e a servizi igienici, quale diritto inalienabile di ciascuno, sia davvero garantito!



Addressing Health Inequalities through the United Nations’ Sendai Framework for Disaster Risk Reduction 2015-2030

This article focuses on the Sendai Framework for Disaster Risk Reduction 2015-2030 and how it addresses health and vulnerability. It is hoped that this short report will assist communities of research, policy in understanding the aim of the Sendai Framework and identifying synergies and foster collaboration, particularly through research and evidence-translation for policy makers

Amina Aitsi Selmi

by Amina Aitsi-Selmi

 MBBChir MA(cantab) MRCP MPH MFPH PhD  

Consultant in International Public Health, Global Disaster Risk Reduction/International Public Health, Public Health England

Addressing Health Inequalities through the United Nations’ Sendai Framework for Disaster Risk Reduction 2015-2030



The year 2015 is a crucial year in global policy with the publication of three landmark UN agreements: 1) the Sendai Framework for Disaster Risk Reduction 2015-2030 (agreed by 187 Member States after negotiations at the World Conference on Disaster Risk Reduction in March 2015);[1] 2) the Sustainable Development Goals (SDGs)[2] which are the successors of the Millennium Development Goals (agreed in September); and the climate change agreements (to be agreed in December). The success of these global agreements is partly dependent on ensuring coherence and building on synergies to avoid duplication and encourage joint initiatives. For example SDG targets 1.5, 2.4, 11.b, 11.5 and 13.1 all pertain to disaster risk reduction (DRR) and are, therefore, areas of synergy with the Sendai Framework.[3]

A comprehensive approach to future economic development – in low-, middle- and high-income countries – must ensure that future economic activity has people’s wellbeing and the environment’s preservation at its heart. It is encouraging that, so far, the agreements acknowledge the role of unmanaged development processes in increasing the risk of disasters and disease and the need to address vulnerability by influencing wider socioeconomic factors. This article focuses on the Sendai Framework and how it addresses health and vulnerability. It is hoped that this short report will assist communities of research, policy in understanding the aim of the Sendai Framework and identifying synergies and foster collaboration, particularly through research and evidence-translation for policy makers.

Health in the Sendai Framework

The Sendai framework for disaster risk reduction 2015–2030 has a substantial emphasis on health – much more so than its predecessor, the Hyogo framework for action 2005–2015.[4] There are more than 30 explicit references to health (compared to three in its predecessor), referring to the implementation of an all-hazards approach to managing disaster risk including links to epidemics and pandemics, the International Health Regulations and to rehabilitation as part of disaster recovery and health system resilience.[5] These are welcome links as disasters often exacerbate the causes of ill-health, whether through direct physical injury, mental health sequelae, infectious disease outbreaks through damage to water and sanitation infrastructure or disruption to health service access which impact those with chronic disease.[6]

Over the next 15 years, the framework’s main objective is to achieve the “substantial reduction of disaster risk and losses in lives, livelihoods and health and in the economic, physical, social, cultural and environmental assets of persons, businesses, communities and countries.” Voluntary commitments with a specific public health focus that have been agreed include: enhancing the resilience of national health systems through training and capacity development; improving the resilience of new and existing critical infrastructure, including hospitals, to ensure that they remain safe, effective and operational during and after disasters, to provide live-saving and essential services; establishing a mechanism of case registry and a database of mortality caused by disaster to improve the prevention of morbidity and mortality and enhancing recovery schemes to provide psychosocial support and mental health services for all people in need; enhancing cooperation between health authorities and other relevant stakeholders to strengthen country capacity for disaster risk management for health; and the implementation of the International health regulations (2005).

Disaster impacts are strongly influenced by physical, social, economic and environmental factors apparent as underlying vulnerability from poverty, inequity and poor urban planning and land use.[7] The Sendai Framework acknowledges that reducing disaster risk requires concerted action across a wide range of sectors, institutions and disciplines. In alignment with the Social Determinants of Health approach,[8] which calls for intervention on the wider determinants that impact individual lives and health, reducing disaster risk is, therefore, relevant within and beyond the health sector.

Vulnerability in the Sendai Framework

The United Nations Office for Disaster Risk Reduction (UNISDR) defines vulnerability as “The conditions determined by physical, social, economic and environmental factors or processes, which increase the susceptibility of a community to the impact of hazards”.[9] Vulnerability may vary within a population by subgroup (e.g. income level or type of livelihood) and may change over time, adding complexity to vulnerability measurement.[10]

An important area of progress is reflected in Priority 1 of the Sendai Framework: understanding risk. Risk assessment and modelling that incorporate all dimensions of risk including vulnerability can help to communicate usable risk information to users and assist decision-makers in understanding the potential impact of disasters and highlighting effective policies to reduce risk, increase preparedness, and improve response and recovery.

Traditionally, the focus of risk assessments has been on (natural) hazards or physical infrastructure alone. However, the Sendai Framework gives prominence to the vulnerability of populations, communities and groups and calls on the scientific community and its partners to: discuss and identify main gaps and challenges in the development of vulnerability data and models, considering physical, socio-economic, institutional and environmental factors; identify needs for improved understanding and models for community resilience; and promote enhanced collection, availability and dissemination of datasets fundamental to assessing exposure and vulnerability, such as up-to-date disaggregated census data, building typologies, poverty and household surveys, sectoral data (e.g., school locations and attributes) and systematic post-disaster analysis of building and infrastructure failure and socio-economic impacts on communities; but also: strengthening the design and implementation of inclusive policies and social safety-net mechanisms, including access to basic health care services towards the eradication of poverty; finding durable solutions in the post-disaster phase to empower and assist people disproportionately affected by disasters, including those with life threatening and chronic disease. The latter recommendation will be particularly important in the coming years as non-communicable diseases continue to rise in low- and middle-income countries.

Four distinct and largely independent research and policy communities – disaster risk reduction, climate change adaptation, environmental management and poverty reduction have been working to reduce vulnerability to hazards but face challenges in terms of facilitating learning and exchanging information.[11]  In addressing these challenges to produce useful, usable and used risk information that incorporates vulnerability as a critical dimension of risk, different communities of producers and users of information across sectors and disciplines will need to work together at all levels, local, national, regional and global to ensure the aspirations of the Sendai Framework (and its closely related policy agreements of 2015) are achieved.

Next steps: convening the scientific community to leverage science for life-saving policy

The Sendai Framework strongly endorses the role of science and the importance of the scientific community in supporting the implementation of the framework over the next 15 years. Multidisciplinary research is highlighted as critical to producing science that is used, usable and used through improved databases, the use of baselines and disaggregated data, more effective dissemination of evidence and knowledge and capacity building to name but a few areas of recommendation. The framework is a call to all scientists to collaborate in making a positive difference to ‘lives, livelihoods and health’. One of the Sendai Framework’s priorities for action is: to promote investments in innovation and technology development in long-term, multihazard and solution-driven research in disaster risk management to address gaps, obstacles, interdependencies and social, economic, educational and environmental challenges and disaster risks.

In order to offer an opportunity to explore the implications for the scientific community of the Sendai Framework, the United Nations Office for Disaster Risk Reduction (UNISDR) is organising an international conference to launch a science and technology global partnership and develop a 15 year road map for the global science and technology community to support the implementation of the Sendai Framework until 2030.  The conference will take place in Geneva, 27-29th of January 2016 (For further information and call to abstracts, see


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  3. Aitsi-Selmi A, Murray M. Ensure healthy lives and promote well-being for all at all ages. ICSU, ISSC (2015): Review of the Sustainable Development Goals: The Science Perspective. Paris: International Council for Science (ICSU). Available at [Accessed 18 October 2015].
  4. UNISDR. The Hyogo Framework for Action (HFA). Available from  [Accessed 18 January 2015]. 2005.
  5. Aitsi-Selmi A MV. The Sendai framework: disaster risk reduction through a health lens. Bulletin of the World Health Organization 2015;93:362.
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  7. UNISDR. Proposed Elements for Consideration in the Post‐2015 Framework for Disaster Risk Reduction: By the UN Special Representative of the Secretary‐General for Disaster Risk Reduction. Geneva: United Nations Office for Disaster Risk Reduction; 2013. Available from: [cited 18 October 2015]. 2013.
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