Repealing NV Provisions under TRIPS

Non-violation provisions allow a WTO member country to convene another member country before the WTO Dispute Settlement Body on allegations of loss of an expected benefit because of that country’s action, even if  such action does not constitute violation of a WTO agreement. Developing countries are wary of these provisions and the moratorium on their use under TRIPS is up for debate at the WTO Ministerial Conference in Buenos Aires on 10-13 December 2017

By Daniele Dionisio*

Head of the research project PEAH – Policies for Equitable Access to Health

 Repealing Non-Violation Provisions under TRIPS

 

Non-violation (hereinafter NV) provisions based on actions that do not conflict with World Trade Organization (WTO) agreements are measures provided under Article XXIII, subparagraph 1(b), of the General Agreement on Tariffs and Trade 1994 (GATT) and Article XXIII of the General Agreement on Trade in Services 1995 (GATS), and regulated under Article 26 of the WTO Dispute Settlement Understanding (DSU).

NV provisions exist in many bilateral trade agreements also involving developed country members, such as in the Australia-United States Free Trade Agreement (AUSFTA) Article 21.2 (c).

NV provisions imply that WTO member countries are allowed to take another member country to the WTO Dispute Settlement Body on allegations of loss of an expected benefit because of that country’s action, even if  such action does not constitute violation of a WTO agreement. These disputes are called NV complaints or claims.

While NV complaints are intended to help preserve the balance of profits struck during deals, for the time being WTO members have agreed not to initiate them under the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). According to TRIPS Article 64.2, this moratorium was to last for the first five years of the WTO, but has been extended since then from one WTO ministerial conference to the next.

As a follow-up to instructions to the TRIPS Council laid down in paragraph 11.1 of the 2001 Doha Decision on Implementation-Related Issues and Concerns, most WTO members at the 2003 WTO Ministerial Conference suggested repealing the NV provisions in TRIPS, or extending the moratorium. Unfortunately, no consensus was reached at that time, nor did it arise from TRIPS Council discussions to what extent and how these complaints could be incorporated into the WTO’s dispute settlement procedures.

Under these circumstances, a decision taken at the 10th Ministerial Conference in 2015 tasked the TRIPS Council with non-stop debating the issue and releasing a recommendation for the 11th WTO Ministerial Conference  to take place in Buenos Aires, Argentina, on 10-13 December  2017.

Relevantly, the October 2017 meeting of the TRIPS Council fell short of consensus whether to lift or indefinitely prolong the moratorium. As such, the Council would have to reconvene to try to reach an agreement and submit recommendation to the General Council meeting (scheduled for 30 November-1 December), and through it to the 11th Ministerial Conference.

Ultimately, it will be up to the Ministerial Conference to tackle these questions at a time when developing countries are wary of NV provisions. Meanwhile, some developed countries (including Australia, Canada, the EU and New Zealand) would like to see the moratorium renewed, while others, namely the Switzerland and the United States, agree that the NV clause should be allowed in TRIPS to discourage members from getting around their commitments.

This context adds to the awareness that NV provisions are a bone of contention. As a tool backed by the developed countries, they are feared to put unpredictability and precariousness in international trade law, and serve ‘behind doors’ cross-retaliation lobbying, i.e., by threatening a dispute in one trade area to achieve a gain in a different one.

Jeopardizing the developing countries

WTO developing members would be put at risk should NV provisions be allowed in the TRIPS agreement. As a result, these countries might face pressures to reverse already enacted policies or measures under the threat of NV claims.

NV claims could be used to threaten developing member countries’ use of flexibilities laid down in the TRIPS agreement. As regards access to medicines, the implementation of TRIPS flexibilities by these countries under Articles 30 or 31 (i.e., to grant compulsory licenses) could be charged with keeping patent owners from their legitimate or reasonable expectations. Inherently, no wonder should developed member countries claim that price cuttings of medicines under compulsory licenses deprive them of foreseen patent protection benefits.

With respect to medicines, many other forms of government regulation could be argued not to conflict with the TRIPS agreement, yet to make pointless or erode the expectations of the patent owners.

High risk sectors 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 NV complaint against this country would be allowed to re-establish the conditions of competition in the original transaction.

What’s more, the sectors relevant to packaging and labelling requirements, and to intellectual property (IP) protection enforcement measures, may also result as risk target areas, since they might affect the patent holders’ access to the market of medicines.

Under these perspectives, it would make it easier for a claim to be lodged against a WTO member for nullifying or eroding benefits by applying IP protection rules or packaging and labelling models that, despite full alignment with TRIPS requirements, are deemed to be insufficiently stringent or fraudulent.

At risk there would even be an amendment to the TRIPS Agreement  (new Article 31bis gone into effect on 23 January 2017) that brings a solution to Paragraph 6 of the 2001 Doha Declaration on TRIPS and Public Health, and allows countries manufacturing generic medicines under compulsory license to export all of the medicines to least-developed countries lacking manufacturing capabilities.

Should NV provisions be allowed in TRIPS, they  would likely act as a boost for complaints against WTO member countries using the amendment on the grounds of a loss of expected benefit to the patent holders.

Getting rid of NV provisions under TRIPS

Taken together, the non-transparent dynamics bound up with NV provisions compound fear that their allowance under TRIPS, or the renewal of their moratorium (as an alleged tool of cross retaliation), would be something that ultimately backs the developed economies rather than making headway on the right to health in resource-limited countries.

It is therefore a matter of equity that NV provisions be repealed under TRIPS.

The questions highlighted here link trade and health priorities together as key issues for non-discriminatory solutions at the upcoming WTO Ministerial Conference in Buenos Aires. These should align with the WTO’s principles of non-discriminatory treatment by and among members, improved public welfare, and commitment to transparency.

In this connection, WTO’s lifting of NV provisions under TRIPS would mean a rejection of ambiguous positions while helping oppose the drive of international trade for ever more unbearable IP protection rules.

———————–

* Daniele Dionisio is a member of the European Parliament Working Group on Innovation, Access to Medicines and Poverty-Related Diseases. 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 

d.dionisio@tiscali.it http://www.peah.it/ https://twitter.com/DanieleDionisio https://www.linkedin.com/in/daniele-dionisio-67032053

 

 

 

 

Health Breaking News: Link 262

Health 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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Medical Ethics and Social Media in Pakistan

...Still, the fact that doctors hold power over their patients is indisputable. One of the fundamental duty/responsibility of governments, medical boards and hospital administrations in this regard is/should be to ensure that rules are put into place in order to diminish the probability of any abuse of this power...

...there are serious institutional questions that need to be addressed here and patient-doctor interaction is more complicated than we would like to believe...

...We need to develop a policy framework within which the various facets of patient-doctor relationship are analysed and which forms the basis for nationwide guidelines that help doctors to understand their roles and responsibility better in their social media interactions...

 By Muhammad Usman Khan*

WFP’s Technical Consultant to Planning and Development Department

Medical Ethics and Social Media in Pakistan

 

In the recent fiasco a doctor has added a patient on Facebook. The patient was the famed two time Oscar winner Sharmeen Obaid Chinoy’s sister. Sharmeen took to twitter bemoaning lack of boundaries in Pakistan and lodged a complaint against the doctor who was subsequently suspended. She asserted that the doctor added her sister on Facebook after a private check up and went on to comment on her pictures. The matter has been dissected from all ends of ideological spectrum and I do not seek to address the validity of any opinion. It does however beg the question: what are the institutional mechanisms and policy frameworks in Pakistan that aim to address these issues?

The field of medical ethics guides us in the process and helps untangle a lot of questions in this regard. However, it is important to remember that in our society being friends with your doctor is not unheard of and is by and large not viewed as something problematic. The potential adverse outcomes associated with patient-doctor friendship are not obvious to most people in Pakistan.

At the same time, as adults, we understand that the word ‘friend’ as has been applied to Facebook has a virtual implication that does not automatically spill into our lives and does not immediately hold us accountable against some perennial conception of friendship. We do not consider Facebook friendship requests with the same degree of seriousness as we do real life friendship. We should also be cognizant of the fact that our view of privacy does not translate onto the virtual world as seamlessly as some of us think it should. Nonetheless, when you send someone a friend request, it is reasonable to assume that you desire to stay in touch with them. Whether this translates into a friendship is not clear. For the sake of argument let’s suppose that it does. What are the pitfalls of such an association?

American Medical Associations observation from 1847 rings true even today:

The natural anxiety (of a physician), the solicitude which he experiences at the sickness…..of anyone  who is rendered dear to him, tends to obscure his judgement, and produce timidity, and irresolution in his practice.

This is not to say that a doctor does not experience anxiety at the misery of patients with whom he has no personal relationship. Rather, it is the quantum of the anxiety that is under consideration here. Under normal circumstances where the patients is not a relation or a friend, doctors are trained to maintain a sense of calm that allows them to dispense their duties adequately and in line with their fiduciary responsibility.

A physician, then, is to maintain the intricate balance between not developing a relationship outside of the professional setting and ensuring a professional and friendly disposition during his/her interactions with the patients. An overlap in these two relationships is unavoidable under certain circumstances. The token village doctor can’t escape this concurrence. This seemingly simple bifurcation can take various iterations given the subjective nature of interaction between patient and doctor. Doctors are barely trained to navigate this murky domain and little to no professional guidance is available from the institutions (hospitals, ministries, medical boards) to deal with such scenarios. The limits to this relationship are then set by the doctor, by the patient, by them both or neither.

A doctor may become overly invested in a patient who is a friend, leading to over investigation and unfair distribution of time. Alternatively, the patient and doctor may not discuss areas of medical import because of their friendship. This is more likely to happen when the problem is related to psychological or sexual domains.

If the boundaries of the relationship are delineated too close to the impersonal end of the spectrum, a doctor would not give appropriate attention to the patient.

What then is the role of social media?

The field of medical ethics tells doctors to maintain confidentiality, security and boundaries.  On one hand, social media can provide information to patients that allows them to make decision about their care providers and engage with them virtually so as to break the ice. But at the same time, it allows for enough information to move in either direction so as to have negative psycho-social implications. Similarly doctors can find out more about their patients through social media which can be useful in certain healthcare settings but can result in a breach of trust.

Pakistan Medical and Dental Council’s (PMDC) code of ethics is outdated in its details and needs serious upgradation on multiple fronts. It offers no way forward in terms of doctor-patient relationship and their interactions over social media. International medical bodies are more helpful on this front. UK’s General Medical Council (GMC)’s guidelines on the matter do offer some insights and continue to guide doctors to err on the side of caution. In terms of the penalty GMC states that serious or persistent failure to abide by the rules will put their registration at risk. What constitutes as serious and persistent needs to be quantified as well in Pakistan’s local context. The crux of the matter is that actions by the doctor that can be constituted as failure to perform the duties of a fiduciary on social media, be it breach of confidentiality or causing psychosocial damage, is contingent upon inappropriate online interaction. In a lot of ways, declining a friend request precludes the possibility of such interaction. The act of adding a patient on Facebook on its own, however, reflects a huge potential for the breach of the fiduciary duty. More information is needed to actually determine whether this responsibility was breached in the current case.

A doctor needs to be deeply aware of his/her place in the society and should take pains to ensure that the patient is at ease under all circumstances. The debate in the west by and large has been around the issue of why patients should not add their doctors on Facebook. The converse is not entertained as a real issue given that the idea of personal boundaries in patient-doctor interaction are very well defined and are reinforced within the medical community through various trainings and lawsuits. It is also critical to point out that by and large the western social norms do not stand to contradict these ethical boundaries.

Still, the fact that doctors hold power over their patients is indisputable. One of the fundamental duty/responsibility of governments, medical boards and hospital administrations in this regard is/should be to ensure that rules are put into place in order to diminish the probability of any abuse of this power. However, using presuppositions about power to explain away everything is both disingenuous and convenient. It does not leave room for real inquiry into the dynamics of individual interactions. It doesn’t offer any practical response other than exertion of power in the opposite direction. What we do know is that there are serious institutional questions that need to be addressed here and patient-doctor interaction is more complicated than we would like to believe.

What has been missing from the discourse on the issue so far is what the driving force of any honest intellectual inquiry is i.e. the assertions that we don’t know enough. Ironically it is the only thing we know for sure. Going by Sharmeen’s statements, what the doctor did was both unethical and worthy of bring reprimanded. However, the adequate response is something that is not obvious at all. We need to develop a policy framework within which the various facets of patient-doctor relationship are analysed and which forms the basis for nationwide guidelines that help doctors to understand their roles and responsibility better in their social media interactions. The primary action in this regard is to revisit the PMDC code of ethics and ensure that all medical colleges have the relevant stipulations embedded in their own by-laws and these are enforced and reinforced through adequate trainings and penalties. Only then a culture will emerge where such matters can be talked about in a nuanced manner.

————————————-

*About the author:

https://www.linkedin.com/in/muhammad-usman-khan-3a1034143/

 

 

Health Breaking News: Link 261

Health 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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Operativo in Italia: Sistema BES

La legge n. 163/2016 prevede che l’andamento nell’ultimo triennio degli indicatori di benessere equo e sostenibile (BES) diventi un allegato al Documento di economia e finanza redatto ad aprile di ogni anno; e che il ministero dell’Economia valuti, in una relazione al Parlamento entro il 15 febbraio dell’anno successivo, l’impatto della legge di bilancio su tali indicatori

By Daniele Dionisio

Membro, European Parliament Working Group on Innovation, Access to Medicines and Poverty-Related Diseases

Responsabile del Progetto Policies for Equitable Access to Health – PEAH 

Operativi in Italia gli Indicatori BES

 

Il Benessere Equo e Sostenibile – BES entra a far parte della programmazione economica in Italia. Obiettivo è associare al PIL (Prodotto Interno Lordo, ovvero il peso dei beni e servizi prodotti dal Paese in un anno) una serie di indicatori mirati alle variabili fondamentali della funzione del benessere e qualità di vita  per le quali il PIL non è sufficiente né correlato. 

L’Italia è il primo paese europeo e del G7 ad includere indicatori  del benessere nella programmazione economica, nonostante che sollecitazioni a dotarsi di indicatori BES siano ben presenti nell’Agenda 2030 per lo sviluppo sostenibile diramata dall’ONU nel 2015.

Come stabilito dalla legge di Bilancio 163/2016, ed in riferimento ai 17 obiettivi di sviluppo sostenibile dell’Agenda ONU 2030, un comitato nazionale di esperti ha elaborato 12 Indicatori BES.  Lo schema di decreto del ministero dell’Economia con gli indicatori è stato sottoposto in estate alle commissioni Bilancio di Camera e Senato, che hanno espresso parere favorevole. Nelle more della formalizzazione finale, il governo ha comunque già inserito nel Def (Documento di Economia e Finanza) i primi quattro indicatori. Eccoli di seguito:

Reddito medio disponibile aggiustato pro capite
Rapporto tra il reddito lordo disponibile delle famiglie (consumatrici + produttrici) aggiustato (ovvero inclusivo del valore dei servizi in natura forniti dalle istituzioni pubbliche e senza fini di lucro), e il numero totale di persone residenti in Italia (valori nominali in euro).
Permette di stimare l’ammontare complessivo del reddito disponibile per le persone residenti in Italia, compreso il valore dei servizi in natura.

Indice di disuguaglianza del reddito disponibile
Rapporto fra il reddito equivalente totale ricevuto dal 20% della popolazione con il  più  alto reddito  e quello ricevuto dal 20% della popolazione con il più basso reddito.
Fornisce un’informazione sulla distanza in termini di reddito tra i più ricchi e i più poveri che, poiché considera i redditi equivalenti, tiene conto della diversa composizione familiare (diversi bisogni tra bambini e adulti; economie di scala che si realizzano con la coabitazione).

Tasso di mancata partecipazione al lavoro
Rapporto tra la somma di disoccupati e inattivi “disponibili” (persone che non hanno cercato lavoro nelle ultime 4 settimane ma sono disponibili a lavorare), e la somma di forze lavoro (insieme di occupati e disoccupati) e inattivi “disponibili”, riferito alla popolazione tra 15 e 74 anni.
L’indicatore esprime una misura dell’offerta di lavoro insoddisfatta più ampia rispetto al tasso di disoccupazione, poiché coglie anche quella parte di popolazione inattiva che si dichiara disponibile a lavorare pur non avendo cercato lavoro nelle 4 settimane che precedono l’intervista, dando così conto dei fenomeni di scoraggiamento e dei comportamenti “attendisti” dovuti agli esiti di passate azioni di ricerca.

Emissioni di CO2 e altri gas clima alteranti
Tonnellate di CO2 equivalente emesse su base annua da attività agricole, urbane e industriali, per abitante.
Sono incluse le emissioni di anidride carbonica (CO2), metano (CH4) e protossido di azoto (N2O), espresse in “tonnellate di CO2 equivalente”, con pesi che riflettono il potenziale di riscaldamento  in rapporto all’anidride carbonica: 1 per CO2; 298 per N20; 25 per CH4. Non viene considerato l’effetto compensativo legato alla presenza di boschi e altra copertura vegetale.

La legge n. 163 prevede che l’andamento nell’ultimo triennio degli indicatori BES diventi un allegato al Def redatto ad aprile di ogni anno; e che il ministero dell’Economia valuti, in una relazione al Parlamento entro il 15 febbraio dell’anno successivo, l’impatto della legge di bilancio su tali indicatori.
In sintesi, il Ministero dell’Economia e delle Finanze, entro il 15 febbraio 2018, valuterà per la prima volta l’impatto delle politiche economiche sui primi  4 indicatori. Successivamente, con il Def 2018, saranno introdotti gli altri otto indicatori come desunti di seguito dall’appendice II della Relazione finale del Comitato per gli indicatori di benessere equo e sostenibile:

Indice di povertà assoluta
Percentuale di persone appartenenti a famiglie con una spesa complessiva per consumi inferiore al valore soglia di povertà assoluta, sul totale delle persone residenti.

Speranza  di vita in  buona salute alla nascita
Numero medio di anni che un bambino nato nell’anno di riferimento può aspettarsi di vivere in buona salute, nell’ipotesi che i rischi di malattia e morte alle diverse età osservati in quello stesso anno rimangano costanti nel tempo.

Eccesso di peso
Proporzione standardizzata di persone di 18 anni e più in sovrappeso o obese sul totale delle persone di 18 anni e più.

Uscita precoce dal sistema di istruzione e formazione
Percentuale della popolazione in età 18-24 anni con al più il diploma di scuola secondaria di primo grado (licenza media), che non è in possesso di qualifiche professionali regionali ottenute in corsi con durata di almeno 2 anni e non frequenta nè corsi di istruzione nè altre attività formative.

Rapporto tra tasso di occupazione delle donne 25-49 anni con figli in età prescolare e delle donne  senza figli
Rapporto tra il tasso di occupazione delle donne di 25-49 anni con almeno un figlio in età prescolare (0-5 anni) e il tasso di occupazione delle donne di 25-49 anni senza figli, per 100.

Indicatore di criminalità predatoria
Numero di vittime di furti in abitazione, borseggi e rapine per 1000 abitanti.

Indice di efficienza della giustizia civile (durata media effettiva in giorni dei procedimenti di cognizione civile ordinaria definiti dei tribunali)
Il dato tiene conto dei procedimenti civili di cognizione ordinaria di primo e secondo grado (contenzioso + non contenzioso) dell’area SICID al netto dell’attività del Giudice tutelare e dell’Accertamento Tecnico Preventivo in materia di previdenza.

Indice di abusivismo edilizio
Numero di costruzioni abusive per 100 costruzioni autorizzate dai Comuni.

La scelta dell’Italia di dotarsi di indicatori BES appare necessaria anche alla luce del rapporto ASviS 2017 (Alleanza italiana per lo sviluppo sostenibile, rete di 170 organizzazioni), che indica i punti di forza e debolezza dell’Italia riguardo ai 17 obiettivi dell’Agenda ONU 2030 per lo sviluppo sostenibile. In sintesi, mentre si registrano miglioramenti per nove target, tra cui educazione, salute e alimentazione, è evidente un regresso per povertà, gestione delle acque, disuguaglianze ed ecosistema terrestre.

I dati del rapporto suggeriscono che una strategia basata su politiche integrate (che non trascurino interventi specifici in settori quali, ad esempio, consumo di suolo, approvvigionamento idrico e qualità dell’acqua e degli ecosistemi) migliorerebbe le prestazioni dell’Italia.

In questo scenario, l’entrata in azione, accanto al PIL, degli indicatori BES costituisce, senz’altro, un importante passo in avanti.

 

PER APPROFONDIRE

Legge 4 agosto 2016, n. 163 http://www.gazzettaufficiale.it/eli/id/2016/08/25/16G00174/sg

Testo dello schema di decreto e della relazione della Commissione che ha predisposto gli indicatori  http://www.senato.it/service/PDF/PDFServer/BGT/1029767.pdf

Rapporto ASviS 2017 http://www.asvis.it/rapporto-2017/

UN: Transforming our world: the 2030 Agenda for Sustainable Development https://sustainabledevelopment.un.org/post2015/transformingourworld

 

 

 

Global Health Initiatives: What Do We Know About Their Impact On Health Systems?

Global Health Initiatives such as GAVI, GFATM and PEPFAR have incurred criticism of being selective and narrowly defined while placing poor emphasis on - and falling short of - health systems strengthening

By Angela Owiti*

Trainee at Wemos foundation

Global Health Initiatives

 What Do We Know About Their Impact On Health Systems?

 

The Global Health Initiatives (GHIs) were created to help meet the Millennium Development Goals (MDGs) (1). They pool funds and expertise and focus their efforts across different countries towards disease specific interventions, such as anti-retroviral therapy (ART), vaccines and insecticide treated bed nets. While these programmes have reached substantial outcomes in many low and middle income countries (LMICs), they also received criticisms in the first decade of their advent for operating through parallel delivery systems and causing unwanted weakening effects on the countries’ health care systems (2). The first comprehensive report on the interaction between GHIs and country health systems by the World Health Organization (WHO) Maximizing Positive Synergies Collaborative Group recommended that GHIs need to place more emphasis on strengthening health systems. In addition, they concluded that with some adjustments in the way they operate, GHIs can offer critical opportunities to improve ‘efficiency, equity, value for money and outcomes in global public health’ (1).

Moving towards strengthening of health systems

Following the criticisms and recommendations, three large GHIs- the Global Alliance for Vaccines and Immunization (GAVI), the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM), and the United States President’s Emergency plan for AIDS Relief (PEPFAR)- responded and  embraced a commitment towards strengthening health systems since around 2010 (3). However, their HSS (health system strengthening) strategies were seen as being selective and narrowly defined by both Marchal et al (4) and Storeng (5). Since then, the GHIs increasingly encourage countries to request for resources targeted at strengthening health systems, albeit with that narrow view of optimizing the delivery of their disease-specific health programmes (2). Hence, this raises questions of whether health systems in LMICs are really benefitting.

I therefore examined whether GAVI, GFATM and PEPFAR are having reported impacts on the health systems. As a follow-up of reviews published in 2009 and to coincide with the time that the three GHIs started to focus explicitly on HSS, I identified and reviewed 19 articles published between 2010 and 2017 on the effects of GHIs on country health systems, with a particular focus on countries in Sub-Saharan Africa (SSA). The articles however mainly described the situation before the new focus on HSS which was introduced around 2010. Below I present the findings of my literature review.

Findings

The literature review showed that the achievements of GHIs yielded both positive and negative effects. Most of the results relating to the impact on the health systems identified in the reviewed articles are on the health service delivery and the health workforce function, while governance is seldom scrutinized.

Key positive effects include: an increase in access to ART (6); increased linkages between HIV and TB programmes and other healthcare programmes such as maternal and child health services and family planning (6) and pre-service training to increase the capacity of health care workers (HCWs) (7). Adverse effects described include: the ‘internal brain drain’ of health care workers from public health facilities (which already struggle with shortages) to private sector or GHI-funded organizations (8)(9);conflict between top-down strategies of disease programmes and local planning activities (10)(11); and parallel systems which create duplicate tasks and an increased workload for HCWs (also for already overburdened staff); over-emphasis on in-service training of HCWs resulting in per-diem hunting and duplicate training (7)(9). Other findings cover the over-reliance on external donor funds which generate concerns over the long-term sustainability of the programmes, and that GHIs limit their efforts towards a few diseases thus many high burden problems such as maternal and child health, non-communicable and neglected tropical diseases are not equally addressed (10).

Paucity of evidence

Two features from the literature review stood out. First, most of its findings were similar to those of the previous reviews published in 2009 (2)(1). This does not come as a total surprise, because most of the data collected in the identified and reviewed articles were collected before 2010. Secondly, the results showed that there seems to be unequal attention to all GHIs. While my focus was on GAVI, GFATM and PEPFAR, my search did not produce any articles on the interaction of GAVI with health systems. To me this is evidence that not enough attention is being given by both the recipient and donor countries, and the global health research community on the interaction of GHIs with country health systems. An issue which has been previously raised and discussed by the WHO’s Maximizing Positive Synergies Collaborative Group (1). More than half a decade after these GHIs’ explicit commitments to strengthen health systems, this attention seems to be long over-due.

Short term versus long term effects

GHIs were initially intended to salvage emergency situations. Their quick response was mainly in the form of supporting health systems with interventions which fill urgent gaps and primarily focused on increasing inputs. These include short-term interventions such as those that improve or upgrade facilities, improve services or provide salary support (12). Though these interventions have helped to ensure the scale up of treatment such as in the case of HIV/AIDS, they do not lead to the processes that bring about sustainable change and performance. I do agree with Chee et al (12), that it may have been easier to think in the short term but with time it became evident that this approach caused fragmentation in the health systems and, as a result, the negative effects which are also reported in the studies I reviewed were observed.

Strengthening health systems on the other hand is not just about filling gaps but ensuring that the six health system building blocks – leadership and governance; financing; service delivery; health workforce; health information systems and medicines and other commodities – function better (13). It also involves “managing these building blocks in a manner that strives to achieve more equitable and sustained improvements across health services and health outcomes” (12). The 2004-2009 Malawian Emergency Human Resources Programme (EHRP) that was co-funded by the GFATM was a promising example. It involved the recruitment and pre-training of HCWs, but more importantly policies and activities that are related to financial and non-financial incentives, such as employment conditions and staff placements, were implemented to address issues such as inadequate staffing and low motivation. The EHRP was also done with the collaboration of different international initiatives, the health sector-wide approach (SWAp) and the Malawian government. All of which is intricately related to the system building block of service delivery. There was a reported significant increase in the HCW density. However, the longer term effects of the EHRP on Malawi’s health workforce and its sustainability are not reported in literature.

Research on health systems is needed

The Sustainable Development Goals (SDG) demonstrates a renewed global commitment to health, underpinned by SDG3 including its ambitious target on Universal Health Coverage (UHC). For that we need to build strong and responsive health systems to ensure that all people and communities have access to essential and affordable health services. Achieving UHC for all countries requires global commitment. GAVI, GFATM and PEPFAR claim to be part of the solution. But both the donor and recipient countries need to hold them accountable and ensure that they are not just talking the talk but also walking the walk. Positive benefits will only happen if we explicitly set out to achieve them. For this we need research on health systems! Good measuring frameworks and knowledge sharing to highlight both the best practices and lessons learnt. This will help countries build their systems and meet the needs of the people and the communities.

*About the author

Angela Owiti is pursuing an Advanced Master degree in International Development (AMID) at the Radboud University in the Netherlands and is a trainee at Wemos foundation. This literature review was conducted for the foundation’s activities in the Health Systems Advocacy Partnership (HSAP), which is active in five countries in SSA: Kenya, Uganda, Zambia, Tanzania and Malawi.

References

  1. Samb B, Evans T, Dybul M, Atun R, Moatti JP, Nishtar S, et al. An assessment of interactions between global health initiatives and country health systems. Lancet [Internet]. 2009;373(9681):2137–69. Available from: http://dx.doi.org/10.1016/S0140-6736(09)60919-3
  2. Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G. The effects of global health initiatives on country health systems: A review of the evidence from HIV/AIDS control. Health Policy Plan. 2009;24(4):239–52.
  3. Warren AE, Wyss K, Shakarishvili G, Atun R, de Savigny D. Global health initiative investments and health systems strengthening: a content analysis of global fund investments. Global Health [Internet]. 2013;9(1):30. Available from: http://globalizationandhealth.biomedcentral.com/articles/10.1186/1744-8603-9-30
  4. Marchal B, Cavalli A, Kegels G. Global health actors claim to support health system strengthening – Is this reality or rhetoric? PLoS Med. 2009;6(4):1–5.
  5. Storeng KT. The GAVI Alliance and the “Gates approach” to health system strengthening. Glob Public Health [Internet]. 2014;9(8):865–79. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4166931&tool=pmcentrez&rendertype=abstract
  6. Rasschaert F, Pirard M, Philips MP, Atun R, Wouters E, Assefa Y, et al. Positive spill-over effects of ART scale up on wider health systems development: Evidence from Ethiopia and Malawi. J Int AIDS Soc. 2011;14(SUPPL. 1):1–10.
  7. Bowser D, Sparkes SP, Mitchell A, Bossert TJ, Bärnighausen T, Gedik G, et al. Global Fund investments in human resources for health: Innovation and missed opportunities for health systems strengthening. Health Policy Plan. 2014;29(8):986–97.
  8. Mussa AH, Pfeiffer J, Gloyd SS, Sherr K. Vertical funding, non-governmental organizations, and health system strengthening: perspectives of public sector health workers in Mozambique. Hum Resour Health [Internet]. 2013;11(1):26. Available from: http://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-11-26
  9. Chima CC, Homedes N. Impact of global health governance on country health systems: the case of HIV initiatives in Nigeria. J Glob Health [Internet]. 2015;5(1):10407. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4416331/
  10. Mwisongo A, Soumare AN, Nabyonga-Orem J. An analytical perspective of Global health initiatives in Tanzania and Zambia. BMC Health Serv Res [Internet]. 2016;16(S4):223. Available from: http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1449-8
  11. Oliveira Cruz V, McPake B. Global Health Initiatives and aid effectiveness: insights from a Ugandan case study. Global Health [Internet]. 2011;7(1):20. Available from: http://globalizationandhealth.biomedcentral.com/articles/10.1186/1744-8603-7-20
  12. Chee G, Pielemeier N, Lion A, Connor C. Why differentiating between health system support and health system strengthening is needed. Int. J. Health Plann. Manage. [Internet] 2013 Jan; 28(1):85–94. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3617455/
  13. World Health Organization. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. [Internet]. 2007 p. 1–56. Available from: http://www.who.int/healthsystems/strategy/everybodys_business.pdf 

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