Health Breaking News 323

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

Health Breaking News 323


What is this thing called neoliberalism? (With apologies, and gratitude, to Cole Porter) 

The US Affordable Care Act: Reflections and directions at the close of a decade 

An economy that serves the people: new UN guidance to anchor policy-making to human rights 

Asian NGOs Raise Concern Over IP And Seeds In RCEP Trade Deal 

IMF Conditionalities Still Under the Fire of Criticism by Daniele Dionisio 

European Parliament push for a more ambitious EU health budget in 2021-2027 

New Research Study Describes DNDi As A “Commons” For Public Health 

Report from two EU agencies confirms superbugs as a rising threat 

How clean water can be the most powerful weapon against superbugs 

Novartis secures FDA innovation prize for 30-year-old drug 

Congress is grilling pharma CEOs. Here are 8 ideas for bringing down drug prices 

How High Drug Prices Inflate C.E.O.s’ Pay 


Cancer drug pricing gets in the way of treatment in developing countries 

Global fund for hepatitis prepares for rollout 

Research Roundup: SFOPs funding for FY19, Lassa fever outbreak in West Africa, and new TB drug may shorten treatment time 

Nationwide measles and rubella immunization campaign reaches 11.6 million children in Yemen 

WHO calls for more money in fight against Ebola as violence hampers response once again 

Latest numbers from DRC Ebola as of 26 February 2019 

WHO publishes new estimates on congenital syphilis 

Enteric infection and dysfunction—A new target for PLOS Neglected Tropical Diseases 

Faced with unreasonable medicines prices, the Netherlands introduces pharmacy exemption in patent law 

UK government promises national strategy to boost clinical trial reporting 

The Oversell And Undersell Of Digital Health 

Human Rights Reader 474 

North Korea’s silent health crisis 

UN says North Korea has asked for help on food shortages 

UN probes substandard food aid for mothers and children  

Billions at risk from heat stress at home 

Why Should Governments Refill the Green Climate Fund’s Coffers? 

With Oceans in Grave Danger, Some Donors See Hope in Tech Solutions 

From Ebola to Antimicrobial Resistance

 “The mothers in Congo care a lot for their babies and young children, that is why they bring the babies into health centers whenever sick, they really really do care for them, and the children get contaminated in health centers... they come out with Ebola!

Dr. Mike Ryan, WHO Assistant Director General for the Department of Health Emergencies

By Garance F Upham

Vice-President, World Alliance Against Antibiotic Resistance (WAAAR

Editor in Chief AMR CONTROL 

Ex-Member Steering Committee, Patients for Patient Safety, WHO Patient Safety Program (2004-2014)

From Ebola to Antimicrobial Resistance: Coming Into a Health Center Could Kill You!

Is WHO Now Placing Hygiene As a Global Priority? Will Governments Listen?

The views expressed below are those of the Author and do not engage her Board or the WAAAR



The January 2019 World Health Organization (WHO) Executive Board (EB) meeting heard with some amazement that: “More than 85%, even 86%, of Ebola cases in Beni, Democratic Republic of Congo, have been acquired in health systems.” , as Dr. Mike Ryan, WHO Assistant Director General for the Department of Health Emergencies, testified, on Jan 28, in Geneva’s WHO headquarters to the EB, striking like a thunderbolt in clear skies.

He was just back from the Democratic Republic of Congo (DRC), testifying to the by-yearly meeting of the EB attended by the 34 Member States delegations of countries this year (at the level of the minister of health, and/or the director of national health services, and/or director of international cooperation, and approximately the 30 representatives of non-EB members).

And just in case this startling fact escaped the attention of some dozing bureaucrats, Mike went on: “The mothers in Congo care a lot for their babies and young children, that is why they bring the babies into health centers whenever sick, they really really do care for them, and the children get contaminated in health centers… they come out with Ebola!” [1]

He testified as to the progress made in stopping the epidemics in many locations while highlighting that outbreaks still occur in some places.

Clearly, he was telling the world that there would be no Ebola epidemic if healthcare systems were not as filthy as they can be, and therefore were TRANSMITTERS AND AMPLIFYERS OF EBOLA, or of any other hard to treat disease for that matter!

Speaking to people on his way out of the EB room (reserved for state representatives as civil society members-such as myself, in a delegation with Medicus Mundi, as WAAAR is not yet accredited to the WHO-), Dr. Ryan explained how his WHO team were able to stop the epidemic in Beni and most other places of outbreaks by enlisting Congolese people to draft basic prescriptions on hygiene and Infection Prevention and Control (IPC) and enforcing them while training staff.

He added that waste management remains a big hurdle, as children are prone to play in open air hospital refuse, with used syringes and bloody remains!

Dr. Ryan’s statements were indeed all the more remarking that the role of health centers worldwide in the spread of hard to treat, or outright non-treatable and often deadly diseases, is hardly ever talked about except, sometimes, in the specialized literature.

The WHO website on Ebola throughout the massive epidemic that struck West Africa in 2014-2015 never even mentioned “patient to patient transmission” or the role of un-hygienic health centers and notably dirty injections.

Meanwhile, the media was then, and is today, full of articles on Ebola as the result of poor people’s ignorance (sic), refusal to admit disease (sic), or reluctance to bury their dead in our Western ways, resisting to healthcarers sometimes with extreme violence, at times destroying health centers. Such articles are too numerous to be listed here.

Back in November, Dr. Peter Salama, recently made the third Deputy Director General by the DG Dr. Tedros Adhanom Ghebreyesus, started to publicly mention the role of health centers as “transmitters” and “amplifiers” of Ebola, notably to children, but was cautious not to offend the RDC authorities in mentioning private unregulated health centers as transmitters. [2]

Dr. Ryan did not take such precautions and spoke of health care centers overall as guilty of spreading diseases.

Let us quote (1970s early Ebola discoverer) Susan P. Fisher-Hoch writing in 2005 on the history of nosocomial outbreaks of Virus of Hemorrhagic Fevers (VHF) such as Ebola, or Lassa, flaring up in Nigeria today, and other VHF: “Poor people are uneducated, not stupid. Even in the remotest settings, the community grasps very quickly that the hospital is where people become infected with VHFs, so they immediately desert the hospital, and even hide their sick from medical personnel. » [3]

In the light of Fisher-Hoch’s understanding, and considering that the region has been plunged into a horrible civil war, with 4 million women subjected to rape and torture as acts of war over the past decades, the fact that populations could engage in violence against Ebola teams is very regrettable, sometimes atrocious,  but hardly surprising. The press, there too, which massively covered the Nobel Prize to Dr. Denis Mukwege [4] , doesn’t place this violence neither in the context of dangerous health structures, nor of the war-like situation in this part of the world. We can only hope that the elections recently held be a harbinger of less violence in the DRC and the region. We can only admire those Congolese people helping to vaccinate, attempting to treat, trying to implement IPC in life threatening situations.

While there has yet to be an evaluation of the Merck Ebola vaccine efficacy, administered in concentric circles of contacts (and possibly soon adding other vaccines – the Russian EB delegation asked Dr. Tedros to do so), the fact is that massive efforts are deployed, and it may be the case that, without the vaccinations, we would already be in the 10 000 cases range as in Western Africa.

Dr Ryan could be the harbinger of a massive change in the WHO leadership on the need for IPC, which could come back to the forefront as a specialized department under the Emergency Health Department.

However, for that Member States would have to understand and fund that initiative.

How can governments talk of Global Health Security while ignoring the fact that filthy under-equipped health structures with staff untrained in basic hygiene procedure would have been spreading common disease, dangerous diseases (Hepatitis C, HIV, Tuberculosis, now Ebola) and the entire array of drug-resistant diseases (AMR infections) or, tomorrow, bioweapons?

Back in 2015, Dr. Brima Kargbo, Chief Medical Officer, Sierra Leone, explained to an overflow room side event at the UN: “Health carers who died of Ebola were not working in specialized Ebola centers, but in regular health care, because in the later there is not the minimum in terms of IPC, such as gloves, in those places.“

The event entitled:  “From Ebola to AMR: the Urgency of IPC” (May 2015 World Health Assembly, WHA, United Nations, Geneva) was co-chaired by the Republic of South Africa and the USA, a WAAAR initiative. [5]

From Ebola to AMR Infections, the role of health structures?

Just published in the Lancet Infectious Disease this fall, a thorough study by the European Centers for Disease Control – ECDC revealed that the majority of antimicrobial resistant infections were contracted in healthcare in the EU and associated European countries region in 2015: ECDC estimated that 426 000 patients contracted an AMR infection during care!

 “Findings From EARS-Net data collected between Jan 1, 2015, and Dec 31, 2015, we estimated 671 689 … infections with antibiotic-resistant bacteria, of which 63·5% (426 277 of 671 689) were associated with health care. (…)”

“Considering that, in our study, a large proportion of the burden was due to health-care-associated bloodstream, respiratory tract, or surgical site infections, and that more than half of health-care-associated infections are considered preventable, reducing the burden of antibiotic-resistant bacteria in the EU and EEA through enhanced infection prevention and control measures could be an achievable goal.”

Published in the Lancet, this study, signed by the Burden of AMR collaborative group of the ECDC, [6] was among the most discussed of AMR publications in recent years. However, unfortunately, the discussion centered on the exact numbers more than on the amazing fact: Health structures’ weak or non-existent IPC are largely responsible for the global AMR crisis!

We recalled the outburst of Dr. Dominique Monnet, Head, Antimicrobial Resistance & Healthcare-Associated Infections Programme of the ECDC, (among the co-authors of this 2015 new publication). We were in the last meeting of the DRIVE-AB in Brussels (fall of 2017), debating on Market incentives mechanisms and so forth, and from the round table, Dr Dominique Monnet drew the attention on the room to the basics, and took the risk of sticking out: “Without more efforts on infection prevention and control, any new antibiotics will be like pouring oil on the fire!” (quote from memory).

IPC neglected in national AMR plans to implement GAPAMR

The 2015 UN adopted Global Plan of Action on AMR (GAPAMR) placed Infection prevention and control on top of the agenda. But the UN General Assembly of 2016 on AMR largely ignored this with, I counted, 6 countries mentioning IPC out of over 120 in their statement.

In mid 2018, a meeting of all WHO regions representative experts estimated that there was a real dearth of action:

• Improved communication to policy makers who do NOT think that IPC is important is a key next step
• While IPC core components are important for any country, LMICs would benefit from guidance on minimum IPC requirements (which is not always as expensive as we think)
• Cost of not preventing HAIs (Hospital Acquired Infections) is very high
• Need more research and data on the economic case and cost of HAIs, cost-benefit and cost-effectiveness of IPC interventions
• Need to develop the case to demonstrate that IPC can be low-cost.

Yet another 2019 AMR Resolution

We are in 2019 and that same EB which heard the report on Ebola, or passed and drafted the very good resolutions on WASH (acronym for Water-Sanitation-Hygiene) and on Patient safety, also drafted a Resolution on AMR, which should make participants cry over the sacrifice of their lunchbreak meals (spent in side room debating) because it requires WHO and member states to do more monitoring of antibiotic (AB) use but nowhere does it mention that lack of IPC is the DRIVER of AMR epidemics worldwide.

In it, IPC and WASH are only mentioned as obvious ways to reduce the burden of infectious diseases. [7] Where are you Jim?

Jim O’Neill, in his remarkable AMR Review, had a much better understanding of IPC. [8] [9] see Chapter 6, with annex from the London School of Economics.

Yet, internally the WHO draft (not yet published) on Universal Health Coverage (UHC) and AMR, are excellently drawing attention to that fact. But not Member States declarations, because, coming from Ministries of Health, it is difficult to admit to being part of the problem!

A while back, notable author Dr. Timothy Walsh (discoverer of NDM-1 in India) with co-authors involved in AGISAR WHO, such as Dr Peter Collignon, wrote of CONTAGION as the master word to understand. They wrote that AMR infections spread is not correlated with antibiotic consumption but with risks of transmission either from un-hygienic health care centers or from the environment (lack of waste treatment for husbandry, hospital refuse or antibiotic pharmaceutical production units. [10]

And what of FECAL threat?

In the early years of our understanding of hygiene, the term “fecal threat” (Péril Fécal) came up first with the recognition that contamination from human or animal feces of hands, food, water, was the very important channel for the spread of disease.  It is surprising how Ebola contamination (and AMR diseases’ transmission) is just about never mentioned.

WAAAR Vice President and IPC French leader Dr. Vincent Jarlier pointed out that even in hospitals contamination with basins is neglected [11]

Meanwhile, our schools and public places toilets are filthy, even in the USA or the EU, and in emerging countries the situation is terrible.

Fecal threat is generally not mentioned in Ebola, notwithstanding the fact that Ebola victims excrete large quantities of virus in diarrhea/and vomiting and the risks of contamination via this route remain high, hence the space suites. The talk of “cuts” on carer’s hands is just ridiculous.

Studies on Ebola transmission show well that, in cases of intra-familial contamination, it is the carers in contact with excreta who get contaminated, from the 70s until today. [12]

Further, the WHO policy of concentric circle vaccinations with Merck’s Ebola rVSV-ZEBOV vaccine (and soon the Russian vaccines as well, if we understand well the 2019 EB discussions) appears to have reduced the number and intensity of the outbreaks.

In the case of AMR infections, the threats are so vast that, while indeed vaccines [13] need to be developed and used rapidly even in husbandry (the success story of salmon vaccinations), the dangers are really diverse and it’s hard to predict where next threat will come from. That means the threat to populations – in the absence of a massive IPC effort, with adequate funding ­­­- is much greater than vis à vis Ebola!

In a pre WHA meeting organized with the Geneva Global Health Hub, G2H2, and the WAAAR Alliance, we sought to spur awareness and brainstorming on these issues with about 50 NGOs represented in attendance. A debate round table was organized with two WHO leaders in AMR: Dr Marc Sprenger, head of AMR Secretariat and Awa Aidara Kane, lead of WHO AGISAR, with Dr. Murfin Purdue, head of REACT Africa and of the Ecumenical Pharmaceutical network.

It included our NGO President (and architect of our national 2015 Preservation of AB Plan) Dr Jean Carlet as well as Mrs Mireille Martini, economist from Finance Watch and the Stiglitz Commission.

I chaired and in introduction, I showed a Bamako 2015 video of the major hospital in an extremely disastrous state, a video done by angry health carers in the face of neglect, just 3 years ago. It speaks for itself. [14]

A review of the litterature would be of interest?

A through review of core topics addressed in the literature and top policy discussions or recommendations would probably come down to: 1) the need for new economic models, 2) the necessity for stewardship, better management of antibiotics, 3) the urgency to reduce AB consumption in human health, 4) the recommendation for patients to abstain from pressuring prescribers for antibiotics, from buying AB over the counter, and from failing to go to the end of their prescriptions (yet all studies point to the need to shorten prescriptions, which are more efficient and less wasteful when shorter), 5) the need to stop/curtail use and overuse of AB in agriculture, from meat to fisheries and from wheat to, even, bio fruits and vegetables (use of glyphosate, recently registered as an antibiotic, and use of streptomycin on bio fruit trees…), 6) reducing pollution of heavy metals and biocides,7) establishing waste management of AB production in emerging countries, 8) management of hospitals waste and 9) waste management of husbandry.

Then, perhaps, infection control would appear!

Among the many examples of priority settings on producing new ABs, the Recent Letter to the Senate [15]

The draft recommendations of the Interagency Coordination Group (IACG) are similarly conceived. The not-too-well informed policy maker will come away convinced that a better management of antibiotics and funding R&D for new products is the most important way to face the rise in AMR infections. Of course IPC is mentioned but it comes only second, in such a way as to understand that reducing infections will reduce the need for antibiotics, obviously true. But health structures are not presented as drivers of AMR outbreaks in communities!

The Ad Hoc IACG on Antimicrobial Resistance

The Ad Hoc Interagency Coordination Group on Antimicrobial Resistance, commonly known as IACG, just released its draft recommendations in January 2019 (to be presented to civil society on Feb 25 at the WHO for discussion). In them, access to antimicrobials and their prudent use come in as the first recommendation (A1), and IPC is subsumed under that:

Recommendation A1: The IACG calls on all Member States to ensure equitable and affordable access to existing and new quality-assured antimicrobials and their prudent use by competent, licensed professionals across human, animal and plant health.
This recommendation must be supported by efforts both to reduce the need for antimicrobials and improve access through:
a. Lowering the prevalence of infection through clean water, sanitation and hygiene;
b. Decreasing the likelihood of diseases and their spread through delivery of existing vaccines and strengthening infection prevention and control measures; “[16] 

IPC comes back and again in the text, but it is never said that poor levels of hygiene and unsafe injections, unsafe use of sharps, lack of workforce training, lack of investigations of outbreaks, lack of staff and especially lack of well trained staff, all of that does play the key role in AMR infections explosive spread globally. To repeat what Dr. Monnet said: Without strong IPC, new antibiotics will be fuel on the fire.

At present, all partnership initiatives focus on “new fuels” and superbly ignores the situation: degradation in the EU, catastrophic in LMIC. And similarly in agriculture: while calls to reduce AB in meat production is very important, notably for Critical AB, the urgency of not throwing waste into the environment comes in second, while it should be first.

Nowadays, in families in France or the US, all the talk is on the bad cold, the flu like illnesses or the mild to severe gastroenteritis making the rounds of the schools and how the children bring these back into families. CONTAGION is a household word. But in the sheltered areas of policy makers, the word contagion is basically ignored.

Member States Ministers of Health don’t understand the issues well yet, neither does not-for-profit civil society generally (always sharpening the knives on “access” but forgetting transmission), while among the private sector the pharmaceutical manufacturers dominate, while the IPC related industrial groups tend to complain in private rooms.

Hopefully, the WHO may take the lead in putting IPC as one of the core element to achieve real Universal Health Coverage!

India recently adopted a national IPC Plan within which antibiotic stewardship was integrated as a component. While it awaits each national Indian states endorsement and, above all, implementation (and big investments!), the thought was right: stewardship is subsumed under IPC as a necessary complement. Not the reverse!

We must protect patients, and carers alike. We must prevent dangerous viruses such as Ebola, Lassa, Nipah, Hep.C or HIV from being spread via health structures, and we must prevent antibiotic resistant infections from exploding via filthy health structures. Resisting and rolling back AMR threat demands it, and massive investments to that effect. After that we can talk of adding new antibiotics to our medical care armada. The reverse will only exacerbate the problem, as Dr. Monnet understood it, and could well mean a situation out of control.

Ben Stockton, with the Bureau for Investigating journalism, is an exception in the media, his articles on AMR are relevant and well conceived. I especially liked the one on the role of Water, which I saw after I had completed this article. See:
References and subparagraphs

[1]  One may still hear him directly in the live webcast, Jan 28th, second morning session, about 48 mn into the proceedings).

[2]  Huffington Post: Series of War Zone Attacks Puts DRC Ebola Outbreak On ‘Edge of Crisis’  and also

In the DG Tedros new organization of the WHO there are three very important Deputy DG. Dr. Peter Salama is directly on step higher than Dr. Ryan in the WHO hierarchy. The other two DDGs are the remarkable Dr Soumya Swaminathan, in charge of Programs, that is, with the very difficult role of implementing all that which the Member States want but are not ready to pay for, and the big UHC drive, and a lot of monitoring and accountability. Dr Soumya was previously the DG of the Indian Medical Research Institute.

And the English, Mrs. Jane Ellison, Deputy Director General for Corporate Operations.

[3] Susan P: Fisher-Hoch, British Medical Bulletin 2005; 73 and 74:123-137.  

In her BMJ article she writes: « With the knowledge of the practices and consequences of poor practice in Africa, and now in Asia, we have to conclude that transmission of blood-borne viruses in medical facilities of all kinds is probably common within the endemic area of the haemorrhagic fever viruses. Indeed, hepatitis C virus (HCV) and human immunodeficiency virus (HIV) may be the viruses most commonly spread by this method. The difference with the haemorrhagic fever viruses is that the consequences of haemorrhagic fever viruses are immediately noticeable, whereas with HCV and HIV it takes years, even decades, for the transmission to be appreciated. »

Susan P Fisher Hoch was co-discoverer of Ebola when it first emerged in the mid 70s. Her book “Virus Hunters”, co-authored with husband McCormick is a must to read.


[5]  WAAAR organized event with EB member and AFRO group leader the Republic of South Africa, the DG of Health Services, Mrs Precious Matsoso, head of delegation, and the USA WHA’s delegate representative, Dr Mitchell Wolfe (now at CDC Washington and then Deputy Assistant Secretary for Global Health). Besides WHO DG Dr. Margaret Chan, who gave a short introduction, the main speaker for WHO was Dr. Edward T. Kelley, Director Service Delivery and Safety.

[6]  “Findings From EARS-Net data collected between Jan 1, 2015, and Dec 31, 2015, we estimated 671 689 … infections with antibiotic-resistant bacteria, of which 63·5% (426 277 of 671 689) were associated with health care.(…)” 

Title of article: “Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis”
Alessandro Cassini, Liselotte Diaz Högberg, Diamantis Plachouras, Annalisa Quattrocchi, Ana Hoxha, Gunnar Skov Simonsen, Mélanie Colomb-Cotinat, Mirjam E Kretzschmar, Brecht Devleesschauwer, Michele Cecchini, Driss Ait Ouakrim, Tiago Cravo Oliveira, Marc J Struelens, Carl Suetens, Dominique L Monnet, and the Burden of AMR Collaborative Group 5 Nov 2018, The Lancet ID.

A newsy report on the above:

[7], see RESOLUTION EB144/R11

[8]  AMR Review,, see Chapter 6, 22 March 2016 – Infection prevention, control and surveillance: Limiting the development and spread of drug-resistance, with annex from the London School of Economics (Study by LSE Master’s in Public Administration students on the cost and benefit of WASH interventions in Brazil, India, Nigeria and Indonesia main report.)

[9]  Interview with Lord Jim O’Neill in AMR Control

[10]  « Reduction of antibiotic consumption will not be sufficient to control antimicrobial resistance because contagion—the spread of resistant strains and resistance genes—seems to be the dominant contributing factor. Improving sanitation, increasing access to clean water, and ensuring good governance, as well as increasing public health-care expenditure and better regulating the private health sector are all necessary to reduce global antimicrobial resistance »

Title of article:  Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysis
Peter Collignon, John J Beggs, Timothy R Walsh, Sumanth Gandra, Ramanan Laxminarayan. Lancet Planet Health 2018; 2: e398–405


[12]  Bulletin of the World Health Organization, 61 (6): 997-1003 (1983) Ebola virus disease in southern Sudan: hospital dissemination and intrafamilial spread. ROY C. BARON,’ JOSEPH B. MCCORMICK,2 & OSMAN A. ZUBEIR

[13] See page 60,  Chatham House

Establishing the importance of human and animal vaccines in preventing antimicrobial resistance

[14]  Report on the event : and (,

The Bamako video (in French but easy to understand in watching): a striking video of Gabriel Touré Tertiary Hospital in Bamako, Mali / extravagant level of…filth!

2013: 110 000 cases of hospitalized patients / Hospital has 450 beds, it is the main tertiary care hospital of the country. Hospital waste are dumped in the courtyard along with human feces, all toilets are clogged up and closed, garbage is not collected except by families of patients… Premature babes sleep on the floor! And health staff is angrily testifying of neglect!

[15]  See the « Joint Letter to the Senate-Help and Finance re-economic Incentives for antibiotics, Feb 5, 2019, which can be read on:


IMF Conditionalities Still Under the Fire of Criticism

This article adds food for thought to unbroken criticism targeting the lending policies of the International Monetary Fund (IMF) whereby a gap seemingly persists between the declared intentions and the general practice

By  Daniele Dionisio

PEAH – Policies for Equitable Access to Health

IMF Conditionalities Still Under the Fire of Criticism


The mandate of the International Monetary Fund (IMF) encompasses duty to facilitate financial stability, international trade, and economic growth, while securing assistance in the form of loans to borrowing countries suffering from balance-of-payments constraints.

As per IMF latest terms (IMF: Conditionality November 6, 2018, just a make-up with respect to March 6, 2018 edition):

When a country borrows from the IMF, its government agrees to adjust its economic policies to overcome the problems that led it to seek financial aid. These policy adjustments are conditions for IMF loans and serve to ensure that the country will be able to repay the IMF. This system of conditionality is designed to promote national ownership of strong and effective policies.

Conditionality helps countries solve balance-of-payments problems without resorting to measures that are harmful to national or international prosperity. At the same time, the measures are meant to safeguard IMF resources by ensuring that the country’s balance of payments will be strong enough to permit it to repay the loan. 

The member country has primary responsibility for selecting, designing, and implementing policies to make the IMF-supported program successful.

Most IMF financing is paid out in installments and linked to demonstrable policy actions. Program reviews provide a framework for the IMF Executive Board to assess whether the program is on track and whether modifications are necessary. 

Prior actions… are steps a country agrees to take before the IMF approves financing or completes a review. They ensure that a program will have the necessary foundation for success.

IMF lending has always involved policy conditions…. In recent years, the IMF has become more flexible in the way it engages with countries on issues related to structural reform as the conditionality system continues to evolve.

A bone of contention

In the face of this, critics contend that a gap persists between the rhetoric of declared  intentions and the general practice since, as maintained  a couple of years ago by Eurodad, ‘…The IMF continues to attach problematic conditions to its loans, notably by suggesting reforms in sensitive economic areas. ‘

So far, loan disbursements have been linked to economic  and trade liberalization with regressive consequences for poor people. In most cases  conditionalities have involved cutting public spending, including  government subsidies, ceilings on government wage bills (common in Africa), and privatization of public services.

Relevantly, critics have charged  IMF reform programmes with a narrow vision on economic stability and for not protecting social spending on health and education.

The impact of the reform recipes has been highlighted especially in Africa in terms of cuts in public spending and adopting user fees policies which are known to run contrary to poor and vulnerable population settings, especially women.

In addition, the same recipes have also been implemented in some western  countries such as  Greece where cuts in public spending and dismissal of health workers have led to deterioration in the health of the population.

As such, word is spreading that IMF loans risk spurring unrest and deepening social and economic crisis in the borrowing countries. Under these circumstances, it comes as no surprise that Pakistan refused  on 20 November 2018 to accept tough conditions laid down by the IMF for a financial bailout package including conditions to further increase power tariffs, imposition of more taxes and sharing details related to Chinese financial assistance.

Undoubtedly, what highlighted here discloses the institution great power to shape domestic policies in the borrowing countries, though IMF denies any responsibility for its actions and states that only governments are accountable for expenditure priority allocations (aside from a belated mea culpa in the Greece case wherein the IMF has admitted that conditionalities have done more harm than good).

As a matter of fact, regular reviews  by the IMF  determine whether a loan is released depending on economic performance, not on protection of social spending.

No wonder that this power dynamics makes it very difficult for the recipients of IMF programmes to ignore policy prescriptions, even if they are not legally binding. In this connection, the results of a report released in November 2018 by Eurodad  add food for thought through a comparative analysis of the conditions attached to IMF loans for 26 country programmes that were approved in 2016 and 2017.

Eurodad study

The study  documents that the number of IMF conditions is on the rise (23 out of 26 programmes are conditional on fiscal consolidation), whereby borrowers are forced to ‘…restrict their spending and/or increase their taxes as a result of the loans, contradicting IMF claims that its programmes do not emphasise fiscal contraction.’

Almost all of the analysed  country programmes included dispositions on containing governments’ wage bills. Apart from fuelling social turmoil because of their negative impact on living conditions, these ceilings disrupt the much needed expansion of the health workforce, thus impairing the ability of the health sector to recruit and retain health workers. Overall, this is a matter of paramount importance in low-income developing countries -LIDCs  (which also bear the largest number of IMF expenditure conditions on average).

The report makes it clear how, as a Damocles’s sword,  the prioritisation of debt service payments has jeopardized health spending in the studied countries while increasing reliance on out-of-pocket payments for health services. Debt service costs as a share of the total budget were higher than health spending in eight of the countries studied.

To make things even worse, Eurodad study shows that IMF is increasingly using ‘hidden’ forms of conditionality at a time when new conditions added during programme reviews bear down on the overall conditionality burden of the recipient country.

What’s more, the study results turn the spotlight on evidence that ‘The social spending floors that are part of IMF programmes, and that are supposed to shield vulnerable groups, are at levels below what is needed to guarantee basic healthcare.’

As such, no wonder that … IMF programmes are overall ineffective in restoring debt sustainability in the long term. The majority of countries in the sample are repeat borrowers: 24 out of 26 countries were involved in another IMF programme in the previous 10 years.

Requirements to reform

Owing to its influence on domestic policies of the borrowing countries, the IMF should focus on helping them explore a wide range of options for dealing with fiscal deficits. These options should ensure the protection and increase in social spending, including on health and education, and the removal of budget ceilings, including on the recruitment and retention of health workers.

This change of direction would impact positively in LIDCs where the level of social and investment spending needs to be substantially enhanced to attain the Sustainable Development Goals.

A key problem underlying the damage of IMF reform recipe is that negotiation is usually limited to a narrow circle of finance ministries in the absence of public participation or scrutiny. Transparency of negotiation and participation of other relevant ministries and civil societies are essential to ensure pro-human development policies. As said by the authors of Eurodad  study‘…Real democratic ownership should be more than the mere acceptance of a set of economic reforms by a borrowing government in dire economic circumstances. It should be the result of a process involving stakeholders such as parliaments and civil society organisations.’

Such a process, conducted before approving IMF programmes, should involve a careful  assessment of debt burden implications on the fulfillment of human rights obligations.

At the same time, the IMF should avoid attaching conditions to its lending policy other than the repayment of the loan on the terms fixed.







Health Breaking News 322

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

Health Breaking News 322


Italy’s Draft WHO resolution: Improving the transparency of markets for drugs, vaccines and other health-related technologies 

European Council agrees on SPC manufacturing waiver 

Universities Allied for Essential Medicines-UAEM Europe Conference: Hamburg 26th to 28th April 2019 


BMJ: Innovation for neglected diseases in South Asia 

Are we making progress on the use of antimicrobials in animals? 

The impact of targeted malaria elimination with mass drug administrations on falciparum malaria in Southeast Asia: A cluster randomised trial 

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SDGs ‘failing to create transformational change’ 

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Aid spending should compensate those who have been most impoverished by the unfair global economic system we have helped to create, not be used to further its ends 

170 clinical trials run by NHS Trusts violate disclosure rules 

Human Rights Reader 473 

Trump administration launches global effort to end criminalization of homosexuality

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UN announces roadmap to Climate Summit in 2019, a ‘critical year’ for climate action 

‘No Way to Defend Ourselves Against the Onslaught of Climate Change’ 

Special issue of Critical Public Health journal: “Public health activism in changing times: Re-locating collective agency” Call for abstracts, deadline 1 May 2019

The Original ‘7-Year Itch’ – Coming to an Infestation Near You!

The WHO estimates that around 200 million people are infected globally at any point in time, with up to 71% prevalence in crowded or institutional settings. Annually 0.2% of global disability-adjusted life years (DALYs) are attributed to scabies, a greater burden than leprosy, schistosomiasis, or dengue. These figures may be an underestimate since there is a global lack of high-quality prevalence data and significant amounts of misdiagnosis and under-reporting. In 2017, the WHO deplored the global paucity of evidence, designated scabies as a category-A NTD, and recommended prevalence studies

By  Michael Head *

Senior Research Fellow

Clinical Informatics Research Unit and Global Health Research Institute

Faculty of Medicine, University of Southampton, UK

The Original ‘7-Year Itch’ – Coming to an Infestation Near You!

As cross-posting this article also appears on the blog site of the Royal Society for Tropical Medicine and Hygiene - RSTMH


It’s currently burrowed under the skin of about 200 million people around the world right now, and is spreading abuse, stigma and shame wherever it goes. Your friendly local doctor often cannot recognise it, which is perhaps fair enough given it’s less than 0.5mm long. It’s brewing up a cocktail of ongoing misery including a fair few wounds as a result of people frantically scratching themselves, fair amount of renal disease, and the occasional bout of sepsis.

Public health burden

So, let’s have a chat about the massive public health burden of scabies then. What’s that? You’d rather not? Afraid that’s all I’ve got. No, I don’t mind, do carry on eating your lunch. Oh, yes there are pictures actually. Right here, in fact.

Scabies presentations from our UK care home study (Cassell et al, Lancet Infectious Diseases, 2018)

Scabies is (if you hadn’t guessed by now) an intensely itchy skin condition, transmitted by mites. It causes rashes, and can lead to significant secondary complications including bacterial infections and renal complications. A disease of poverty, it is highly stigmatised as being “dirty” and attracts significant social stigma – the Ethiopian word for scabies “ekek” is used as a term of abuse.

The WHO estimates that around 200 million people are infected globally at any point in time (anecdotally, recent conversations with the WHO suggest that may be a significant underestimate), with up to 71% prevalence in crowded or institutional settings.

Greater burden 

Annually 0.2% of global disability-adjusted life years (DALYs) are attributed to scabies, a greater burden than leprosy, schistosomiasis, or dengue. In Ethiopia, there is an ongoing outbreak with over 400 000 scabies cases. There, 1.2 million doses of ivermectin (anti-parasitic drug) have been administered, there is a median prevalence of 33%, duration of symptoms is five months (that’s over 20 weeks of itching), and over half of cases were in children who typically did not go to school during this time.

There is a global lack of high-quality prevalence data and significant amounts of misdiagnosis and under-reporting. In 2017, the WHO deplored the global paucity of evidence, designated scabies as a category-A NTD, and recommended prevalence studies.

For our contributions – colleagues at Brighton & Sussex Medical School are leading on scabies research studies in Ethiopia and Papua New Guinea.

Pilot study on scabies diagnosis in Ghana

I have a pilot study starting in 2019 covering improved diagnosis of scabies in Ghana. This is working with public health directors in the Volta and Greater Accra regions, and includes training from Ghanaian dermatologists (from the University of Ghana, Ghana Dermatology Society, and the Rabito Clinic).

Previously, between us, we prospectively reported on scabies outbreaks in care homes in the UK (yes, there’s plenty of it in high-income countries too). This was a complex study where we were urged to exclude patients with dementia since that would make the research ethically tricky. We continued to include dementia patients. It certainly did make the ethics very tricky indeed, but we did discover that the most vulnerable patients in care homes are the ones who are most at risk of (among virtually every co-morbidity going) scabies infestation.

Lack of bathing not a cause of scabies

Oh and one further point – a lack of bathing is not a cause of scabies. It’s a common myth (being ‘unclean’), that is spread even by healthcare workers (I myself recently reviewed a paper that stated precisely that). Overcrowding and poverty are key factors (and these populations are likely to wash less). But bathing in itself is not a factor, and the WHO have in fact written to ourselves to thank us for our response (linked above).

There are effective drugs (such as ivermectin), but little in the way of diagnostics and no vaccine and plenty of misinformation and stigma. There is little in the way of policy and guidance, due to the lack of data upon which to base any guidance. Which leads us to conclude…

Scabies, perhaps the biggest global public health problem you know very little about. Now it’s an NTD, we can hopefully start to make progress on this truly neglected disease.



*Dr Michael Head is a Senior Research Fellow, based in the Clinical Informatics Research Unit at the University of Southampton. He has research interests in analyses of the financing of research, evidence-informed policymaking, pneumonia and this probably-unhealthy obsession with scabies (for which he has Professor Jackie Cassell, Brighton & Sussex Medical School to thank).



Equity in Investments – a Need to Map the Research Landscape for Health


Health Breaking News 321

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

Health Breaking News 321


What the recent discussions on access to medicines at WHO’s Executive Board tell us 

Campaigners across EU slam MEPs vote to approve ‘corporate stitch up’ Singapore deal 

Captured states: When EU governments are a channel for corporate interests 

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Trump’s HIV strategy faces potential minefield 

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Nearly 100 children dead as world’s 2nd-largest Ebola outbreak surpasses 800 cases 

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Wellcome commits £10 million to DNDi to develop new generation of oral drugs to treat leishmaniasis 

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‘No More Paying For The Rich World’s Medicine’ – White House 

New High-Tech System Against Falsified Medicines Goes Live In Europe 

A Foundation Looks to Curb Opioid Deaths by Improving Addiction Treatment 

Are Sustainable Development Goals Reaching Indigenous Peoples? 

UNPO Hmong Newsletter #9, February 2019 

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Drought and rising costs to leave 2.4 million Zimbabweans needing food aid 

EU renewables on the up, but 2020 target looms large 

Health Breaking News 320

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

Health Breaking News 320


Further funding to support Research Leaders in sub-Saharan Africa: MRC/DFID African Research Leader scheme 2019 

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TRIPS Debated As WHO Board Reaches Agreement On Universal Health Coverage 

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Thursday 14 February 2019 – Friday 15 February 2019 Challenges and Needs of SDGs’ Implementation in Europe. Organised by the Global Health Centre and ISGlobal Barcelona, Spain 

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Current R&D Causes High Prices In Drugs; New Model Needed To Make Drugs More Affordable, Speakers Say 

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WTO TRIPS Council: South Africa considers strict patentability criteria to address abuses in the pharmaceutical industry 

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Human Rights Reader 472 

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‘Action Alliance “Training 2020” – An Alliance for Independent Continuing Medical Education’ by Christiane Fischer 

Action Alliance “Training 2020” for Independent Continuous Medical Education

MEZIS (Mein Essen zahl ich selbst – I pay for my own lunch) has long been calling for Continuous Medical Education (CME) programs to be free of conflict of interest. On this long journey MEZIS has been able to reach an important milestone: The Alliance for Action 2020 - Alliance for Independent Continuing Medical Education

Christiane Fischer

By Christiane Fischer MD, MPH, PhD*

 Founder and Medical Managing Director at MEZIS

Action Alliance “Training 2020”

An Alliance for Independent Continuing Medical Education


In 2018, MEZIS (Mein Essen zahl ich selbst – I pay for my own lunch) successfully launched another tool to achieve the goal of continuing medical education without any sponsoring by the pharmaceutical industry: The Alliance for Action 2020 – Alliance for Independent Continuing Medical Education. It complements MEZIS strategy to achieve change through committees and media.

What is the background?

Organizers of Continuous Medical Education (CME) Programs such as hospital departments and professional associations often welcome support of human and financial resources from the pharmaceutical industry. An implementation of CME-Programs without sponsorship seems unthinkable for many. However, is that really true?

At the same time, more and more CME-Programs are being organized  independently and without any sponsoring by the pharmaceutical industry. Even conferences of large associations such as  the German Society of General and Family Medicine are successfully carried out without pharmaceutical support- and teach the eternal skeptics of the better. This shows there are already some good alternatives. However, they are not well-known and overarching concepts and structures for independent training are still missing.
Independent organizers also have to compete in a market place highly distorted by exorbitant sponsorship sums from the pharmaceutical industry with organizers such as Omniamed, which used to receive up to 250,000 Euros from the pharmaceutical industry for one day. In August, the Medical Chamber Stuttgart denied Omniamed any CME certification for the first time. Omniamed consequently withdrew from Germany in December 2018, hopefully paving the way for independent organizers of CME events to overtake their sponsored counterparts.


The goal of the Action Alliance is to provide independent continuing medical training. Continuing medical training must take place independently of the interests of the industry and solely in the responsibility of hospitals, professional societies, professional associations and other organs of the medical self-government. This requires a rethinking by physicians and a change in the medical training culture.


The partners joining the Alliance commit to providing sufficiently high quality training without industry participation or financial support. In addition, in agreement with the founding members, there are criteria for content quality that are based on existing ones.

Who is already there?

We are already pleased to have the Drug Commission of the German Medical Association (AkdÄ), the German Society for General Medicine (DEGAM), the neurologist initiative “NeurologyFirst” as well as the two independent training organizations HD Med and Libermed as founding members.

Our aims until 2020

  • Bundling of existing independent concepts and structures for CME-Programs (AkdÄ, DEGAM, NF, medical chambers, HD Med, Libermed).
  • Development of a guideline for  CME-Programs as well as financing concepts (meaningful and necessary amount of annual training, quality features, requirements, practical organization, calculations).
  • The Allies provide guidance to their members in the organization and delivery of independent medical trainings.
  • Creating structures and sharing structures for organizing independent events.
  • Creating a common internet platform:
  • Establishment of a quality label “Partner in the Action Alliance for Further Education 2020”.


Dr. Christiane Fischer was born in 1967 in Emden and grew up in the black forrest in Germany. She studied medicine in Homburg/Saar and Heidelberg and is from her postgraduation Master of Public Health (MPH). From 1999 untill 2013 she worked as the executive director of the BUKO Pharma-Kampagne focussing the impact of patents on access to drugs in poor countries. In 2007 she founded MEZIS and was part of the board until  2013. Since then she works as the Medical Director.  Since 2012 she is member of German Ethics Council.

*On the same topic on PEAH:

Interview to Christiane Fischer: MEZIS (Mein Essen zahl ich selbst – I pay for my own lunch) 


To Protect and Promote the Rights of Mentally-Disabled in Uganda

...Obsolete mental health legislation in Uganda has a number of deficiencies such as failure to differentiate voluntary and involuntary care, inadequate protection and promotion of the human rights of people with mental illness and the presence of slurring and stigmatizing language; and henceforth not in line with the draft mental health policy as well as current trends in mental health care...


By Denis Bukenya

and Michael Ssemakula

Health Rights Researchers & Advocates

Human Rights Research Documentation Center (HURIC), and PHM-Network, Uganda

Galvanizing the Action to Protect and Promote the Rights of Mentally-Disabled Individuals in the Key Populations: a Pathway to Achieve Health for All


Although there are efforts to improve mental health in Uganda, there remains a heavyweight number of deficiencies especially in terms of stigma and misconceptions about the predicament. There is limited appreciation of the mental health illnesses predominantly in low resource settings. Many societies in Uganda tend to demonize mental health illnesses which has resulted into human rights violations such as incarceration of persons with the mental disequilibrium. This is at the expense of the much needed psyche-socio support. Instead people with mental illnesses are subjected to unfair discrimination, detestable beatings, and poor treatment out of ignorance. This eventually results into denial of access to institutional mental health services (such as psychiatric services and  psychotherapy treatment like psychotic drugs) hence the prevalence of the traditional and spiritual divine healers, a mechanism that has been renowned for lack of a regulation thus exploitation of the victims. This increases the urgency for an inclusive prevention and rehabilitation multi-stakeholder levels of assistance through community inclusiveness in addressing the current burden of mental health disorders and the functioning of mental health programs and services in Uganda.

According to research by (Lumbuye-Guba, 2003), over 45 per cent of the youths have used drugs or alcohol. Sadly the indigenous demand for hard drugs has also unrelentingly continued to increase, with an approximation of 5-10 per cent of the populace being reliant on and consistent users; 18 per cent of men and 2 per cent of women both smoke and drink. Other drugs of abuse include cannabis, which grows extensively in the green equatorial climate of Uganda and abuse is common especially among young urban elites and juveniles. The national mental hospital shows that 30 per cent of hospital admissions are associated with drug abuse. Inhalants such as paint thinner, and glue are also common among street and slum youth. Eating of marungi (Khat) is also spreading hastily. Heroin use cases have also been reported in the country.  Services are dispersed and staff ability to address this is largely deficient.

A report by (Basangwa, 2004) assessed that 35 per cent of Ugandans suffer from some form of mental disequilibrium, of which 15 per cent need treatment. Although data proximities on mental illnesses in Uganda are very scanty, anecdotal research study evidence shows an upsurge in the occurrence of mental disorders. According to (UBOS, 2006), an envisaged 7 per cent of the households in the country had disabled members, of which 58 per cent had at the very least one individual with a mental disorder. This indicates that about 4 per cent of the households had at least a member with a mental disorder. Juveniles on the streets think drugs improve their socio-psyche lives and a major risk for street youths in Uganda today is a combination of drugs, HIV/AIDS and reckless sexual behavior.

Alliance forming in efforts to assist people affected is lacking. Worsened by gaps in the policy on the mental health such as offensive derogatory terms, which call victims, “persons suffering from mental derangement”, and existence of forced medical intervention without consent, the mental health legislation is therefore outmoded. The mental health system operates on an outdated mental health Law that was last revamped in the 1964. The legislation focuses on detention care of mentally-ill persons and is not in accordance with contemporary international human rights standards regarding mental health care. This obsolete legislation has a number of deficiencies such as failure to differentiate voluntary and involuntary care, inadequate protection and promotion of the human rights of people with mental illness and the presence of slurring and stigmatizing language; and henceforth not in line with the draft mental health policy as well as current trends in mental health care.

Services are still significantly underfunded (with only 1 per cent of the health expenditure going to mental health), and skewed towards urban areas, and mental disorders are not covered in any social insurance schemes we have in Uganda at the moment. Although mental health is one of the key components in the Health Sector Development Plan 2015/2016-2019/2020, we have no comprehensive mental health plan, and there is no information to draw a clear strategy for mental health treatment and prevention. Therefore, there is need for increased stakeholder engagement, through community involvement and participation, if national and global targets for mental health are to be attained. The mental health collaborative interventions are not moving as fast as would be expected. There is low utilization of mental health services. Health workers infrequently discuss the relationship between drug abuse and mental illnesses with populations and patients there in. Health care providers largely display negative attitudes towards mental health patients. At this prevalence rate, the gains made in prevention and control of mental illnesses could easily be reversed; yet the conditions are preventable through provision of appropriate information and ensuring the effective interventions are in place. Communication interventions through Participatory Reflection and Action methods are important means to engage policy enabling powers, government officials, public and private health professionals, traditional and religious leaders, community leaders, patients and their families in bringing about political, behavioral and societal change in reverence to mental health.

Mental-disability implications in Uganda mainly affect the youths, women, and sex workers. The majority of the young people and juveniles get affected through excessive drug use as a result of a gap in parental control and lack of guidance. Many of them end up in juveniles’ remand centres and prisons where they learn adverse behaviors and turn into intransigent criminals; therefore, we need to offer communities and parents with guidance to prevent and reduce drug use by their children and also emphasize the importance of use of clear, positive communication between parents and children. All young people deserve the best start in life. But too often, young people with mental health disorders are unable to fulfil their potential. Mental-illness unsympathetically costs individuals and society especially on the human development index.  People with mental health problems have too often in the past experienced unfair discrimination and poor treatment. In recent years however, we have seen a mild shift in attitudes towards mental health, but the stigma and misconceptions surrounding mental-illnesses still hold strong in many vulnerable settings which is an entombment towards achieving Universal Health Coverage in Uganda.

In order to address challenges facing vulnerable populations with mental disorders, emphasis should be on modifying the approaches towards appreciating the prevalence of mental disability, creating awareness, and treatment through regionalization of mental health service provision system at district level. This is an imperative mechanism that will ease access to psychosomatic health to enhance the attainment of the global goal of health for all and Sustainable Development Goal #3.5 of strengthening the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of the alcohol. Such methodologies should be purely community based through decentralization of the mental health services as a significant approach to address mental health challenges. This enables victims to continue receiving social support from their families and communities which reduces the stigma.

Owing from the above is the necessity of the egalitarian system of health service provision which needs to incorporate ways to ease accessibility of mental health services. In the Ugandan perspective is the proposition of the National Health Insurance Scheme (NHIS) to minimize the adverse implications of the catastrophic health expenditures on household welfare. However, mental health is not explicitly included in the NHIS. The challenge lies in the fact there is not known NHIS policy in Uganda today. There is light at the end of the tunnel with the NHIS Bill at the floor of parliament awaiting approval, and it is hoped that this will provide the legal framework though, as usual, the process has stagnated for a long period close to a decade.

As activists working with the People’s Health Movement in the Ugandan chapter it is incumbent upon us to acknowledge the Astana Declaration in regard to Mental Health owing to the fact that there needs to be the inclusion of Primary Health Care in Mental Health concerns in Uganda in a bid to ease access to proper mental health care. The declaration is the current guide to the attainment of strengthened UHC by mean of preventive, palliative, rehabilitative and curative care. Delivery of care to mental health in this perspective targets individuals, family, community and finally the national health system. This form of care is easily accessible since it is near people.



Lumbuye-Guba, C. (2003). Challenges of Intervening in Drug Abuse in Uganda. Kampala: National Institute on drug abuse.

Basangwa, D. (2004). Understanding Mental Health Relapse. Kampala:

UBOS. (2006). Uganda Demographic Health Survey Preliminary report. Kampala: