Access to medicines and quality of medicines: always together!

The universal availability of essential quality medicines, at affordable prices and with appropriate quality standards, is a fundamental prerequisite to ensure universal access to health

Access to Medicines and Quality of Medicines: Always Together!

by Raffaella Ravinetto *, Clinical Sciences Department,

 and Christophe Luyckx**, Public Health Department

 Institute Tropical Medicine Antwerp

 

 

The universal availability of essential quality medicines (1), at affordable prices and with appropriate quality standards, is a fundamental prerequisite to ensure universal access to health.

In the field of prices of essential medicines, a lot has been done in the last decade for avoiding that the enforcement of inadequate intellectual property rules in the pharmaceutical field kept new medicines out of the reach of people living in middle- and low-income countries (2). Even if much more must be done to make all the essential medicines available to all those who are in need, India has set -with its Patent Act of 2005 (3)- a valuable model for maintaining the primacy of public health over commercial interests. Importantly, the lessons learned in the field of HIV/AIDS to increase the affordability of quality-assured essential antiretrovirals (4) seem now to start to serve as an example in other therapeutic fields: for instance, legitimate exceptions to patent-monopoly, like compulsory licenses, are now used to increase the access to appropriate anti-cancer medicines for those in need (5).

However,  the gap between high-income countries vs. middle- and low-income countries is still outstanding in what concerns the assurance of appropriate quality standards for all essential medicines (6). The World Health Assembly (WHA) has been discussing for many years the challenge to individual and public health represented by poor-quality medicines, without reaching an agreement on measures to be implemented to fight them. Only in 2012, the 65th WHA approved a resolution to create a new ‘€˜Member State mechanism’€™ (i.e. an intergovernmental mechanism, open to all WHO Member States), proposing international collaboration on ‘€˜substandard, spurious, falsely-labelled, falsified or counterfeit (SSFFC) medical products’€™ (7). Its explicit goal is ‘€˜to promote the prevention and control of SSFFC medical products and associated activities, to protect public health and promote access to affordable, safe, efficacious and quality medical products’€™. Noteworthy, the definition of “€œSSFFC medical products”€ is quite comprehensive: in fact, it encompasses medicines, vaccines, medical devices and in vitro diagnostic tests. Also, this definition does not prioritize counterfeits (products whose identity has deliberately and fraudulently hidden) (8) over substandards (legitimate, authorized products that do not comply with appropriate quality standards) (9). In fact, sub-standards are at least as dangerous as counterfeits, because their effects are often life-threatening or fatal, due to either direct toxicity or lack of efficacy. In addition, substandards are often the result of structural negligence, and structural negligence in pharmaceutical production should never be considered less important than a deliberate or fraudulent action, because the consequences are equally serious for the final user (10). As we already reminded elsewhere (11), the creation of the Member Mechanism offers a precious opportunity to tackle this problem in a comprehensive, patient-centered approach, aimed in first place at protecting individual and public health from the effects of ineffective or contaminated medicinal products, which are mainly prevalent in resource-poor countries. To do so, the Member State mechanism should prioritize activities that:

Promote preventive measures, aimed at avoiding that poor-quality medical products reach the patients, rather than identifying them a posteriori, when a significant harm may have already been done, as it happened in recent cases in Bangladesh (12), Panama (13), Pakistan (14), and as showed by many retrospective surveys conducted on antimalarials (15, 16);

Promote measures that may help to eliminate poor-quality medical products as a whole, rather than concentrating on counterfeits only. Even if there may be commercial interests to do so, a counterfeits-focused approach is market-centered rather than patient-centered, and it leaves many neglected patients exposed to the risk of being treated with substandard medicines.

Strengthen the national and international regulation, with special focus on initiatives that promote collaboration, knowledge-sharing, resource-sharing and networking among national medicines regulatory authorizes, as described in a recent, very interesting concept paper by the WHO Pre-qualification programme (17);

Reinforce the current WHO Pre-qualification programme (18) and possibly expand it to more therapeutic fields in addition to HIV/AIDS, malaria, tuberculosis and reproductive health.

Educate and sensitize the main public and private stakeholders to adopt and implement procurement practices for medicines and other medical products based on stringent quality assurance criteria, in order to avoid risks for the patients and to promote the economical sustainability of quality production.

We hope that the Member State mechanism, which met for the first time in Buenos Aires in November 2012, will manage to overcome all the ideological, economical and commercial interests that could hamper its work, and that it will promote effective and patient-centered measures to ensure universal access to medicines of ensured quality. Just as States have a duty to ensure access to essential medicines for all, they should also ensure the same level of quality assurance and protection from ineffective or toxic medical products to everyone, irrespectively of the income level of the individuals, households and countries. Access to medicines and quality of medicines should be universal, and they should always go together, everywhere and for everyone.

Bibliography and websites

1 – http://www.who.int/topics/essential_medicines/en/

2 – http://www.msfaccess.org/

3 – Lancet Special Report. India’s patent laws under pressure. Vol 380 September 15, 2012. http://www.thelancet.com/

4 – MSF Access Campaign. Untangling the web of antiretroviral price reduction. 15th Edition. July 2012. Available at http://utw.msfaccess.org/

5 – Arie S. Bayer challenges India’€™s first compulsory licence for generic version of cancer drug BMJ2012;345:e6015

6 – Caudron J-M, Ford N, Henkens M, Mace C, Kiddle-Monroe R & Pinel J (2008) Substandard medicines in resource-poor settings: a problem that can no longer be ignored. Tropical Medicine and International Health 13, 1062-€“1072

7 – http://apps.who.int/gb/ssffc/

8 – WHO Fact sheet N°275; http://www.who.int/mediacentre/factsheets/fs275/en/

9 – WHO frequently asked questions. What are substandard medicines? Available at http://www.who.int/medicines/services/counterfeit/faqs/06/en/index.html

10 – Dorlo TPC, Ravinetto RM, Beijnen JH, Boelaert M.  Commentary: Substandard medicines are the priority for neglected tropical diseases. BMJ 2012;345:e7518

11 – Ravinetto R, Boelaert M, Jacobs J, Pouget C, Luyckx C. Editorial. Poor-quality medical products: time to address substandards, not only counterfeits. Tropical Medicine and International Health 2012. doi:10.1111/j.1365-3156.2012.03076.x

12 -€“ Dorlo TPC, Eggelte TA, Schoone GJ, de Vries PJ, Beijnen JH (2012) A Poor-Quality Generic Drug for the Treatment of Visceral Leishmaniasis: A Case Report and Appeal. PLoS Negl Trop Dis 6(5): e1544. doi:10.1371/journal.pntd.0001544

13 -€“ E Danielle Rentz et al., Outbreak of acute renal failure in Panama in 2006: a case-control study. Bulletin of the World Health Organization 2008; 86: 749-756. Available at WHO website

14 -€“ Arie S. Contaminated drugs are held responsible for 120 deaths in Pakistan. BMJ 2012;344:e951 doi: 10.1136/bmj.e951

15 – C. Maponga and C. Ondari, The quality of antimalarials. A study in selected African countries. WHO/EDM/PAR/2003.4, May 2003. Available at: http://apps.who.int/medicinedocs/en/d/Js4901e/

16 – Survey of the quality of selected antimalarial medicines circulating in six countries of sub-Saharan Africa. WHO (Quality Assurance and Safety of Medicines, Department of Essential Medicines and Pharmaceutical Policies), January 2011. Available at: www.who.int/medicines/publications/WHO_QAMSA_report.pdf

17 -€“ Regulator prequalification of medicines: a future concept for networking. WHO Drug Information Vol. 26, No. 3, 2012

18 – http://www.who.int/topics/prequalification/en/

 

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*Raffaella Ravinetto holds a Pharmacy Degree from the University of Torino and a Postgraduate Diploma in Tropical Medicine from the Antwerp Institute of Tropical Medicine.

After a seven-year experience as a Clinical Research Scientist in the private pharmaceutical sector, she worked in emergency and development programs in the Balkans and in Africa. In 2002, she joined Médecins Sans Frontières (MSF), where she followed various dossiers on access to essential medicines and quality of medicines, while performing regular field assessments. She currently works at the Antwerp Institute of Tropical Medicine, as head of the Clinical Trials Unit, coordinator of the Switching the Poles Clinical Research Network and promoter of Quamed (a Network promoting evidence-based strategies for universal access to quality medicines). She was president of the Italian branch of MSF (2007-2011). Her main areas of interest include North-South collaborative clinical research, research ethics (particularly in relation to resource-constrained settings) and access to health.

 

**After 8 years experience in the field of pharmaceutical marketing and communication, Christophe Luyckx joined the humanitarian sector where he implemented social marketing programs for various NGOs, donors and consultancy offices, aimed at strengthening the impact of generic medicines in developing countries.

Christophe has also served as CEO of PSF (Pharmaciens sans Frontières) and PAH (Pharmacie et Aide Humanitaire) and was Marketing Director of an important procurement agency for generic medicines where he developed the procurement channels from China and India.

These various assignments and experience in over 20 countries led Christophe to identify the quality of medicines as a major concern for developing countries and encouraged him to join the Institute of Tropical Medicine of Antwerp where he currently coordinates QUAMED – quality medicines for all -.

Christophe holds a master’€™s degree in Social Communications and a University degree in Public Health and Health Promotion.

 

News Link n. 32

 

The news links are part of the research project GESPAM (Geopolitica, Salute Pubblica e Accesso alle Medicine/Geopolitics, Public Health and Access to Medicines), which aims to focus on the best options for the use of trade and government rules related to public health by resource-limited countries.

 

NEWS LINK 32

Il rilancio della cooperazione internazionale: perché solo insieme si cresce http://www.cooperazioneintegrazione.it/news/2013/01/rilanciocoop.aspx

PAHO Director’s Corner http://new.paho.org/hq/index.php?option=com_content&view=article&id=6419&Itemid=39346&lang=en

DONOR FUNDING FOR HEALTH IN LOW- & MIDDLE-INCOME COUNTRIES, 2002–2010 http://www.kff.org/globalhealth/upload/7679-06.pdf 

Letters To The President Obama http://www.interaction.org/letters-president  

President Obama, Set a Goal to End Hunger http://www.huffingtonpost.com/david-beckmann/obama-hunger_b_2442728.html

EU’s next step to fight global child hunger  https://www.devex.com/en/news/80143/print  

On Day One: Ensuring Food Security  http://www.diplomaticourier.com/news/topics/environment/1314-on-day-one-ensuring-food-security?mkt_tok=3RkMMJWWfF9wsRouuaXMZKXonjHpfsX87%2B0uX6%2Bg38431UFwdcjKPmjr1YcIRMB0dvycMRAVFZl5nQhdDOWN

Global health education in U.S. Medical schools  http://www.biomedcentral.com/1472-6920/13/3

US FTC Finds Sharp Rise In ‘Pay-For-Delay’ Deals Blocking Generics  http://www.ip-watch.org/?p=25732&utm_source=post&utm_medium=email&utm_campaign=alerts

Free Drugs Are “Crucial Part” Of Neglected Topical Disease Fight  http://www.ip-watch.org/?p=25624&utm_source=post&utm_medium=email&utm_campaign=alerts

Could a new business model be the next wonder drug?  https://www.devex.com/en/news/79455/print

Developing countries’ private debt is on the rise, and the international institutions are ill-prepared  http://eurodad.org/1544376/?mkt_tok=3RkMMJWWfF9wsRouuK%2FPZKXonjHpfsX87%2B0uX6%2Bg38431UFwdcjKPmjr1YYBT8B0dvycMRAVFZl5nQhdDOWN

Official Offers Reflections On WHO Reform, Private Sector Role  http://www.ip-watch.org/?p=25704&utm_source=post&utm_medium=email&utm_campaign=alerts

Business’ Privileged Access To EU-India Trade Documents http://www.ip-watch.org/?p=25617&utm_source=post&utm_medium=email&utm_campaign=alerts

World Trade Organisation’s new boss will face an in-tray filled with problems  http://www.guardian.co.uk/world/2013/jan/13/world-trade-organisation-new-director-general?mkt_tok=3RkMMJWWfF9wsRouua7PZKXonjHpfsX87%2B0uX6%2Bg38431UFwdcjKPmjr1YcJRcB0dvycMRAVFZl5nQhdDOWN

Responsibility in the Time of Cholera: What the UN and Others Should Do in Haiti  http://blogs.cgdev.org/globalhealth/2013/01/responsibility-in-the-time-of-cholera-what-the-un-and-others-should-do-in-haiti.php 

China, UK unveil joint global health program  http://usa.chinadaily.com.cn/china/2013-01/17/content_16133956.htm

Family planning stands pat http://usa.chinadaily.com.cn/china/2013-01/16/content_16122760.htm

Looking Ahead at Global Health in 2013  http://www.chathamhouse.org/media/comment/view/188419 

 

 

 

 

 

News Link n. 31

 

The news links are part of the research project GESPAM (Geopolitica, Salute Pubblica e Accesso alle Medicine/Geopolitics, Public Health and Access to Medicines), which aims to focus on the best options for the use of trade and government rules related to public health by resource-limited countries.

 

News Link 31

Dear President Obama: Africa is calling  https://www.devex.com/en/news/80092/print 

2013 EU humanitarian aid budget: Who gets what?  https://www.devex.com/en/news/80093/print 

Widespread Use Of New TB Drug Faces Challenges, Science Reports  http://globalhealth.kff.org/Daily-Reports/2013/January/11/GH-011113-TB-Drug-Approval.aspx 

The Financial Transaction Tax: Globalization’s Payback Time for the World’s Poor  http://www.huffingtonpost.com/philippe-dousteblazy/financial-transaction…  

Q&A: Middle Eastern web technology for social change, with Esra’a Al Shafei  http://www.scidev.net/en/new-technologies/icts/features/q-a-middle-eastern-web-technology-for-social-change-with-esra-a-al-shafei-1.html

India rejects claims it exported fake medicine to Africa  http://www.guardian.co.uk/world/2013/jan/02/india-rejects-fake-medicine-africa 

‘Two Indias exist everywhere, especially in healthcare’ – video http://www.guardian.co.uk/global-development/video/2013/jan/07/india-hea…

Can India Defeat Poverty? http://www.foreignpolicy.com/articles/2013/01/08/can_india_defeat_povert…

Innovation to fund global health http://thehill.com/blogs/congress-blog/healthcare/275677-innovation-to-f…

A  New  Agenda  for  the  G20:  Addressing  Fragile  States  http://blogs.cfr.org/patrick/2012/12/12/a-new-agenda-for-the-g20-addressing-fragile-states/?cid=nlc-public-the_world_this_week-link26-20130104&mkt_tok=3RkMMJWWfF9wsRouuq%2FBZKXonjHpfsX87%2B0uX6%2Bg38431UFwdcjKPmjr1YcGS8Z0dvycMRAVFZl5nQhdDOWN

Disease Eradication  http://www.nejm.org/doi/full/10.1056/NEJMra1200391

Video of the Week: Cash and Carry with the World Food Programme in Zimbabwe http://blog.usaid.gov/2013/01/video-of-the-weekcash-and-carry-with-the-world-food-programme-in-zimbabwe/

USTR holds NGO briefing on TPP negotiations http://www.keionline.org/node/1635

Top tech breakthroughs of 2012 http://www.scidev.net/en/health/news/top-tech-breakthroughs-of-2012.html

Twelve countries sign UN treaty to combat illegal tobacco trade http://www.un.org/apps/news/story.asp?NewsID=43899&Cr=tobacco&Cr1=%23.UO…

Information is key to effective malaria control http://www.guardian.co.uk/global-development-professionals-network/2013/jan/10/malaria-awareness-raising-africa 

FAO Food Price Index down 7 percent in 2012 http://www.fao.org/news/story/en/item/168067/icode/ 

 

 

 

 

 

 

 

 

 

 

News Link n. 30

 

The news links are part of the research project GESPAM (Geopolitica, Salute Pubblica e Accesso alle Medicine/Geopolitics, Public Health and Access to Medicines), which aims to focus on the best options for the use of trade and government rules related to public health by resource-limited countries.

News Link 30

Aids, un nemico sempre in agguato: intervista con Mario Figoni   http://www.pianetaqueer.it/news/focus-h-i-v/265-aids-un-nemico-sempre-in-agguato.html

SANITÀ, INVECCHIAMENTO E NUOVE TECNOLOGIE  http://www.nelmerito.com/index.php?option=com_content&task=view&id=1852&Itemid=1

Il nuovo Global Burden of Disease study: cosa c’è di nuovo?  http://www.saluteinternazionale.info/2012/12/il-nuovo-global-burden-of-disease-study-cosa-ce-di-nuovo/

Emerging economies drive frugal innovation  http://www.who.int/bulletin/volumes/91/1/13-020113/en/index.html

Effect of vitamin A supplementation on cause-specific mortality in women of reproductive age in Ghana: a secondary analysis from the ObaapaVitA trial http://www.who.int/bulletin/volumes/91/1/11-100412-ab/en/index.html

First new tuberculosis drug for 50 years – works on drug-resistant forms of the disease  http://www.msfaccess.org/about-us/media-room/press-releases/first-new-tuberculosis-drug-50-years-%E2%80%93-works-drug-resistant-forms

At Europe’s Doorstep, Fierce War Against TB  http://online.wsj.com/article/SB10001424127887324660404578201593636497964.html

Editorial, Opinion Pieces Address Effects Of Health Worker Murders In Pakistan On Polio Eradication  http://globalhealth.kff.org/Daily-Reports/2013/January/04/GH-010413-Opinion-Polio-In-Pakistan.aspx

Taking Calls on Abortion, and Risks, in Chile  http://www.nytimes.com/2013/01/04/world/americas/in-chile-abortion-hot-line-is-in-legal-gray-area.html?_r=0

Thai-EU FTA Raises Alarm for People With AIDS   http://www.ipsnews.net/2012/12/thai-eu-fta-raises-alarm-for-people-with-aids/  

In China, Grass-Roots Groups Take On H.I.V./AIDS Outreach Work  http://www.nytimes.com/2013/01/03/world/asia/chinese-groups-slowly-carve-out-space-in-work-against-hiv-aids.html?pagewanted=1&_r=0 

Global development podcast transcript: hopes and fears for 2013  http://www.guardian.co.uk/global-development/2012/dec/28/global-development-podcast-2013-transcript 

Renowned US doctor appointed to support UN efforts to eliminate cholera in Haiti http://www.un.org/apps/news/story.asp?NewsID=43853&Cr=haiti&Cr1=cholera#.UOhUC2_8Lie

Q&A with Eric Goosby, US Global AIDS Coordinator  http://www.globalpost.com/dispatches/globalpost-blogs/global-pulse/qa-eric-goosby-us-global-aids-coordinator

Transforming Health with Mobile Technology   http://www.impatientoptimists.org/en/Posts/2012/12/Transforming-Health-with-Mobile-Technology

Efforts To Eliminate FGM ‘Breaking New Ground’ With Approval Of U.N. General Assembly Resolution http://globalhealth.kff.org/Daily-Reports/2012/December/21/GH-122112- Opinion-FGM-Resolution.aspx 

Myanmar eyes microfinance, private sector development   https://www.devex.com/en/news/80050/print 

Collaborative Capacity Building In Intellectual Property: Leveraging On African Diaspora Exchange  http://www.ip-watch.org/?p=25523&utm_source=post&utm_medium=email&utm_campaign=alerts

US aid policy under John Kerry: Expect few changes   https://www.devex.com/en/news/80027/print 

Most-Read IP-Watch Stories Of 2012: India Pharma, Europe, ACTA, WIPO Technical Assistance, Gene Patents  http://www.ip-watch.org/?p=25510&utm_source=post&utm_medium=email&utm_campaign=alerts

 

News Link n. 29

 

The news links are part of the research project GESPAM (Geopolitica, Salute Pubblica e Accesso alle Medicine/Geopolitics, Public Health and Access to Medicines), which aims to focus on the best options for the use of trade and government rules related to public health by resource-limited countries.

 

News Link 29

TOP 10 GLOBAL HEALTH MILESTONES OF 2012  http://psiimpact.com/top-10-global-health-milestones-of-2012/

Ricerca scientifica: non è sufficiente dire Bad Pharma  http://www.saluteinternazionale.info/2012/12/ricerca-scientifica-non-e-sufficiente-dire-bad-pharma/

Ambassador Goosby Named Head Of State Department’s New Office of Global Health Diplomacy  http://globalhealth.kff.org/Daily-Reports/2012/December/17/GH-121712-Goosby-Diplomacy-Office.aspx 

The Office of Global Health Diplomacy: A Christmas Miracle or Lump of Coal?  http://blogs.cgdev.org/globalhealth/2012/12/the-office-of-global-health-diplomacy-a-christmas-miracle-or-lump-of-coal.php 

Susan Rice withdraws for secretary of state  https://www.devex.com/en/news/79958/print

The U.S. Role in Global Polio Eradication http://csis.org/publication/us-role-global-polio-eradication

Science put at heart of US global AIDS strategy  http://www.scidev.net/en/health/hiv-aids/news/science-put-at-heart-of-us-global-aids-strategy.html

US Chamber Holds Annual IP Attaché Roundtable, Announces New “IP Index”  http://www.ip-watch.org/?p=25409&utm_source=post&utm_medium=email&utm_campaign=alerts

KEI notes on the 15th round of Trans-Pacific Partnership Agreement (TPPA) negotiations in Auckland, New Zealand  http://www.keionline.org/node/1617

The MDGs: Where Does Nutrition Fit? http://www.developmenthorizons.com/2012/12/the-mdgs-where-does-nutrition-fit.html

Future of Agriculture: Online Discussion blog  http://blogs.oxfam.org/en/future-of-agriculture 

FAO: Poor Countries Must Invest in Farming to Tackle Hunger http://ictsd.org/i/news/bridgesweekly/151477/

Analysis: Five reasons malnutrition still kills in Nepal http://www.irinnews.org/Report/97046/Analysis-Five-reasons-malnutrition-still-kills-in-Nepal 

Waiting For Customs And Trademark Reforms, EU Rights Owners Get “Proactive” Against Fakes  http://www.ip-watch.org/?p=25321&utm_source=post&utm_medium=email&utm_campaign=alerts

Howard Berman Unveils Landmark Foreign Assistance Reform Legislation  http://www.democrats.foreignaffairs.house.gov/press_display.asp?id=1010

Finally, a 2013 EU budget https://www.devex.com/en/news/79950/print

EU to join efforts with the World Bank to develop water and energy in Central Asia  http://europa.eu/rapid/press-release_IP-12-1402_en.htm?locale=en

European Unitary Patent And Court Becomes Reality  http://www.ip-watch.org/?p=25258&utm_source=post&utm_medium=email&utm_campaign=alerts

Dispatch From Sweden: Development Talks, Gender Equality, and the Nobels http://blogs.worldbank.org/voices/dispatch-from-sweden-development-talks-gender-equality-and-the-nobels

SHIFTS IN AIDS RELIEF AND BEYOND  http://www.usglc.org/2012/12/13/shifts-in-aids-relief-and-beyond/

GENERAL ASSEMBLY ENCOURAGES MEMBER STATES TO PLAN, PURSUE TRANSITION OF NATIONAL HEALTH CARE SYSTEMS  TOWARDS UNIVERSAL COVERAGE  http://pnhp.org/blog/2012/12/13/united-nations-passes-resolution-supporting-universal-coverage/  

The Ongoing Fight for Safety, Equality, and Health  http://www.intrahealth.org/page/the-ongoing-fight-for-safety-equality-and-health

OP-ED: Women Out Loud  http://www.ipsnews.net/2012/12/op-ed-women-out-loud/

80 Programs to Improve the Health and Lives of Women in the Developing World http://www.impatientoptimists.org/en/Posts/2012/12/An-Explosion-of-Private-Sector-Innovation-Improving-Maternal-Newborn-and-Child-Health-in-Developing-World

How Big Pharma Prevents The Poor From Accessing Life-Saving Medicines  http://thinkprogress.org/health/2012/12/15/1336081/how-big-pharma-prevents-the-poor-from-accessing-life-saving-medicines/?mobile=nc 

Will innovative financing replace ODA?   https://www.devex.com/en/news/79995/print 

The year of cataclysm for the NHS http://www.nhscampaign.org/NHS-reforms/nhs-2012-review.html  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fondi in calo per le malattie neglette: un panorama frammentato da riordinare

 

 La Ricerca e Sviluppo (R&S) di nuovi strumenti diagnostici e terapeutici per le malattie neglette legate alla povertà (PRMN) è in sofferenza per la sensibile tendenza al ribasso dei finanziamenti

 

Fondi in calo per le malattie neglette: un panorama frammentato da riordinare

Daniele Dionisio

 

Come appena riferito da Policy Cures  “…Con 3 miliardi di dollari destinati nel 2011, i fondi per la ricerca globale nel settore superano oggi di circa 440 milioni di dollari gli stanziamenti del 2007, ma sono inferiori ai fondi del 2009, e simili a quelli del 2010…”€  [1, 2]

Questa stagnazione è preoccupante se si pensa che le PRMN (fra cui, ma non solo, AIDS, morbillo, polio, dengue, polmoniti, malaria, tubercolosi, malattia del sonno, leishmaniosi, diarree) insieme causano 5 milioni di morti all’€™anno nei paesi a basso reddito, dove 3 miliardi di persone sopravvivono con meno di 2 dollari al giorno  e le medicine salvavita protette dai brevetti sono fuori portata, mentre regole del commercio e governi stanno stravolgendo i diritti di proprietà intellettuale a favore di politiche allineate a interessi di monopolio [3-5]

Tutto questo in un momento in cui la assenza di una agenda operativa condivisa su scala mondiale rende ragione di un quadro generale decisamente frammentato, con sovrapposizione e duplicazione di iniziative.

In questo contesto, l’€™impegno dell’€™Unione Europea (UE) in R&S per PRMN  non è distribuito uniformemente fra gli Stati Membri, rappresenta solo lo 0.0024% del PIL combinato UE, e manca di adeguata condivisione con tutti i partners [6].

La UE dovrebbe coordinarsi e collaborare strettamente con le iniziative dei partners, non ultima la Roadmap appena lanciata dall’ Unione Africana sulla Responsabilità  Condivisa e Solidarietà  Globale per la Risposta ad AIDS, Tubercolosi e Malaria in Africa [7]

Ed è auspicabile una collaborazione più stretta della UE con il Fondo Globale per la Lotta ad AIDS, Tubercolosi e Malaria per compattare le forze in questi tempi di recessione economica globale [8].

Ma è altresì necessaria più aperta collaborazione UE con l’€™OMS circa i modelli e le fonti che l’€™OMS ha indicato e  sta esaminando per l’€™ottimale finanziamento di R&S per le malattie della povertà  [9]. Nel merito ben si presterebbero parte dei proventi (almeno il 10%) da  una Tassa sulle Transazioni Finanziarie oggi prossima all’€™attuazione in UE [10]  .

Nel frattempo gli Stati Uniti continuano a detenere un ruolo leader nella R&S per PRMN, anche attraverso le alleanze politico-strategiche che l’€™amministrazione Obama sta moltipicando negli scacchieri di Asia-Pacifico e Africa [11-14]

E questo mentre la spesa estera in R&S per PRMN da parte dei BRICS (Brasile, Russia, India, Cina, Sud Africa), soprattutto in termini di cooperazione Sud-Sud, è in lievitante ascesa, e gli Stati del Golfo, Turchia, Indonesia, Argentina, Messico e Corea del Sud sono protesi allo sviluppo di tecnologie per la salute in grado di coniugare innovazione, qualità  e basso costo [15, 16].

Riordinare questo panorama altamente frammentato è obiettivo prioritario se la R&S per PRMN deve fare di più e meglio. Allo scopo, sostegno generalizzato a OMS  e una agenda di lavoro comune per la condivisione delle priorità , senza dispersioni e ridondanze, sono assolutamente necessari.

 

RIFERIMENTI

1. http://www.policycures.org/downloads/GF2012_Report.pdf

2.  http://www.scidev.net/en/health/news/r-d-funding-for-neglected-diseases-failing-.html

3. http://www.action.org/documents/CALL_TO_EU_LEADERSHIP_ON_GLOBAL_HEALTH_RD.pdf

4. http://apps.who.int/gb/ebwha/pdf_files/A61/A61_R21-en.pdf 

5. http://www.msfaccess.org/content/acta-and-its-impact-access-medicines 

6. http://www.dsw-online.org/fileadmin/user_upload_en/PDF/GH_R_D_EU/Saving_Lives_and_Creating_Impact_DSW-PC_Report.pdf 

7. http://www.au.int/en/sites/default/files/Shared_Res_Roadmap_Rev_F%5b1%5d.pdf 

8. http://www.action.org/documents/ACTION-TBEC_Briding_the_Gap_Sept2012_EMBARGOED.pdf

9. http://www.ip-watch.org/2011/12/14/who-expert-group-to-recommend-binding-rd-treaty-negotiation/ 

10. http://www.euinside.eu/en/news/after-all-the-ftt-will-be-introduced-though-not-across-the-eu 

11. http://www.policycures.org/downloads/GF2012_Report.pdf 

12. http://www.pepfar.gov/ 

13. http://globalhealth.kff.org/Daily-Reports/2010/November/09/GH-110910-Obama-In-India.aspx

14. http://www.devex.com/en/news/76981/print

15. www.g20civil.com/documents/199/472/

16. http://pib.nic.in/newsite/erelease.aspx?relid=080683

 

News Link n. 28

 

The news links are part of the research project GESPAM (Geopolitica, Salute Pubblica e Accesso alle Medicine/Geopolitics, Public Health and Access to Medicines), which aims to focus on the best options for the use of trade and government rules related to public health by resource-limited countries.

 

News Link 28

Changing the World: A Bold Endorsement of the Power of Vaccines and Immunization  http://www.impatientoptimists.org/en/Posts/2012/12/Changing-the-World-A-Bold-Endorsement-of-the-Power-of-Vaccines-and-Immunization

Asia: Hopes rise in fight against HIV/AIDS   http://www.globalpost.com/dispatch/news/regions/asia-pacific/121129/HIV-AIDS-epidemic-china-cambodia-myanmar-thailand-vietnam-indonesia 

Cancer’s New Battleground — the Developing World   http://www.theworld.org/cancer-new-battleground/

Building Resilience to Recurrent Crisis. USAID POLICY AND PROGRAM GUIDANCE  http://transition.usaid.gov/resilience/USAIDResiliencePolicyGuidanceDocument.pdf

Novartis vs. India: Supreme Court hearing ends   http://www.msfaccess.org/content/novartis-vs-india-supreme-court-hearing-ends

CHINA AND GLOBAL FUND SIGNAL STRONG PARTNERSHIP  http://www.theglobalfund.org/en/mediacenter/newsreleases/2012-11-30_China_and_Global_Fund_Signal_Strong_Partnership/

Chinese-Style Decentralization and Health System Reform  http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001337

A beginner’s guide to land grabs   http://www.oxfam.org/en/grow/video/2012/beginners-guide-land-grabs 

FEB 21, 2013 LOCAL PHARMACEUTICAL PRODUCTION AND ACCESS TO MEDICINES  http://www.medicusmundi.org/en/contributions/events/2012/local-pharmaceutical-production-and-access-to-medicines

A FRAMEWORK CONVENTION ON GLOBAL HEALTH: A CATALYST FOR JUSTICE  http://www.who.int/bulletin/volumes/90/12/12-114371.pdf

PUBLIC HEALTH ROUND-UP  http://www.who.int/bulletin/volumes/90/12/12-011212.pdf 

Single European Patent Dominates IP Summit As European Parliament Vote Nears http://www.ip-watch.org/?p=25226&utm_source=post&utm_medium=email&utm_campaign=alerts

GFINDER 2012 report http://www.policycures.org/g-finder2012.html

African scientists seek more commitment against tropical diseases  http://big5.xinhuanet.com/gate/big5/news.xinhuanet.com/english/world/2012-12/11/c_132034319.htm 

Making bad drugs? Three strikes and you’re out   http://thehill.com/blogs/congress-blog/healthcare/271721-making-bad-drugs-three-strikes-and-youre-out 

UNITAID NEW GRANTS TOTAL US$ 120 MILLION   http://www.unitaid.eu/resources/press-centre/releases/1053-eb17-project-release

DfID oversight of EU aid spending in poor countries gets ‘amber-red’ rating https://www.devex.com/en/news/79933/print 

How corrupt is your government?  https://www.devex.com/en/news/79900/print 

 

 

 

 

 

News Link n. 27

 

The news links are part of the research project GESPAM (Geopolitica, Salute Pubblica e Accesso alle Medicine/Geopolitics, Public Health and Access to Medicines), which aims to focus on the best options for the use of trade and government rules related to public health by resource-limited countries.

 

News Link 27

“Good health at low cost”: il caso Etiopia  http://www.saluteinternazionale.info/2012/11/good-health-at-low-cost-il-caso-etiopia/

New Nestlé Chinese Medicine and World Health Organization  http://www.examiner.com/article/new-nestl-chinese-medicine-and-world-health-organization?cid=rss 

New PEPFAR blueprint paves way toward AIDS-free generation https://www.devex.com/en/news/79855/print

WHO Members Agree On “Strategic Work Plan” On Health R&D – But No Convention  http://www.ip-watch.org/?p=25034&utm_source=post&utm_medium=email&utm_campaign=alerts 

WHO Members Agree On Roadmap To Fight Poor Quality Medicines  http://www.ip-watch.org/?p=24860&utm_source=post&utm_medium=email&utm_campaign=alerts

Event This Week: The Creation Of Unitary Patent Protection In The European Union  http://www.ip-watch.org/?p=24941&utm_source=post&utm_medium=email&utm_campaign=alerts

Medicines Patent Pool Statement on Johnson & Johnson’s Darunavir Announcement http://www.medicinespatentpool.org/medicines-patent-pool-statement-on-johnson-johnson%E2%80%99s-darunavir-announcement/

Pharma Companies Improving Access To Medicines But Lack Oversight Of Outsourced Clinical Trials, Analysis Says  http://globalhealth.kff.org/Daily-Reports/2012/November/28/GH-112812-Access-To-Medicine-Index.aspx

Drug industry’s influence over research  http://www.washingtonpost.com/business/economy/as-drug-industrys-influence-over-research-grows-so-does-the-potential-for-bias/2012/11/24/bb64d596-1264-11e2-be82-c3411b7680a9_story_1.html

Conflicted influences  http://www.washingtonpost.com/wp-srv/special/business/NEJM-articles/index.html

Scientists and drug company connections  http://www.washingtonpost.com/business/economy/scientists-and-drug-company-connections/2012/11/24/f4711d8e-36a1-11e2-9cfa-e41bac906cc9_graphic.html

World Bank Group President Jim Yong Kim Opening Remarks at Neglected Tropical Diseases Conference, Washington DC http://www.worldbank.org/en/news/2012/11/16/neglected-tropical-diseases-conference.print

More infectious HIV strains spreading in India  http://www.scidev.net/en/south-asia/news/more-infectious-hiv-strains-spreading-in-india.html

Statement by the President on the Observance of World AIDS Day http://www.whitehouse.gov/the-press-office/2012/11/29/statement-president-observance-world-aids-day 

Treatment Action Group’s 2012 Report on Tuberculosis Research Funding Trends, 2005–2011 http://www.treatmentactiongroup.org/tbrd2012

Mumbai Grapples With Drug Resistant TB Strain  http://online.wsj.com/article/SB10001424127887324894104578115232986766350.html

China considers easing family planning rules http://www.reuters.com/article/2012/11/28/us-china-family-idUSBRE8AR06A20121128

China bans hospitals from refusing patients with HIV-AIDS http://www.foxnews.com/world/2012/11/23/china-bans-hospitals-from-refusing-patients-with-hiv-aids/#ixzz2DC9BnIBL

What You Need to Know About Foreign Aid (And Why We Need to Protect It) http://www.impatientoptimists.org/en/Posts/2012/11/Protect-EU-Aid-Its-a-Smart-Investment

India Skirts Patent Laws to Help Companies and Poor  http://m.spiegel.de/international/world/a-869601.html#spRedirectedFrom=www

The US Proposal for IP Enforcement in the TPPA and Impacts for Developing Countries http://keionline.org/node/1614 

 

Interview: Mario Raviglione, Director WHO Stop TB Department

 

Interview

Mario Raviglione, Director of WHO Stop TB Department

GESPAM had the pleasure to interview Mr. Mario Raviglione as Director of the Stop Tuberculosis (TB) Department at the World Health Organization (WHO) since 2003.

Mario Raviglione joined WHO in 1991 to work on TB/HIV research and TB epidemiology in Europe. He contributed to the development of the DOTS (Directly Observed Treatment Short course) strategy in 1994, and set up the global drug-resistance surveillance project (1994) and the global TB surveillance & monitoring system (1995). In his first decade at WHO, he also worked on experimental regimens for treatment of latent infection in the mouse model (early 1990s), described the feasibility of preventive therapy in Africa (1995), first reported the TB control crisis in Eastern Europe (1993), and co-developed estimates and projections of the global TB epidemic. Between 1999 and 2003, Raviglione  was Coordinator for Strategy and Operations globally, taking charge particularly of surveillance and programme monitoring; operational research; TB/HIV and multi drug-resistant TB responses; and DOTS expansion worldwide.
Currently, as Stop TB Department Director, he is responsible for setting norms, policies and standards on global TB control, coordinating technical support, monitoring the global situation, and developing innovative interventions through translation of new evidence into policies & practice and through addressing system challenges such as community and private sector engagement.
He has published over 250 articles and chapters on the topics of infectious diseases, HIV/AIDS and TB in the most influential health journals and books, including in the last five editions of the prestigious Harrison's Principles of Internal Medicine. He is among the top 10 most cited authors in the TB field.
Mario Raviglione graduated from the University of Turin in Italy in 1980, and trained in internal medicine and infectious diseases in New York (where he was Chief Medical Resident at Cabrini's Medical Centre) and Boston, where he was appointed an AIDS Clinical Research Fellow at Beth Israel Hospital, Harvard Medical School. In 2005, he received the Princess Chichibu TB Global Award for his achievements in TB control. In 2009 he was nominated Fellow of the Royal Academy of Physicians (F.R.C.P., London, UK). In 2010 he received the Wolfheze 20 Year Jubilee Award for his contributions to modern TB control practices in Europe. As a leading expert in TB, Mario Raviglione  has served as a visiting professor at Johns Hopkins and Geneva Universities. He has been visiting professor at the medical schools of the University of Brescia and the University of Modena & Reggio Emilia in Italy, as well as at the Faculty of Science of the University of Pavia.

Background information from WHO Global Tuberculosis Report 2012  

... the global burden of TB remains enormous. In 2011, there were an estimated 8.7 million new cases of TB (13% co-infected with HIV) and 1.4 million people died from TB, including almost one million deaths among HIV-negative individuals and 430 000 among people who were HIV-positive....Globally, 40% of TB patients had a documented HIV test result... Almost 80% of TB cases among people living with HIV reside in Africa. 
....There were an estimated 0.5 million cases [of TB] and 64 000 deaths among children in 2011....
 The burden of TB is highest in Asia and Africa. India and China together account for almost 40% of the world'€™s TB cases. About 60% of cases are in the South-East Asia and Western Pacific regions. The African Region has 24% of the world'€™s cases, and the highest rates of cases and deaths per capita. Worldwide, 3.7% of new cases and 20% of previously treated cases were estimated to have MDR (multidrug resistant)-TB. India, China, the Russian Federation and South Africa have almost 60% of the world'€™s cases of MDR-TB. The highest proportions of TB patients with MDR-TB are in eastern Europe and central Asia. ...Extensively drug-resistant TB, or XDR-TB, has been reported by 84 countries; the average proportion of MDRTB cases with XDR-TB is 9.0%..... 

GESPAM:  Mr. Raviglione, the WHO-developed Stop TB Strategy aims to dramatically reduce the global burden of tuberculosis by 2015 by ensuring all TB patients, including for example, those co-infected with HIV and those with drug-resistant TB, benefit from universal access to high-quality diagnosis and patient-centered treatment. Which progress so far?

Mario Raviglione: The implementation of DOTS, later enhanced to the Stop TB Strategy, began in the mid-1990s. At that time, the global targets were to achieve everywhere 70% case detection and 85% cure rate. The case detection is today at around 65%, while the treatment success has been consistently above 85% over a number of years.  This means that despite a major increase in detecting cases worldwide, still one third of the estimated cases are not in the system. More importantly, impact targets have been achieved. The TB-related Millennium Development Goal of reversing the incidence trend has been achieved years ago and the other two international targets of halving prevalence and mortality in 2015 compared to 1990 are on track globally, although not in Africa and Europe. Overall, there is huge progress compared to the disastrous situation of the mid-1990s. However, with still 1.4 million deaths and 8.7 million cases every year, there is no room for complacency and TB remains a major killer worldwide.

GESPAM: MDR and XDR-TB:  please, add information about definitions, trends and latest treatment results.

Mario Raviglione: WHO defines MDR-TB as a form of tuberculosis that is resistant to at least isoniazid and rifampicin. Extensively drug-resistant TB (XDR-TB) is defined as MDR-TB + additional resistance to at least any fluoroquinolone and any of the 3 injectable agents. MDR-TB is estimated to affect nearly half a million cases every year, but we do not know exactly the figure since only 4% of TB patients worldwide today are exposed to drug susceptibility testing. If all cases detected had such testing, at least 310,000 patients would be detected. In reality, only 60,000 were reported in 2011 and the treatment success today is less than 50%. This means that these patients are likely to die frequently and spread the resistant strains to their communities.  Although we do not know global trends, we are aware that in some settings, MDR-TB is declining while in others, especially countries with an overlapping HIV epidemic, MDR-TB is on the increase. Major concerns are in the countries of the former Soviet Union where MDR-TB and XDR-TB are widespread.

GESPAM: The Stop TB Department functions include facilitating and engaging in partnerships for TB action. As such, what about factual collaboration with, and contributions from counterparts like the Global Fund, the European Union, BRICS countries, and the Gates Foundation, among others?

Mario Raviglione: WHO works closely with the Global Fund, especially in the past few months when we have been involved much more strategically than in the past as part also of a newly established TB committee that helps the GF secretariat to strategize on TB. It is in the common interest to collaborate since WHO has the mandate to support technically our Member States while the Global Fund is a financing mechanism providing the vast majority of external resources for TB control. With the European Union, it has not proven easy to develop a common agenda, and there isn’€™t one today. This may also be due to the lack of prioritization of tuberculosis, a killer of 4,000 patients every day, by most European countries. Paradoxically, the US Government is much more concerned about the threat of MDR-TB and XDR-TB coming from the EU neighboring countries that the EU itself. We work instead very closely with the BRICS. This year I visited China, India and South Africa, noticing how concerned and more and more committed they are about the TB problem. We also work closely with Brazil on their revolutionary social protection mechanism, truly providing access to the poorest, that we intend to further prioritize and disseminate. We are in constant contact with the Gates Foundation as they provide some support to our Department, although 90% of their investment in TB are focused on research.

GESPAM: As per the Global Tuberculosis Report 2012 mentioned before…..there are critical funding gaps for TB care and control. Between 2013 and 2015 up to US$ 8 billion per year is needed in low- and middle-income countries, with a funding gap of up to US$ 3 billion per year. International donor funding is especially critical to sustain recent gains and make further progress in 35 low-income countries (25 in Africa), where donors provide more than 60% of current funding…..There are also critical funding gaps for research and development. US$ 2 billion per year is needed; the funding gap was US$ 1.4 billion in 2010.

Inherently, do you think revenues from a Financial Transaction Tax (a quorum for which was just reached in the European Union through “€œenhanced cooperation procedure”€ http://www.euinside.eu/en/news/after-all-the-ftt-will-be-introduced-though-not-across-the-eu, could be a resource to partly channel towards TB funding gaps?

Mario Raviglione: Funding gaps, in my philosophy, are not just a matter for international donors. I believe that sustainable development requires domestic commitment and investment. The BRICS now cover more than 95% of their financial needs, but low-income countries, especially in Africa, still rely largely on external resources and the Global Fund covers 90% of these resources. We must therefore support these countries with a plan for progressive take-over by the Governments themselves over the next few years. The financial transaction tax is one way. The problem is that tuberculosis is too often forgotten when it comes to benefit from such initiative. This is why financial gaps exist.

GESPAM: What about WHO role and position regarding cheap TB medicines rolled out by India for poor countries’€™ needs?

Mario Raviglione: WHO’€™s position is that medicines can come from anywhere as long as they are of proven quality. In tuberculosis and in infectious diseases in general, this is key, as poor quality antibiotics not only do not help patients but in fact help create drug resistance.

GESPAM: As per a recent MSF report….South Africa has one of the highest burdens of drug-resistant tuberculosis (DR-TB) worldwide, with a conservative estimate of 13,000 new cases emerging each year. A new drug, bedaquiline (formerly known as TMC207) now offers hope for these patients. Yet despite positive outcomes in early clinical trials and recent agreement for a fast-track regulatory review in the United States and compassionate use in several European countries where the DR-TB burden is comparably low, the drug is not yet made available for patients in desperate need in South Africa.... http://www.msfaccess.org/content/fact-sheet-why-bedaquiline-tmc207-should-be-prioritised-drug-resistant-tb-patients-south

What do you think about MSF call that bedaquiline (TMC207) be prioritized for drug-resistant TB patients in South Africa?

Mario Raviglione: We are working towards policy recommendations for Member States on how to introduce this new drug rationally (a second one will likely come out in late 2013), starting with the crafting of a proper regimen where the new drug is not administered alone, else drug resistance will develop quickly. We are also developing broader recommendations on how to provide wide access through accredited physicians and institutions who guarantee rational use.  We have been working also with South Africa that has asked WHO for a technical opinion on the issue.  If everything works as foreseen, we should be able to provide rapid advice to all countries in early 2013.

GESPAM: Children are often overlooked or misdiagnosed in National TB Programmes, and few child-friendly TB medicines exist  http://www.tbcoalition.eu/2012/11/13/new-report-highlights-the-urgent-need-for-action-on-childhood-tuberculosis/   How is WHO tackling the gap of appropriate TB paediatric formulations?

Mario Raviglione: Paediatric TB has been clearly neglected by all as an important part of the response to TB. For the first time, the WHO global report 2012 included very detailed estimates of the burden, speaking of some half a million new cases every year and of some 70,000 deaths. This is a very large burden. Recently, WHO re-visited the existing drug dosages for children and issues specific recommendations on the correct formulations of fixed-dose combinations for children. Not surprisingly, at the moment, the pharmaceutical industry is not yet producing the correct formulations. A lot of efforts have to be made to work on the appropriate procedures to obtain new paediatric formulations including pharmacokinetic studies. We have encountered some difficulties to pursue the appropriate direction but it looks like, thanks to potential new grants, we may be able to overcome the obstacles and provide the pharmaceutical industry with the guidance and the support necessary for drug companies to start producing the correct formulations as defined by WHO. I am optimistic that this will happen within the next few months.

GESPAM: Thank you Mr. Raviglione for your enlightening answers.

Transnational health care and medical tourism

         Understanding 21st-century patient mobility. Towards a rationale of transnational health region development

 by Tomas Mainil
 University of Antwerp / NHTV Breda University of Applied Sciences
Publisher: NRIT Media, Nieuwegein  ISBN: 978-90-5472-219-9 (non-commercial edition)

Dr. Tomas Mainil is Lecturer at Breda University of Applied Sciences (the Netherlands).  He is responsible for the research line ´Transnational health care in sending and receiving contexts´ which was originated at the Centre for cross-cultural Understanding (CCU). He is research fellow at the Research Centre for Longitudinal and Life Course Studies (CELLO), University of Antwerp (Belgium).  He holds an MA in Sociology (Medical Sociology) and a MSc in Quantitative Analysis, and previously worked at the University of Antwerp (department Sociology) and Ghent University (department of General practice and primary health care) on health-related subjects.  His main interests are globalization and health, the policy and governance dynamics of transnational health care (PhD) and the internal and external characteristics of the transnational health user.

A full version of the PhD can be made available by the author:    tomas.mainil@ua.ac.be   mainil.t@nhtv.nl
Also forthcoming: Botterill, D., Pennings, G. and Mainil, T. (2013). Medical Tourism and Transnational Health Care. Basingstoke: Palgrave Macmillan.

 

International patients increasingly choose to be treated abroad. However, there are differences between the European perspective and other regional discourses about the globalizing health economy. The EU seeks to regulate internal patient mobility and values equality and social protection. Other regional discourses are confronted with  more privatizing/commodification in relation to patient mobility. The thesis examines the different terminologies that exist – such as cross-border healthcare and medical tourism -, arguing towards  the global terminology of transnational health care (Mainil et al., 2012):  2 archetypes of international patients (TBASs or Trans-border Access Searchers and CBASs or Cross-border Access Searchers) and 2 archetypes of professional stakeholders (RCAs or Receiving Context Actors and SCAs or Sending Context Actors) are distinguished.  Characteristics distinguishing TBASs and CBASs are geographical proximity/ distance, cultural proximity/distance and search strategies. Transnational health care is defined by more professional structures and communication networks that are also visible to and can be used by the patient.

The thesis then examines the life world of the transnational health user: 1. The role of the concept of ‘world-making’ on the websites of providers (Mainil et al., 2011); 2. The role of culturalism in the relations between medical professionals and patients (Mainil et al., 2013); 3. The role of the media in the discourse about medical tourism (Mainil et al., 2011); 4. The role of quality management in transnational health care (Mainil et al., 2012); 5. The relationship between public health and transnational healthcare (Mainil et al., 2013) and finally 6. The role of (regional) governments to steer patient mobility through context-controlled, sustainable health destination management (SHDM)/development (Mainil et al., 2012; Mainil et al., 2013).

1. The role of the concept of ‘world-making’ on the websites of providers

Globalization of health care also means that the internet is used by international medical providers to attract international patients. Providers use appealing lyrics and alluring images to use (smiling beautiful female patients and physicians) on their websites. However, the reality of offering health care is less related to the context of leisure, joy and pleasure. Within the study of tourism we know the concept of world-making: displaying images of vacation destinations that are not consistent with reality. The use of world-making in a healthcare context can, then, be ethically unjust.

2. The role of culturalism in the relations between medical professionals and patients

Jargen Habermas describes how two modes of action can be found in today’s society: communicative and strategic action. Communicative action takes place in mutual consultation and dialogue based on historical use while strategic action is based on decisions, power and speed. These two forms of action are also found in the medical tourism industry. We analyze how a department (International Office) within a hospital seeks to find a balance between these two types of action: they move between the international patients and medical professionals. It concerns the dialogue-based world of the patient with his concerns and hopes and on the other side  the professionalized world of doctors in a hospital who act strategically and work. This department attempts to act on the basis of a cultural sensitivity to the other, from an understanding of how the life world of the international patient is constructed. Therefore a need exists to act from an equilibrium in which cultural management can play a role.

3. The role of the media in written discourse on medical tourism

International newspapers (The Guardian, The Financial Times) as well as local newspapers (The Straits Times, Singapore, Bangkok Post, Thailand) display a discourse on medical tourism. This information is available to everyone. Often this information is normative. Before 2002, an ethical discourse is shown: be aware of the dangers for patients and medical professionals, medical tourism as a threat to national health systems.  After 2002 both international and local newspapers chose the market discourse in discussing medical tourism: it offers chances for new markets to consolidate and offers opportunities to multiple stakeholders. The ethical discourse is still present but has been serving the market perspective. It is this discourse that is reflected  in public opinion.

4. The role of quality management in transnational health care

Key stakeholders in transnational health care are hospitals. Hospitals’€™ focus on international patients can be formalized in an International Office (IO) to cater to non-medical services. In Belgium, this is less common, but in Germany or Singapore, such facilitation is present. We conducted a pilot study with regards to quality within such IOs through a benchmarking instrument,  incorporating the variables: medical treatment / facilities (accommodation / travel) / financial issues / quality (cultural / communicative / satisfaction). The various phases of the pilot study show that quality challenges largely depend on the national context and the strategy of the hospital.

5. The relationship between public health and transnational health care

The European Union has a history of  regulations on patient mobility. The synthesis of these regulations led to the “Directive on the Application of Patients ‘Rights in Cross-Border Healthcare”€, soon to be implemented by the Member States. This legal discussion can be linked to the debate over whether international patients can be seen as consumers or citizens with patient rights. The following considerations emerge: Do Europeans want to travel for their health? How should governments act when taking into account socio-economic differences between citizens and between states? How do these differences  relate to the current economic crisis? These considerations lead to several scenarios based on limited or extensive implementation of the Directive, whereby European international patients at times will be citizens with rights, but on other occasions care consumers.

6. The role of (regional) governments can use to steer patient mobility through a context-controlled, sustainable health destination management (SHDM) framework

Finally, all the factors in the context of transnational health care are bundled in a strong plea for a larger role for (regional) governments to strengthen their capacity to position  their regions as transnational health regions. In consultation with various stakeholders in the region, governments determine priorities for the regional system of medical expertise and specialization. In managing this regional health system, governments can make their health region profile visible to transnational health users and other regions. Governments are urged to work as health regions to depict both domestic and foreign patients  in structuring the identity of the region. Health regions comprise a sustainable policy route, as (regional) governments seek to attain public health goals.  We propose combining the notion of sustainable health destination management (SHDM) with the framework of (Smith et al., 2011) on bi-lateral agreements in transnational health care settings. If developed countries arrange bi-lateral agreements with developing and/or BRIC countries to assure health care exchanges, these agreements could align with a SHDM logic.  If for example the UK has bi-lateral agreements with India on health care exchanges, the UK could decide in a first stage  to focus on a bi-lateral agreement structure with a particular region in India, sending off patients to that region, building capacity, and ensuring that public health goals of both the UK and this Indian region are guaranteed.  In a second stage, other Indian regions could be targeted, with a focus on other medical specializations or even focusing on specific age groups such as senior citizens.  In using bi-lateral regional steering mechanisms, this could alleviate the current divide between the goals of  NGO’€™s and WHO, as opposed to the projection of  private healthcare diaspora in transnational health care. In combining SHDM and bi-lateral trade mechanisms  the proposed framework would serve as a vehicle or change agent to reverse the global south debate and to build up health care capacity based on collaborative governance (Brand and Michelsen, 2012).

Sources:

Mainil T., Platenkamp V., Dinnie K., Botterill D., Van Loon F., and Meulemans, H. (2012). Transnational health care: the quest for a global terminology. Health Policy, 108(1), 37-44.

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