Testing of resistance to isoniazid, pyrazinamide and fluoroquinolones is of paramount importance to guide treatment decisions and ensure that patients receive the best standard of care and have the highest chances to be cured. In this report the authors present an overview of the prevalence of resistance to isoniazid, pyrazinamide and fluoroquinolones and discuss the need of rapid diagnostics to detect resistance to these drugs

by Matteo Zignol

and Mario Raviglione

Global Tuberculosis Programme, World Health Organization

Resistance to Isoniazid, Pyrazinamide and Fluoroquinolones in Patients with Tuberculosis

 

Mycobacterium tuberculosis is today the top infectious killer with 1.8 million deaths caused by tuberculosis every year, including 390,000 among people with HIV infection. Every year, 10.4 million people are affected by tuberculosis. Furthermore, some 480,000 multidrug-resistant tuberculosis (MDR-TB) [1] cases emerge annually and an additional 100,000 cases of rifampicin-resistant tuberculosis, requiring the same treatment as MDR-TB, are estimated to arise in the same period of time. Drug-resistant tuberculosis represents a major threat to global health and may compromise the fight against tuberculosis in many countries.

Since 1994 the World Health Organization hosts a global project on surveillance of drug resistance in tuberculosis, which is the oldest and largest antimicrobial resistance surveillance project worldwide.

Very often when discussing of drug resistance in tuberculosis reference is made exclusively to MDR-TB and rifampicin-resistant tuberculosis, which are forms of tuberculosis requiring longer, more toxic and expensive treatment regimens with second-line drugs. However drug-resistance in tuberculosis is not exclusively MDR-TB or resistance to rifampicin.

Like rifampicin, isoniazid and pyrazinamide are the other two powerful drugs that are the pillars of the first-line regimen to treat tuberculosis. Fluoroquinolones (levofloxacin, moxifloxacin and gatifloxacin) represent the cornerstone of the second-line therapy to treat MDR-TB.

In this report we present an overview of the prevalence of resistance to isoniazid, pyrazinamide and fluoroquinolones and discuss the need of rapid diagnostics to detect resistance to these drugs.

Since current laboratory methods are sufficiently accurate for both, isoniazid resistance is usually investigated in parallel with rifampicin resistance: simultaneous resistance to both drugs defines a case of MDR-TB. Data from 155 countries for the period 1995−2015 collected either through continuous surveillance systems based on routine testing of all patients with tuberculosis or periodic surveys, which are discrete studies measuring drug resistance among a selected sample of patients who are representative of an entire population of tuberculosis patients, were used to estimate the prevalence of resistance to isoniazid without concurrent rifampicin resistance. Drug susceptibility testing results were available for 185,745 patients. The proportions of tuberculosis patients with strains that were resistant to isoniazid but susceptible to rifampicin were weighted by the number of new cases of tuberculosis that were notified in the country to generate regional and global averages.

Among all tuberculosis cases, the global average of isoniazid resistance without concurrent rifampicin resistance was 10.2% (95%CI: 8.4%–11.7%), ranging from 6.1% in the African region to 13.3% in the European region. With the expansion of the use of Xpert MTB/RIF testing (Cepheid, Sunnyvale, CA, USA) in many countries it is important to note that on average around one in 10 TB patients diagnosed to be sensitive to rifampicin will have isoniazid resistance that cannot be detected by the current Xpert MTB/RIF assay. These patients are likely to have poorer treatment outcomes and higher risk of acquiring rifampicin resistance during treatment compared to patients with fully susceptible tuberculosis, as shown in a recent systematic review of 3,744 patients with isoniazid-resistant tuberculosis (Gegia M et al. Lancet Infect Dis. 2017;17(2):223–234).

Pyrazinamide resistance is not routinely investigated as part of diagnostic and surveillance efforts in most settings because of the limitation of the currently available phenotypic test (MGIT 960) which is expensive, difficult to perform and poorly reproducible. For this reason, little information about the extent of resistance to pyrazinamide at the population level is available. Sequencing of the pncA gene of M. tuberculosis that expresses resistance to the drug is becoming an alternative method to investigate resistance to pyrazinamide. Data were gathered from surveys conducted in five countries (Azerbaijan, Bangladesh, Belarus, Pakistan, and South Africa) on a total of 4,972 patients. Levels of resistance varied substantially in the surveyed settings (3.0–42.1%) and resistance to pyrazinamide was always significantly associated to rifampicin resistance. Despite this finding, for a substantial proportion of patients with rifampicin-resistant tuberculosis (19–63%) pyrazinamide is still effective, confirming that this drug could still be used as part of the second-line regimen for the treatment of MDR-TB, as currently recommended by the World Health Organization.

Later generation fluoroquinolones, including levofloxacin and more importantly moxifloxacin and gatifloxacin (which are the newest molecules belonging to the 4^th generation), are considered the most important drug class for the treatment of MDR-TB.  Fluoroquinolones are currently being investigated in clinical trials to assess the efficacy of short rifampicin-sparing regimens for the treatment of tuberculosis (e.g. the NC-005 trial of TB Alliance). The prevalence of resistance to fluoroquinolones is unknown in many countries due to the limited laboratory capacity to perform second-line drug susceptibility testing. Data were gathered from surveys conducted in five countries (Azerbaijan, Bangladesh, Belarus, Pakistan, and South Africa) on a total of 5,015 patients. Overall levels of resistance to fluoroquinolones among all tuberculosis patients ranged from 0.5 to 12.4% for levofloxacin, and from 0.9 to 14.6% for moxifloxacin. Among patients with rifampicin resistance the prevalence of resistance to fluoroquinolones was significantly higher, ranging from 8.4 to 26.8% for moxifloxacin. Cross resistance between levofloxacin and moxifloxacin (when tested at 0.5 μg/mL) was nearly complete. High levels of fluoroquinolones resistance were detected in Pakistan, which can be the expression of extensive and unregulated use of fluoroquinolones in that country.

Testing of resistance to isoniazid, pyrazinamide and fluoroquinolones is of paramount importance to guide treatment decisions and ensure that patients receive the best standard of care and have the highest chances to be cured.  Over the past few years progress has been made on the development of rapid molecular tests to detect drug resistance in tuberculosis, with Xpert MTB/RIF being the best example, given the limited technical requirements, relatively low cost and rapidity in producing results.  However, at the moment, easy-to-perform, automated and rapid molecular tests to detect resistance are currently available only for rifampicin. The understanding of the genetic basis of drug resistance and of the correlation between genotypic and phenotypic testing results is rapidly improving. This should lead to the development of a larger range of molecular diagnostic tools capable to effectively detect resistance to several drugs, in particular to isoniazid, pyrazinamide and fluoroquinolones, in addition to rifampicin. Candidates exist and are undergoing testing in trials, although it may take a few more years before they become widely available. These rapid drug susceptibility tests are today a must as medical practice keeps evolving towards more precision and personalization. Without new rapid tests a large number of patients will continue receiving therapies which are often inadequate to combat the bacilli they harbor, with a higher risk of treatment failure, creation of additional resistance and continued transmission of the disease.

——————————————————————

[1] MDR-TB is defined as a form of tuberculosis that is resistant to at least isoniazid and rifampicin

The current EU policy has a low ability to align access to orphan drugs across different Member States, leaving high inequity, especially between richer and poorer countries...
The variation stems from the fact that although the marketing authorisation of drugs is at the European level, pricing and reimbursement decisions, and therefore patient access, are on a national level...
Perhaps, to assure equal access to orphan drugs for all rare diseases, an EU-wide procurement should be considered...
The EU can procure orphan drugs centrally and charge the MS based on their affordability while setting a fixed pan-European list price. Ultimately this will result in a differential pricing scheme

By Katherine Eve Young

MD, MSc, MPH Manager Pricing & Market Access Creativ-Ceutical

and Mondher Toumi

Professor of Public Health University of Aix-Marseille, and CEO at Creativ-Ceutical

The Unacceptable Inequity of Orphan Drugs Access in Europe: a Call for Urgent Policy Change

 

The treaty on European Union states that ‘the Union is founded on the values of respect for human dignity, freedom, democracy, equality, the rule of law and respect for human rights, including the rights of persons belonging to minorities. These values are common to the Member States (MS) in a society in which pluralism, non-discrimination, tolerance, justice, solidarity and equality between women and men prevail… A high level of human health protection shall be ensured in the definition and implementation of all EU policies and activities, thus solidifying the EU’s duty to promote good health.’

On one hand lies the EU model. On the other hand, data shows that the battle against wealth and health inequality in Europe is still an ongoing feat. Eurostat data shows that Europeans from Central and Eastern Europe die younger than their Western counterparts. In their already shorter lives, around 20 years are not lived in good health. Thus, while men in Denmark can expect to live 90% of their lives in good health, men in Estonia only live 71% of their already shorter lives as healthy individuals.

The determinants of health are multifactorial and as such, the causes of health inequalities are complex. Health is determined by social and economic factors such as education, environment, lifestyle determinants, working conditions, and social protection.[1] Undoubtedly, health is also determined by healthcare systems, such as the presence of universal coverage and the price and affordability of medicines.  The European Pharma Forum in 2008 has extensively discussed the price of drugs as a cause of health inequity in Europe.

Orphan drugs, medicines intended for the diagnosis, prevention or treatment of rare diseases are central to discussions on high drug prices and low health equity. Rare diseases are usually severe conditions with no or limited choice of therapeutic options, and thus present with a high level of unmet need. Regardless of the unmet need, orphan drugs are notorious to have higher prices than non-orphan drugs rendering them inaccessible to some patients across Member States. The variation stems from the fact that although the marketing authorisation of drugs is at the European level, pricing and reimbursement decisions, and therefore patient access, are on a national level.  The European Commission, Ministries of Health of Member States, and relevant European organisations have voiced their concerns regarding health inequity and non-accessibility of orphan drugs to vulnerable population.[2]^,[3] As a possible solution to address these inequity concerns, several discussions on differential pricing have joined the narrative.[4]^,[5]^,[6]^,[7]^,[8] Differential pricing (DPR) ‘is based on the economic concept of price discrimination whereby prices of the same products are variedly set for different consumer groups in different geographical or socio-economic segments based on the income or purchasing power of those buyers.’[9]

Amidst the discussion on how differential pricing can offer solutions to the ongoing issue of inequitable access to drugs, it has been found too challenging to implement. The differentiation and grouping of countries based on income levels is the first hurdle. Second, due to the free movement of people and goods in Europe, parallel trade is unavoidable and thus different prices between states will cause the importation of drugs from low-priced countries to high-priced countries. This may lead to drug shortages in low-priced countries. As such, similarity in absolute prices among neighbouring countries is continuously utilised in Europe. Thirdly, the harmonisation of value assessment and the agreement on the formula for differential price calculations across member states is a high wall to climb which will not only need relevant policy change, but also significant political will and the assured cooperation of all Member States, the industry and the public healthcare systems. DPR has been effectively used in vaccines, contraceptives, and anti-retroviral treatments globally. The European Commission has considered procuring orphan drugs at the EU level but this has been faced with resistance from Member States and was not pursued.

Publications and insight on EU orphan drug access are available but these are not recent. Three publications related to the comparison of EU prices in rare diseases date from 2004–2011, when fewer orphan drugs were launched and thus are relatively less comprehensive in terms of the number of orphan drugs analysed. In more recent years, the inequitable access to orphan drugs has significantly increased as the prices have soared and the affordability in lower GDP countries has plunged.  Various studies in the literature have investigated the relevant issue of inequitable access of drugs between high GDP and low GDP countries in Europe. No study was found assessing the relative prices of orphan drugs. To appreciate this issue better, we did a study where we assessed the affordability of orphan drugs in 12 European countries.[10] We compared the annual treatment cost per patient adjusted by nominal GDP per capita, GDP in PPP per capita, % GDP contributed by the government, government budget per inhabitant, % GDP spent on healthcare, % GDP spent on pharmaceuticals, and average annual salary of similarly available orphan drugs in high and low GDP countries in Europe: Bulgaria, France, Germany, Greece, Hungary, Italy, Norway, Poland, Romania, Spain, Sweden, UK. We have uncovered that the median annual costs of orphan drugs in all countries varied minimally. However, when the annual costs were adjusted using GDP per capita, the lower GDP countries showed three to six times higher relative costs (Figure 1).

The same pattern was evident when costs were adjusted using the other economic parameters. When the costs were adjusted using average annual salary per inhabitant, the lower GDP countries showed higher costs than high-GDP countries by a factor of around 3 to 9. This means that an average individual in lower GDP countries will have to work nine times more (Bulgaria) than their western counterparts in order to afford the same drug.  To note, drug spending in low GDP countries is mostly out of the pocket which exacerbates affordability issues. GDP share contributed by the government and government budget per inhabitant show the lower per capita spending by the government in low-GDP countries resulting in increased relative costs per patient, lower ability to pay, and thus in limited access to orphan drugs for rare diseases which lack alternative treatment.

Our results validate that the current EU policy has a low ability to align access to orphan drugs across different Member States, leaving high inequity, especially between richer and poorer countries. The European model upholds the principle of equity in patient access to treatment and solidarity where the richer population subsidizes marginalized or economically challenged populations. However, these principles have not been fully achieved yet and the current inability to cater to vulnerable populations is unacceptable in more ways than one. Perhaps, to assure equal access to orphan drugs for all rare diseases, an EU-wide procurement should be considered.

It is noteworthy to observe that in the agriculture sector we have been able to put in place the EU – Common agriculture policy (EU-CAP), a complex and expensive compensation system that leads to the differential pricing of agriculture goods but which consequently benefits a large and quite rich EU country like France. The EU-CAP guarantees a stable fix price of agriculture products throughout the EU which avoids visibility and speculation on producers. As the market price of the products is often below the guarantee price, the EU pays the producers the deficit as a form of compensation. France captures 60% of this money. This means that instead of investing in economic changes and future revenue, we are investing in covering the deficit of agriculture producers who are producing at a cost that is significantly above the market price. Of note, the EU-CAP represents around 50% of the EU budget.

Why is this framework considered unfeasible for orphan drugs? The EU has considered multiple options on how to resolve the unacceptable inequity, from differential pricing with compensation, to EU global procurement for all MS and the distribution at a differential price even though the listed price is uniquely fixed, a similar process as the EU-CAP. These were never implemented. We firmly believe that there is no reason why we could not implement a similar process for orphan drugs. The EU can procure orphan drugs centrally and charge the MS based on their affordability while setting a fixed pan-European list price. Ultimately this will result in a differential pricing scheme while avoiding parallel trade at the same time.

Rare disease remains a neglected area with little empathy from decision makers and manufacturers leading to major inequity in access. New policies are needed. Equally important, alignment among Member states is needed to attain the principles set in the EU treaty. In this Union, we all look forward to the day when we will achieve the valued respect for human dignity, democracy, equality, justice, solidarity – and consequently the well-being of all people.

 

References

[1] WHO. Commission on Social Determinants of Health, 2005-2008. http://www.who.int/social_determinants/thecommission/en/

[2] European Commission. Solidarity in Health: Reducing Health Inequalities in the EU http://ec.europa.eu/health/social_determinants/policy/commission_communication_en

[3] Kenny, M. Crazy” European Orphan Drug Pricing System Has To End. SCRIP Pharma Intelligence Pink Sheet. 2016 https://pink.pharmamedtechbi.com/PS118869/Crazy-European-Orphan-Drug-Pricing-System-Has-To-End

[4] De Cock Jo. Differential Pricing of Medicines in Europe: Implications for Access, Innovation, and Affordability. ISPOR 19th Annual European Congress Plenary Session. October 2016. Vienna, Austria. https://www.ispor.org/Event/ReleasedPresentations/2016Vienna

[5] Vogler S. Differential Pricing of Medicines in Europe. ISPOR 19th Annual European Congress Plenary Session. October 2016. Vienna, Austria. https://www.ispor.org/Event/ReleasedPresentations/2016Vienna

[6] Kanavos P. Differential Pricing of Medicines in Europe: Implications for Access, Innovation, and Affordability. ISPOR 19th Annual European Congress Plenary Session. October 2016. Vienna, Austria. https://www.ispor.org/Event/ReleasedPresentations/2016Vienna

[7] Towse A, Pistollato M, Mestre-Ferrandiz J, Khan Z, Kaura S, Garrison L (2015) European Union Pharmaceutical Markets: A Case for Differential Pricing?, International Journal of the Economics of Business, 22:2, 263-275

[8] Remuzat C, Tavella F, Toumi M. Differential pricing for pharmaceuticals: overview of a widely debated pricing concept and key challenges. ISPOR 18th Annual European Congress. Milan, Italy. November, 2015. https://www.ispor.org/research_pdfs/51/pdffiles/PHP71.pdf

[9] Yadav, P. Differential Pricing for Pharmaceuticals. Study conducted for the U.K. Department for International Development. 2010

[10] Young K, Soussi I, Toumi M. The Perversion of External Reference Pricing (ERP): A Comparison of Orphan Drug Affordability in 12 European Countries. A Call for Policy Change. Journal of Market Access & Health Policy (in press)

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La République démocratique du Congo continue à être confrontée à une crise humanitaire de très grande ampleur, et cela depuis plus de deux décennies, bien que la grande majorité du territoire nationale demeure stable, mais les provinces du Sud-Kivu, du Nord-Kivu, du Tanganyika et du Kasaï central sont les théâtres des tueries, massacres et violations répétitives des droits de l’homme à l’heure actuelle

By Alphonse Kitoga

Secretary General, Grands-Lacs en Action pour la Paix et le Développement Durable -The Great-Lakes in Action for Peace and the sustainable Development

GLAPD_ Africa, asbl

SOS A LA SITUATION HUMANITAIRE DANS LES PROVINCES DU TANGANYIKA, DU KASAЇ-KANANGA, DU NORD-KIVU et DU SUD-KIVU EN REPUBLIQUE DEMOCRATIQUE DU CONGO/DRC

 

 

I. INTRODUCTION

Avec environ 65 millions d’habitant, la R.D.Congo a une superficie de 2 345 410 KM2 (4 fois la France et 80 fois la Belgique) et avec 26 provinces et, Kinshasa sa capitale compte environ 10 millions d’habitants (plus que les populations du Congo-Brazzaville, du Gabon et de la République Centrafricaine réunies).

En effet, dans plusieurs provinces de la RDC les milices ne font que se multiplier (on arme et on manipule les jeunes/les adolescents(es) qui ne peuvent plus étudier car leurs parents se sont appauvrit et n’ont pas de travail. Avec l’arrivée de près de 15.000 réfugiés Burundais dans la plaine de la Ruzizi au Sud-Kivu en raison des tensions ethniques qui se vit dans leur pays le Burundi qui sème panique et désolation dans le chef de la population de cette région martyrisée. Signalons également que les provinces du Nord et du Sud-Kivu compte plus de 1.000000 des déplacés et plus de 200 000 réfugiés Rwandais qui surplombe toutes les deux provinces!

II. RESUME EXECUTIF ET NARRATIF

La République démocratique du Congo continue à être confrontée à une crise humanitaire de très grande ampleur, et cela depuis plus de deux décennies, bien que la grande majorité du territoire nationale demeure stable, mais les provinces du Sud-Kivu, du Nord-Kivu, du Tanganyika et du Kasaï central sont les théâtres des tueries, massacres et violations répétitives des droits de l’homme à l’heure actuelle.

Cependant que, cette crise est principalement la conséquence de conflits armés, des conflits intercommunautaire, coutumiers et de violences armées qui perdurent dans l’Est, le nord-Est et dans le centre du pays. Ces conflits sont causés en particulier par des luttes pour le contrôle des ressources naturelles et l’accès à la terre, par des tensions ethniques et par l’activisme de groupes armés congolais et étrangers (FDRL, LRA, groupes Maï-Maï, AFD/NALU, le M23, les Pygmées/Batwa contre les Bantous-Baluba dans le Tanganyika et les miliciens du Chef coutumier Kamwina N’sapu dans le Kasaï central/Kananga avec les forces de l’ordre/l’armée régulière), dans un contexte caractérisé par une pauvreté exacerbée et une trop faible présence des institutions de l’Etat. Les exactions graves commises par les parties belligérantes sur les populations civiles, tels que viols, meurtres, recrutements forcés des enfants/adolescents dans les forces et groupes armés et pillages, demeurent la cause principale des déplacements de population et de la crise humanitaire liée à ces déplacements. Des centaines de milliers de civils ont fui ces exactions en 2011 à ces jours!

L’année 2016-2017 a également été marquée par des violences intercommunautaires entre les Pygmées/Batwa contre les Bantous-Baluba qui ont éclaté en la province de Tanganyika en octobre 2016, provoquant la fuite de près de 470.000 personnes déplacées et dont le site de Kalunga à Kalemie compte à lui seul 17.500 déplacés et nombreux dans eux sont des femmes, des enfants et des adolescents. A cela s’ajoutent près de 650 000 déplacés internes prenant fuite du conflit intercommunautaire et coutumier orchestré par les miliciens du Chef coutumier Kamwina N’sapu dans le Kasaï central/Kananga avec les forces de l’ordre/l’armée régulière.

Les besoins humanitaires demeurent également très importants dans les autres provinces où l’on a relevé des taux élevés de malnutrition aigüe et sévère, d’insécurité alimentaire, et de mortalité maternelle, infantile et néo-natale. Les causes en sont avant tout le faible niveau de développement, l’enclavement et la précarité des infrastructures, les épidémies et les catastrophes naturelles pour ne citer que ceux-là.

Bien que la situation se soit stabilisée depuis un certain temps, très peu de mouvements de retour ont été observés à ce jour. Les acteurs humanitaires ont répondu aux besoins les plus urgents et ont porté assistance à des millions de personnes. Mais cela reste très peu insuffisant et visible pour ceux qui en n’ont besoin le plus. L’action humanitaire a été confrontée à des défis importants, en particulier concernant l’accès aux populations vulnérables dans des zones très enclavées. Dans les régions en proie à la violence, les conditions de sécurité précaires affectant les partenaires humanitaires ont réduit les opérations d’assistance. Le bas niveau de financement a constitué un frein supplémentaire.

Pour pallier à cela, les axes suivants doivent être pris en ligne de compte:
1. Renforcer la protection de la population civile vulnérable (surtout les femmes, enfants et les adolescents) dans les zones d’intervention humanitaires ;
2. Réduire la morbidité et la mortalité maternelle, infantile et néonatale au sein des populations cible;
3. Améliorer les conditions de vie des personnes déplacées, retournées, rapatriées, réfugiées, et de leurs communautés d’accueils affectées, et
4. Restaurer les moyens de subsistance des communautés affectées, sur la base de critères de vulnérabilité.

Du fait de la persistance de violations graves des droits de l’homme et du droit international humanitaire, en particulier dans les zones affectées par des conflits armés, intercommunautaires et la violence armée, la protection des civils doit être au coeur de la communauté humanitaire dans toutes ses interventions.

III. CONTEXTE HUMANITAIRE PAR SECTEUR EN RDC

Bien que la majorité du territoire national demeure peu stable, la RDC continue à être marquée par une crise humanitaire de très grande ampleur. Celle-ci est la conséquence des conflits armés et violences armées qui perdurent.

Les populations vivent dans un état de l’insécurité permanente, chaque jour des braquages des véhicules, les pillages, assassinats, tueries,…
La situation sécuritaire sur toute l’étendue du pays continue aussi à ce détérioré du jour au lendemain. Presque toutes les parties du pays sont confrontées à des problèmes récurrents d’insécurité et de l’activité des groupes armés, milices du Chef coutumier Kamwina N’sapu au Kasaï centrale, les conflits intercommunautaires entre les Bantous et les Pygmées, dans le Tanganyika, l’ancien Kivu avec sa multitude des groupes armés avec le retour du phénomène M23 et conflits intercommunautaires au Maniema. La crise humanitaire dans l’ensemble du pays a également pour cause la pauvreté, le manque de développement d’infrastructures, les épidémies et les catastrophes naturelles comme dit précédemment.

Secteur de la santé: Besoins identifiés:

Toutes les provinces de la RDC continuent d’être exposées, à des degrés divers, aux endémies ou épidémies, aux mouvements de population et aux catastrophes naturelles. Plusieurs épisodes d’épidémies ont été rapportés dans plusieurs zones de santé. Il s’agit essentiellement du paludisme (plus de 20 millions de cas, la RDC étant l’un des pays les plus touchés par le paludisme en Afrique), du choléra (12 161 cas), de la méningite (218 cas), de la fièvre jaune (5 cas confirmés) et 15 cas suspects de fièvres hémorragiques virales non confirmés.

La mortalité maternelle, néo-natale et infantile continue d’être une préoccupation dans presque toutes les provinces, soit un taux de 549 décès maternels pour 100 000 naissances vivantes et un taux de mortalité infantile des moins de 5 ans dépassant 2/10 000/ jour dans 22% des zones de santé.

Plan de réponse du Secteur:
Objectif général: contribuer à la réduction de la morbidité et de la mortalité liées aux conséquences Sanitaires dans les situations de crise.

Objectifs spécifiques:
1) Renforcer les actions en faveur de la réduction de 10%; de la mortalité maternelle, néo-natale et de la mortalité infantile des moins de 5 ans;

2) Activer les mécanismes de riposte en moins de 15 jours dans au moins 80% des épidémies constatées / confirmées;

3) Renforcer les capacités techniques et institutionnelles dans la prise en charge des cas / personnes en situation d’urgence sur tout chez les femmes, les enfants, les adolescents et les vieillards.

Secteur de la protection: Besoins identifiés:

Plusieurs facteurs mènent à l’heure actuelle à une aggravation de la vulnérabilité des populations. A une vulnérabilité structurelle très forte s’ajoutent une crise conjoncturelle due à la présence des groupes armés et autres acteurs non étatiques, les vaines tentatives de l’armée congolaise (FARDC) et de la MONUSCO de les déloger et les violations du droit international humanitaire (DIH) et des droits de l’homme (DDH) perpétrées par les agents de l’Etat eux-mêmes. Ces violations entraînent une aggravation de l’instabilité, une insécurité localisée permanente, des déplacements forcés et des séparations familiales dans les zones touchées.

La prévention des violences sexuelles et la prise en charge multisectorielle de toutes les victimes restent un besoin important dans le pays tout comme le sont la protection et la prise en charge des femmes et enfants/adolescents victimes de violations de leurs droits.

Plan de réponse du Secteur:
Objectif général: Accroître la protection de la population civile affectée par l’insécurité, les conflits, le déplacement et les violations sévères des droits de l’homme.

Objectifs spécifiques:
1) Renforcer et harmoniser le système de collecte et d’analyse de données sur la situation des populations civiles et leurs besoins de protection dans le but de surveiller les risques et d’améliorer l’identification des priorités des activités de protection.
2) Améliorer l’accès à l’assistance, la justice, la compensation, la réhabilitation et la restitution des victimes.

Secteur de l’éducation: Besoins identifiés:

Les chiffres les plus récents montrent qu’en moyenne 46% des filles achèvent l’école primaire contre 66,5% des garçons, et seulement 28,8% des filles s’inscrivent au secondaire contre 51,2% des garçons; 1 homme adulte sur 5 et près d’1 femme sur 2 sont analphabètes au Congo. Les chiffres pour l’Est du Congo ainsi que pour la province du Kasaï sont en dessous de la moyenne. La complexité actuelle de la situation nécessite une adaptation de l’assistance humanitaire et la mise en place de mécanismes de ciblage des besoins plus pertinents, basés sur l’analyse des vulnérabilités des familles bénéficiaires.

Plan de réponse du Secteur:
Objectif général: contribuer à l’accès à des activités éducatives de qualité dans un environnement protecteur et adapté en faveur des filles et des garçons, adolescentes et adolescents de 3 à 18 ans, en situation de handicap ou non, victimes de catastrophes naturelles ou causées par l’homme, de conflits ou vivant dans des conditions de forte vulnérabilité.

Objectif spécifique 1: l’accès de 240 000 filles et garçons (>50% filles) à une éducation de base et de qualité (formelle et non-formelle) est assuré;

Objectif spécifique 2: au moins 19 00 espaces d’apprentissage sont adaptés, aménagés et protecteurs;

Objectif spécifique 3: l’inégalité d’accès à l’apprentissage est réduite grâce à la mise oeuvre pour la prise en compte du genre et des enfants en situation de handicap;

Les activités suivantes sont possibles pour réaliser ces objectifs:

1. Appui à l’identification des enfants, des jeunes et des adolescents (f/g) de 3-18 ans en vue de leur inscription dans les écoles existantes ou dans les espaces d’apprentissage à créer;
2. Plaidoyer et sensibilisation des responsables de l’Enseignement primaire, secondaire et professionnel (EPSP) pour le recrutement des enseignants en quantité et de qualité suffisantes et leur déploiement rapide dans les régions d’intervention; tout en encourageant une égale représentation des femmes et des hommes et la non-discrimination à l’égard des enfants en situation de handicap;
3. Réhabilitation et aménagement d’espaces d’apprentissage temporaires avec l’accès aux blocs de latrines pour tous et distinct entre filles et garçons, la mise en place de points d’eau, en utilisant des matériaux locaux ou temporaires afin de réduire le coût de l’aménagement.
4. Appui aux activités d’allégement de la charge financière des parents (activités génératrices de revenus, AGR);
5. Organisation de cantines scolaires avec vivres;
6. Fourniture de kits d’apprentissage aux enfants;

Secteur de la sécurité alimentaire: Besoins identifiés:

La baisse de la production agricole, le mauvais état des routes de desserte agricole et la dégradation de l’état nutritionnel de groupes ciblés, l’abandon des moyens de subsistance, l’insécurité, le manque d’accès à l’eau de qualité et une alimentation saine et équilibrée. Les voies de communication sont délabrées empêchant les échanges et l’accès au marché des populations au pouvoir d’achat faible!

Plan de réponse du Secteur:

Objectif général: restaurer les moyens de subsistance des communautés en crise alimentaire.
Objectifs spécifiques:
1) Répondre aux besoins alimentaires d’urgence des populations cibles;
2) Rétablir l’autonomie de production alimentaire pour les familles d’accueil, les ménages nouvellement accessibles et ceux affaiblis par les crises;
3) Soutenir la production alimentaire d’urgence pour des ménages d’enfants malnutris, des personnes déplacées, retournées, rapatriées et autres groupes vulnérables;

Pour cela, les principales activités seront les suivantes:

-Assistance alimentaire d’urgence aux populations en crise pour atténuer les effets immédiats;
-Assistance urgente aux groupes vulnérables (distribution de vivres, non vires et de kits agricoles);
-Réhabilitation urgente des infrastructures de base (pistes et marchés ruraux, vivres contre travail);
-Protection contre la perte complète des avoirs relatifs aux moyens de subsistance et/ou soutien en faveur de l’accès à ces avoirs (vivres contre travail, rations de protection des semences, foires aux semences).

Secteur de l’Eau, hygiène et assainissement: Besoins identifiés:

La vulnérabilité dans les provinces précitées est les théâtres de mouvements perpétuels de population. Avec une telle instabilité, le choléra et les maladies d’origine hydrique peuvent se développer de manière exponentielle pour plusieurs raisons:
• Les déplacements favorisent la dispersion des germes pathogènes;
• Les personnes déplacées créent une pression additionnelle sur les ressources en eau et les infrastructures sanitaires des autochtones, ce qui génère une pénurie et une dégradation précoce des équipements existants;
• Les hôpitaux et Centres de Santé dans les zones d’accueil sont débordés du fait de l’arrivée de nouvelles personnes et sont de ce fait moins capables de répondre aux flambées d’épidémies endémiques;
• Les personnes déplacées sont souvent plus vulnérables aux maladies.

Plan de réponse du Secteur:
Objectif général: réduire les risques de transmission des maladies infectieuses d’origine hydrique sur les populations déplacées et retournées ou victimes d’épidémies et de catastrophes naturelles par des actions de prévention et de réponse d’urgence, ceci pour la sécurité et la dignité des filles, des femmes, des garçons et des hommes.

Objectif spécifique 1: assurer l’accès en eau potable en quantité et en qualité suffisante aux populations affectées dans des conditions de sécurité et de dignité, en consultation avec les communautés locales, en particulier les femmes et des adolescents, pour la désignation de l’emplacement des points de distribution d’eau.

Objectif spécifique 2: assurer l’accès à un environnement sain et protecteur aux populations affectées dans des conditions de sécurité et de dignité par la mise à disposition d’infrastructures d’hygiène et d’assainissement.

Activité 1: construction des latrines collectives différenciées et sécurisées (pour les femmes et les filles), et des latrines familiales. Les latrines collectives visent les communautés ou les lieux publics tels que les écoles, les hôpitaux et les marchés;
Activité 2: construction de douches collectives différenciées et sécurisées.

Par ailleurs, les principaux enjeux en protection des civils dans les provinces affectées par les conflits armés, en particulier dans le Nord, Sud-Kivu , le Tanganyika et en province du Kasaï central, sont liés à l’inaccessibilité et l’enclavement de certaines zones, ce qui favorise les violations graves des droits de l’homme ou du droit international humanitaire par les FARDC et d’autres groupes armés/milices présentes dans ces contrées.

Cette situation, est à l’origine de déplacements massifs des populations, se traduit par des violations de nombreux abus des droits de l’homme. Ceux-ci incluent l’utilisation des enfants (recrutement d’enfant/adolescents dans les groupes et forces armés, exploitation pour le transport de matériel, violences sexuelles); violences sexuelles faites à la femme; administration et justice illégale et/ou parallèle; pillage et taxation illégale, barrières illégales; limites à la liberté de circulation des populations civiles; prises d’otage de civils; attaques à l’encontre de villages; incendies de maisons; occupation de maisons, d’écoles des centre de santé et de villages par les groupes armés; utilisation des biens et des infrastructures civiles; recrutement et travaux forcés des civils et déplacements/retours forcés.

Pari cochet, au vu et au su de tout ce qui se passe en RDC, GLAPD_Africa, asbl, condamne avec une dernière énergie, les exactions, tueries, massacres, viols, pillages et violation répétitive des droits de l’homme, ce qui met en péril la santé de la mère, de l’enfant, du nouveau-né et de l’adolescent, demandons qu’une enquête juste et indépendante soit diligentée pour éclairer cette situation qui prévaut dans les provinces du Nord, Sud-Kivu, Kasaï central et dans le Tanganyika pour que les auteurs de ces exactions ignobles puissent répondre et purgent de leurs actes.

Les fosses communes sont devenues monnaies courantes dont 23 dans le Kasaï, des fosses communes à Maluku/Kinshasa, au Tanganyika, au Sud-Kivu (Kasika, Mwenga, Makobola/Baraka et dans le Nord-Kivu (Beni, Butembo, Lubero, Walikale, Kitchanga, Rutshuru,…). Ces actes ne doivent pas demeurer impunis, car Trop c’est Trop;

Nous déplorons et fustigeons également la mort tragique et inopinée des deux experts des Nations-Unies ainsi que leurs interprètes et motards Congolais qui ont été tués dans le Kasaï central en l’exercice de leurs fonctions, demandons que leurs bourreaux soient punis sévèrement et conformément aux lois de la République et internationales;

La situation socio-économique, politique et sécuritaire de la population en RDC est au bas de l’échelle mondiale, la liberté d’expression et de manifestation publique de la population est piétinée, l’on ne peut lire au quotidien une paupérisation de la population prise en otage et ne sachant pas à quel saint se vouer.

IV. RECOMMANDATIONS

Nous recommandons à l’Etat congolais d’assurer la sécurité de la population et de leurs biens et d’améliorer la situation socio-économique de la population et de traduire en justice les auteurs de violation des droits de l’homme, De restaurer l’autorité de l’Etat sur toute l’étendue du territoire national;

D’améliorer l’espace de la liberté d’expression et de manifestation pacifique publique ainsi que la liberté de presse;

Aux acteurs politiques Congolais de privilégier, le dialogue, la coopération et l’intérêt général de la population en lieu et place de leurs intérêts égoïstes et mesquins;

Aux organisations de la société civile et forces vives de ne pas céder aux intimidations politiciennes et partisanes, de bien jouer leur rôle de neutralité, d’impartialité, de l’indépendance, le principe de Do Not Harm et d’accompagnateur au lieu de se mêler dans les commérages des politiciens;

Au conseil de sécurité des Nations, d’assurer un suivi de proximité sur le nouveau mandat de la MONUSCO, l’application de la résolution 2348 et l’accord de la saint Sylvestre du 31 décembre 2016 et lutte contre les groupes armés et milices et de jouer pleinement leur mandat de la protection des civiles;

A la communauté nationale et internationale de mobiliser les fonds nécessaires pour accompagner la RDC dans le processeur démocratique d’organisation des élections libres et transparentes au financement des différents projets et programmes d’intérêt public et communautaire et s’impliquer dans le processus de la sécurisation de la population civile aux éventuelles violations des droits de l’homme;

Aux organisations humanitaires, caritatives, systèmes des nations-unies, publiques, privées, aux donateurs, aux hommes et femmes de bonne volonté de venir en aide, les populations déplacées de guerre afin de restaurer la santé de la mère, de l’enfant, du nouveau-né et de l’adolescent actuelle a son plus bas niveau et le ramener aux standards internationaux.

Au PMNCH/Partnership for Maternal, Newborn and Child Health  et au mouvement Every Women Every Child/EWEC de nous aider à faire le plaidoyer auprès des donateurs, bailleurs de fonds et décideurs afin de libérerez le fonds nécessaires pour répondre à la situation humanitaire et à la santé de la mère, de l’enfant, du nouveau-né et de l’adolescent en RDC, car le développement de l’Afrique est assujetti par la stabilité permanente de la RDC ainsi pour permettre d’atteindre les ODD à l’horizon de 2030.

Une action humanitaire bien soutenue et avec compassion permet sans ambages à sauver des vies des milieux des Congolais qui sont dans le besoin le plus (surtout chez la femme, l’enfant, le nouveau-né et les adolescents) ainsi promouvoir la santé reproductive.

En définitive, GLAPD_Africa, asbl, reste bras ouverts pour recevoir vos appuis et soutiens éventuels pour aider la RDC de sortir dans l’impasse humanitaire et d’avance droit chemin vers les ODD à l’horizon 2030.

Fait à Kalemie, le 07 avril 2017

Alphonse KITOGA
Secrétaire Général.

——————————————-

Published under licence from Alphonse Kitoga  © Copyright SOS situation Humanitaire-DRC | Great-Lakes in Action for Peace and the
Sustainable Development / GLAPD_Africa, asbl. Tél: +243 81 78 85 806& + 243 85 53 04
686. E-mail: glapd_africa2002@yahoo.fr & alphonse_kitoga@yahoo.fr

 

The essence of the Uganda's Narcotic Drugs and Psychotropic Substances (Control) Act (NDPSA) is to treat people who use and inject drugs (PWUIDs) as criminals who need to be locked up instead of viewing them as human being in need of assistance. The criminalisation of drug use has had the effect of limiting the range of medical  intervention available and accessible to PWUIDs in both private and public facilities. There is no comprehensive facility for the provision of public health services to PWUIDs. There is also no treatment available within Uganda for people who are on drugs and need critical and urgent medical attention like opioid substitution therapy. And there is a direct link between the criminalisation of drug use and HIV/AIDS as well as mental health challenges

By Muhwezi Edward

Harm Reduction Counselor, Uganda Harm Reduction Network

The Uganda’s “Narcotic Drugs and Psychotropic Substances (Control) Act” and how it impacts on Public Health and Human Rights

 

The criminalisation of the use of drugs is barely a Ugandan affair. It is part of an internationalised system that regards drug use as dangerous and which is willing to suppress it using all means and more so the law. Although States began with a much more relaxed approach towards drugs, they later started looking at drug use through the lenses of race and immigration, and after the first world war, undertook international commitments to fight drug use. This has resulted into today’s ‘war on drugs’ with all its negative effects especially on the individuals who use drugs.

Uganda started criminalising drug use following this international trend and with the enactment of the Narcotic Drugs and Psychotropic Substances (Control) Act (NDPSA) has made strides towards being part of this global movement to suppress the use of drugs. The NDPSA came into force in 2016.

The NDPSA, has a decided penal focus and does not prioritise the welfare of persons who use drugs. One of the primary aims of the Act is to give effect to punitive international conventions. Along with the criminalisation of trafficking in narcotics drugs and psychotropic substances, the Act also criminalises the possession of these drugs and prescribes heavy penalties such as a fine of Ugx 10,000,000 (approx. USD 3,000) or three times the market value of the drug, whichever is greater, or imprisonment of a minimum of ten years or both such a fine and imprisonment. The Act also criminalises acts associated with narcotic drugs such as possession of any pipe or utensil for the illicit use of such drugs; ‘recruiting’ or ‘promoting’ the smoking, inhaling, sniffing or other use of such substances and owning, occupying or being ‘concerned in the management’ of any premises used for the cultivation, sale or manufacture of such substances.

The Act makes a measure of provision for the welfare of People Who Use and Inject Drugs (PWUIDs) by empowering the Minister of Health to establish ‘rehabilitation centers’ aimed at providing ‘care, treatment and rehabilitation of persons addicted to narcotic drugs or psychotropic substances’. The Minister is also empowered to appoint an ‘Advisory Committee for the Rehabilitation of Narcotic Addicts’ in order to advise the Minister on matters relating to the administration of the centers and the ‘care, treatment and rehabilitation of drug addicts’. The Act furthermore provides that a person may be committed to spend a part of their period of imprisonment in such a rehabilitation centre upon  conviction of an offence under the Act.

Despite these seemingly progressive provisions, the mechanism for ‘rehabilitation’ contemplated under the Act can only be accessed after one has been convicted and sentenced. Since the time spent in the ‘center’ is considered as part of one’s custodial sentence, it is feared that the provision may have the direct and adverse effect of triggering custodial sentences where fines would otherwise have been imposed. The fact that the envisioned Advisory Committee’ membership does not provide for participation or inclusion of PWUIDs is also viewed as problematic.

Overall, the NDPSAⁱ  conflates support for PWUIDs with the criminal law and even the limited health services provided under such a framework are rendered meaningless and effectively inaccessible. It also leaves the judicial officer with broad and unqualified power to determine which PWUIDs access treatment and who does not, which severely undermines not only the agency and autonomy of such persons but also their rights to health and, ultimately, to life. The essence of the Act is to treat PWUIDs as criminals who need to be locked up instead of viewing them as human being in need of assistance.

The criminalisation of drug use has had the effect of limiting the range of medical  intervention available and accessible to PWUIDs in both private and public facilities. There   is no comprehensive facility for the provision of public health services to PWUIDs. There is also no treatment available within Uganda for people who are on drugs and need critical and urgent medical attention like Opioid Substitution Therapy (OST). The emphasis on criminal approaches to drug use has discouraged many PWUIDs from seeking even those medical services which might be available in the public and private health systems. This is because of the way they are treated by medical professionals and the threat of being taken to court to answer charges related to their drug use upon their recovery.

There is a direct link between the criminalisation of drug use and HIV/AIDS as well as mental health challenges. This is so because the criminalisation of drug-use makes it less likely for PWUIDs to be offered information and services in relation to needle-sharing, which increases transmission of HIV among injecting drug users in particular. Furthermore, the social stigma created in large part by the criminal approach to drug use has further entrenched the isolation and related suffering and depression of PWUIDs.

Owing to criminalization of drug use, the police and other law enforcement agencies use a whole range of legal provisions, even beyond those provisions which have a direct link to drug prohibition, to harass, intimidate, blackmail and extort money from PWUIDs. Laws most frequently used in this respect are offences under the Penal Code including ‘being a common nuisance’; ‘being idle and disorderly’; ‘being a rogue and vagabond’; and carrying on offensive trades.

Criminalisation of drug use is found to cause social stigma and related socio-economic consequences for PWUIDs who have been convicted and imprisoned or who have even just been arrested and detained. They face disruptions in their family lives and education as well as the loss of employment and decreased chances of obtaining employment. An indirect consequence of the criminalisation of drug use is that, when incarcerated, PWUIDs are  often exposed to a wider range of drug use.

In considering the overall effect of criminalisation of drug use, it is suggested that any regulation of drug use should not involve a direct or indirect violation of the rights to life and health of persons who use drug. It is suggested that the principle of ‘harm reduction’ should be embraced in order to reduce the negative consequences associated with drug use. Uganda is in need of the adoption of a nation-wide harm reduction policy which would create an enabling legal environment for PWUIDs to access health services relevant for them to enjoy the highest attainable standard of physical and mental health; and would also involve increased state funding to support the legal and public health needs of the PWUIDs.

 

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ⁱ Narcotic Drugs and Psychotropic Substances (Control) Act, 2015

References

“The Narcotics Drugs and Psychotropic Substances (Control) Act 2015 and the Legal Regulation of Drug Use in Uganda” report by HRAPF & UHRN.

 

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: Link 238

 

Longest, Biggest World Health Assembly Ever Set To Open With Election, Budget Topping Agenda 

WHO, Stakeholders Take ‘First Step’ On Fair Pricing For Medicines 

WHO Touts Its Past Work On Improving Access To Medicines 

Overview of WHO financial situation: Programme Budget 2016-17 

WHO improves transparency of financial data 

PHM: WHO tracker 

Conference: Health commercialisation in Europe: 6th of June 2017 European Parliament 

MSF Warns Of Threats To Public Health In Asian Trade Agreement IP Proposals 

What is Health Policy and Systems Research and how can it strengthen Health Systems? 

Healthy ecosystems as a building block of resilient health systems: Challenging health systems researchers to take action 

From partnerships to self-interest: how can we reverse the trend in EU Development Cooperation? 

China’s Xi Jinping says he will ‘protect’ Paris climate deal, as it hangs in the balance 

Trump could do more damage by staying in the Paris climate deal 

Next month’s ocean conference eyes cutting $35 billion in fisheries subsidies – UN trade officials 

Investment In Primary Care Is Needed To Achieve The Triple Aim 

Boosting agriculture could mitigate African famine threat in a warming world 

Using Agriculture and Agribusiness to Bring About Industrialisation in Africa 

New WFP Report Finds Food Insecurity Accelerates Global Migration 

Preventing the Next Pandemic: Opportunities and Challenges 

Zika virus: Brazil says emergency is over 

U.S. Army/Sanofi Zika Vaccine Collaboration Timeline and Update 

Coming This Summer: More Ticks and Powassan Virus  

First large-scale survey of Chagas disease in the United States confirms that the “Silent Killer” is a major public health challenge for the country 

THE EDGE OF ELIMINATION Racing drug resistance to end malaria in the Mekong 

Landmark agreement signed to prevent malaria in pregnancy and reduce life-threatening complications in sub-Saharan Africa 

Global Fund Accelerates Efforts To End Epidemics 

New open source project engages universities in neglected diseases drug discovery 

Health experts call for new tools to tackle vector-borne diseases 

Shortage Of Affordable Insulin: Should WHO Extend Prequalification To Biosimilars? 

Empowering women: the ‘Tree Tomato Project’ in Rwanda 

‘Stop TTIP’ petition is legitimate, top EU court rules

…Achieving health equity is not just a matter of coming up with technical solutions and providing the means to finance them. We have to consider the political landscape and rectify the dysfunctions in global governance that undermine health… 

professor Ole Petter Ottersen, rector of Oslo University 

By  Daniele Dionisio

PEAH – Policies for Equitable Access to Health

 

Review

Textbook of Global Health

 Co-authored* by Anne-Emanuelle Birn, Yogan Pillay, Timothy H. Holtz

Fourth Edition, Oxford University Press 2017**

 

This book provides a forward-looking, highly exhaustive, up-to-date and balanced analysis over the unsolved issues and gaps still impairing the equitable access to global health on a world scale.

The fourteen chapters (674 pages) are like-minded and uniformly structured as regards introductory key questions that provide a basis for reflection, and closing learning points that summarize key take-home messages. Each chapter includes tables, boxes and figures serving as instrumental tools to enhance clarity while adding building block information for the sake of readers – be they students, stakeholders, politicians or advocates.

‘Example’ paragraphs and case studies all over the text appropriately focus on the critical points at stake and the root realities to deal with.

The first section of the textbook (chapters 1-7) provides the basic tools for understanding global health. The next section (chapters 8-12) analyzes global health and its ongoing challenges from a set of key lenses – the priority areas and building blocks for understanding and improving global health efforts. The final section (chapters 13 and 14) turns to the making of healthy policies across the world – and the roles and responsibilities of those working in the field locally, internationally and transnationally.

So compounded, the book dates back to the historical origins and allows the readers to understand (while offering itself robust explanation of) the reasons underlying  a host of conflicting issues most accounting for the current health inequities on a world scale.

In a nutshell, the authors maintain that the rampant neoliberal globalization underpinning  unfettered trade liberalization (meaning collusion between national-transnational corporations and their political counterparts) is directly responsible for the social inequities and health worsening worldwide.

As the authors stress ‘..the exigencies of market competition and enormous corporate power mean that governments privilege economic priorities and corporate interests over social and environmental needs, even in settings where democratic institutions and decision-making processes are marked by integrity and representativeness…’

The book makes it clear that the root causes of health inequities are to be found in weaknesses in political domains at the national and supranational level. These include democratic deficit, weak accountability, institutional stickiness, missing institutions and restricted policy space for health. This context entails that unbiased solutions for global health only hinge on political will to improve equity, coherence, coordination, collaboration, transparency and accountability both at domestic and international level.

In such connection, the book refers to the recently adopted 2030 UN Agenda for Sustainable Development consisting of 17 Sustainable Development Goals (SDGs) and 169 targets. In this scheme, the health goal ranks high as an overarching aim amidst the other 16 SDGs. It includes nine targets: three related to the Millennium Development Goals (MDGs), three to non-communicable diseases and injuries, and three cross-cutting or focusing on systems encompassing universal health coverage, universal access to sexual and reproductive health care services, and also to reduced hazards from air, water and soil pollution. Furthermore, the health goal strictly entwines with a number of the other 16 goals. As for this, the book highlights that health is a contributor to (and a beneficiary from) poverty reduction, hunger relief and improved nutrition, safer cities, lower inequality, sustainable consumption, affordable and clean energy, toxic chemicals management, clean water and sanitation, and to the efforts to combat climate change and safeguard aquatic and terrestrial ecosystems as well.

Unfortunately, as the authors remark, the current governments’ directions and trade agreements, largely by the most affluent countries, run contrary to these principles while turning agendas into policies which protect monopolistic interests at the expense of equitable access to care and lifesaving treatments in the resource-limited settings.

In this regard the book messages that, since the incentives of  present  patent system are driven by profits (where short-term maximization of returns to shareholders is prioritized), the lower-income countries lacking profitable markets are all the more discriminated.

Below are just few examples of much debated questions from a great many timely featured in the book because of their actual potential to negatively affect health and worsen inequalities in access to care and treatments:

– The credit policies of International Monetary Fund, World Bank and European Commission still incur criticism of indirectly stifling public spending, including for health, in the borrowing countries.

– Mushrooming TRIPS-plus measures still enforce intellectual property (IP) protection beyond what is required by the WTO TRIPS agreement. These measures encompass making it easier to patent new forms of old medicines that offer no added therapeutic benefit for patients (the so-called ‘ever-greening’); restricting ‘pre-grant opposition’, which allows a patent to be challenged before it is being granted; allowing customs officials to impound shipments of drugs on mere suspicion of IP infringement, including ‘in transit’ products that are legal in origin and destination countries; expanding data exclusivity beyond WTO’s request for data protection against unfair commercial use only; extending patent lengths beyond 20-year TRIPS requirements; and preventing drug regulatory authorities from approving new drugs if they might infringe existing patents.

– Investor state dispute settlement (ISDS) provisions are in the crosshairs now that most currently-being negotiated or finalized trade agreements are charged with introducing ISDS clauses whereby many forms of government regulations, including TRIPS-compliant price cuts of medicines, could be sued by the patent owners for making pointless or erode their expectations.

– Pharma companies and their allies still are lobbying governments to scupper any rules that would require them to disclose the real R&D costs and profits of their medicines and the rationale for charging what they do. As such, it is almost unpredictable whether laws enforcing transparency on costs would help curb extortionate drug prices in today’s world.

– Neo-liberal policies still impair the capacity of resource-limited countries to feed themselves. Adding to  investment reduction in food production and support for peasant and small farmers,  state-managed food reserves have been dismantled as ‘too expensive’ and governments have failed to protect farmers and consumers against sudden price fluctuations, while being ‘forced’ to liberalize€ their agricultural markets through reducing import duties.

– Land grabbing and evictions as part of neo-colonialism policies, including for biofuel agribusiness, are on the rise in Africa and elsewhere under national governments complacency and a widespread corruption.

– Health threats from waste continue to thrive on socio-economic inequalities: while high-income countries produce mass consumption and rapid discarding of products (i.e. waste), poor countries incur the concentration and uncontrolled dumping of waste which enhances its dangers to health. Meaningfully, this transfer of waste from rich to poor unfolds when most affluent countries export part of their hazardous waste to Africa and Asia.

– Meanwhile, governments, companies, and institutions at the international level are exceedingly behindhand with fossil fuel divestment in order to promote a healthy climate and a safe planet.

The circumstances highlighted above let the authors state that the burden of consequences on health is borne everywhere by those excluded from power and decision-making, even as the more powerful enjoy greatest profits.

In such context, the authors infer that local governments around the world should tackle neoliberal globalization in an efficient manner to ensure that citizens enjoy equal health benefits on an equitable basis, while advancing public health over political and commercial interests.

This looks even more stringent in today’s arena where a WHO strapped for public financing sees its role thwarted by a number of international bodies and private donors resulting in overlapping/duplication of initiatives and undue pressure towards earmarked programs.

Overall, the book calls for an array of inter-sectorial policies the governments should embrace to achieve equitable global health goals (including through a ‘degrowth’ approach and the safeguard of climate and food access), while ending the misalignment among the right to health, trade rules, and the patent system.

Actually, some recipes for administrations worldwide emerge from the book contents and ideology. These entail, besides other measures:

• Seeking synergies among global level institutions to address global health challenges, support stronger leadership by the WHO to improve global health, and enhance dialogue and joint action with key players in order to coordinate actions, advance in the achievement of commitments, and avoid overlapping and fragmentation.
• Ensuring that leading institutions and organizations enhance working with health ministries to strengthen national systems, invest in infrastructures, improve transparency and accountability, and boost needs-driven rather than market-driven rules.
• Pushing for a coordinated response to fight corruption, while refraining from being caught with corporate holdings in a circle of mutually reinforcing political and commercial interests over public health concerns.
• Rejecting pressures towards adopting heightened IP rights while banning TRIPS-plus clauses and ISDS provisions.
• Pushing for open knowledge and new approaches to pharmaceutical innovation that do not rely on the patent system and de-link the costs of R&D from the end price of medicines.
• Backing generic competition as the most effective way to lower medicine prices in a sustainable way.
• Pushing  for full-exemption of out-of-pocket expenses for the poor; poor-friendly pathways towards universal health coverage; heavy taxation on tobacco and other harmful substances; and reduction or elimination of agricultural export subsidies  and energy subsidies on air-polluting fuels.
• Opposing land grabbing, deforestation and state-managed food reserve dismantling policies.
• Reversing ‘brain drain’, health worker shortage by promoting strategies to retain expert faculty staff.

 

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*Author information

Anne-Emanuelle Birn is Professor of Critical Development Studies (UTSC) and Social and Behavioural Health Sciences (Dalla Lana School of Public Health) at the University of Toronto, where she served as Canada Research Chair in International Health from 2003 to 2013. She is widely published in North America, Latin America, Europe, and Africa; her books include: Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico (2006); and Comrades in Health: US Health Internationalists, Abroad and at Home (2013). Professor Birn’s honors include Fulbright and Rotary fellowships, election to the Delta Omega Public Health Honor Society, and numerous endowed lectureships across the Americas and Asia. In 2014 she was recognized among the top 100 Women Leaders in Global Health. 

Yogan Pillay is Deputy Director General for HIV, Tuberculosis, and Maternal, Newborn, and Child Health Programmes in the National Department of Health, South Africa. He has 20 years’ experience in the planning and implementation of health system reforms and has published widely on the topics of HIV, tuberculosis, and health systems.

Timothy H. Holtz is an Adjunct Associate Professor of Global Health at the Rollins School of Public Health at Emory University. His field experience has focused on infectious disease epidemiology and disease control, and he has worked with the U.S. Centers for Disease Control and Prevention and as a consultant to the World Health Organization. From 2002-2010 Dr. Holtz worked in southern Africa, Eastern Europe, and South America on multidrug-resistant tuberculosis control and tuberculosis/HIV program capacity building. He is an internationally recognized expert on the emerging threat of anti-tuberculosis drug resistance and was part of the team of scientists that discovered extensively drug-resistant tuberculosis (XDR TB). He has also directed an HIV prevention clinical trial research program in Thailand, and an HIV and TB technical assistance program in India. He is a founding member of Doctors for Global Health, a health and social justice nongovernmental organization with projects in the U.S., Latin America, and sub-Saharan Africa.

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** Table of contents

Preface: Why Global Health?

Acknowledgements

1. The Historical Origins of Modern International Health

Antecedents of Modern International Health: Black Death, Colonial Conquest, and the Atlantic Slave Trade
Health, the Tropics, and the Imperial System
Industrialization, Urbanization, and the Emergence of Modern Public Health
The Making of International Health
International Health Institution-Building: The LNHO and the Inter-War Years
Conclusion

2. Between International and Global Health: Contextualizing the Present

The Post-World War II International (Health) Order
The Rise of the WHO and “Third World” Development
Straddling International and Global Health
Conclusion

3. Political Economy of Health and Development

Political Economy of Health (and Development)
Political Economy of Development (and Health)
Recent Development and Global Health Approaches
Conclusion: What Does a Political Economy Approach Bring to the Global Health Arena?

4. Global Health Actors and Activities

Snapshot of Global Health Actors, Agencies, and Programs
Political Economy of Global Health Actors and Activities
Conclusion

5. Data on Health: What Do We Know, What Do We Need to Know, and Why Does it Matter

Why Health Data Matter
Types of Health Data
Conclusion

6. Epidemiologic Profiles of Global Health and Disease

Leading Causes of Morbidity and Mortality Across Societies and the Life Cycle
Epidemiology and the Political Economy of Disease
Conclusion

7. Health Equity and the Societal Determinants of Health

Social Determinants/Determinants of Health: What Makes the Underlying Determinants of Health Societal as Opposed to Individual
Operationalizing Political Economy of Health through SDOH
Understanding Health Inequities
From Political, Economic, Social, and Historical Context to Population Health and Health Inequities: Pathways and Possibilities
Societal Governance and Social Policies
From Living Conditions to Embodied Influences
Addressing Health Inequities and the Social Determinants of Health

8. Health under Crises and the Limits to Humanitarianism

“Ecological Disasters” and Their Implications
Famine and Food Aid
War, Militarism, and Public Health
Refugees and IDPs: Numbers, Types, Places
Complex Humanitarian Emergencies
Political Economy of Disasters and CHEs: Where Does Humanitarianism Fit In?
Conclusion

9. Globalization, Trade, Work, and Health

Globalization and Its (Dis)contents
Health Effects of Neo-liberal Globalization
Work and Occupational Health and Safety Across the World
Signs of Hope for the Future: Resistance to Neoliberal Globalization
Conclusion

10. Health and the Environment

Framing Environmental Health Problems: the Motors and Drivers
Health Problems and Environmental Problems and Vice Versa
Climate Change
What Is to Be Done? Multiple Layers of Change
Conclusion

11. Understanding and Organizing Health Care Systems

Principles of Health Systems
Health Systems Archetypes
Primary Health Care, Its Renewal, and the Turn to Universal Coverage
Health System Reform
Building Blocks of a Health System
Conclusion

12. Health Economics and the Politics of Health Financing

Health Economics: A Snapshot
Health Care Financing Redux
Cost Analyses in the Health Sector
Market Approaches to Health in LMICs
The Role of International Agencies in Health Care Financing
Contrasting Approaches to Investing for Health
Conclusion

13. Building Healthy Societies: From Ideas to Action

What Constitutes Success in Global Health
Vertical Health Programs and Global Health Interventions: Successes and Limitations
Health Societies: Case Studies
Healthy Public Policy: Health Promotion, Healthy Cities, and Emerging Frameworks
Conclusion: The Making of Healthy Societies

14. Social Justice Approaches to Global Health

Recapping the Global Health Arena: Dominant Approaches, Ongoing Challenges, and
Points of Inspiration
A Social Justice Approach to Practicing Health: Individuals, Organizations, and the
Logic of the World Order
Conclusion: What Is To Be Done?