This newsletter obviously pays plenty of attention to the 66th World Health Assembly. It’s not because mainstream media routinely ignore Geneva that we do. WHO is doing more than before in terms of coverage (and social media presence), it appears, and quite some knowledgeable watchers & observers are covering the event. We list some of them in this newsletter. Jim Kim’s speech at the WHA was probably the key event so far. He didn’t disappoint.
However, before you delve into WHA related material, we hope you dedicate 10 minutes of your precious time to the evaluation of our weekly IHP newsletter. As we already told you last week, the evaluation form can be found here. Tell us what you (dis)like, what needs to change, or what you think should be the priorities/structure/… of the newsletter. Thanks a lot!
We also already want to draw your attention to a workshop on maternal health fee exemption policies which will be organized in Ouagadougou (Burkina Faso) from November 25-28, 2013. You find more info on the event in this blog post on the blog Financing Health in Africa. The workshop is organized by the Financial Access to Health Services Community of practice (FAHS CoP), in collaboration with the FEMHealth research project and the universities of Montreal (Canada) and Heidelberg (Germany). It aims to review scientific findings on policies of exemption in maternal health in Africa, with a particular focus on empirical results, methodological approaches and experiences of the interventions themselves. The Organizing Committee is calling for abstracts from researchers, decision makers and operational actors to share their results and experiences. If you want to submit an abstract, you should first create an account on this platform. Abstracts can be submitted till June 30. (If you have any questions or require any support, please contact: Yamba Kafando (firstname.lastname@example.org; email@example.com)).
Meanwhile, the preparations for next year’s health systems research symposium in Cape Town (30 September-3 October 2014) are in full swing. You probably already know that the theme of the symposium will be ‘The Science and Practice of People-centred Health Systems’. “People-centred health systems” are seen as health systems that respect, protect and fulfill human rights – both those of health systems users and health workers. Check out the website of Health Systems Global for some more information and updates. Discussions around Thematic Working Groups are also ongoing and proposals need to be submitted by June 1st. This week, the Society also sent out a survey to solicit members’ participation in the development of Health Systems Global’s first strategic plan. We’re sure you already had your say.
In this week’s guest editorial, Albino Kalolo, a 2010 Emerging Voice from Tanzania, discusses the dire implications of lack of information on user fee exemption policies in his country. Poor people are the first victims.
Enjoy your reading.
Kristof Decoster, Ildikó Bokros, Peter Delobelle, Basile Keugoung & Wim Van Damme
Citizens’ lack of information on health policies in Tanzania: Implications for widening inequities
Albino Kalolo, MD, MSc(Public Health), EV2010 from Tanzania
Poor people face a variety of barriers when accessing health care in Sub-Saharan Africa. Some of these barriers could no doubt be eliminated if poor people were actually more aware of health policies, as a lack of information often leads to undesirable results such as delayed medical treatment, improper health seeking behaviours, and even foregoing medical treatment. This situation contributes to morbidities and mortalities among this group of poor people that could otherwise be avoided, at least to some extent. The example of a lady in her late 30s called “Sikitu” (a Swahili name, which literally means “Nothing”), provides a snapshot of how things are on the ground. Sikitu is a widow living with her four children in a village in Southern Tanzania.
Sikitu had symptoms of cervical cancer when she went to see a doctor in a public district hospital. The doctor later on referred her to the cancer institute in Dar es Salaam for further treatment on account of advanced cervical cancer. After physical examination, Sikitu asked the doctor: “How much should I pay you for all these services I have received?’ The doctor replied: “Cancer services in this country are offered for “free” (without payment) like other chronic diseases such as HIV/AIDS and tuberculosis; you are not supposed to pay directly to the doctor if there are associated costs”. Sikitu was surprised to hear that and was pretty much speechless when she reflected on what has been happening to her and other poor people. She went home and sold the few goats she had to get money for her travel and living expenses (when she will be receiving treatment in Dar es Salaam). A few days later, before travelling to the city for treatment, she went back to see the doctor (ready for the journey) in order to collect the referral documents. She offered him some cashew nuts, as a gift. Then she burst into tears. When asked why she was crying, she explained that she had been coming to the hospital almost every month for the past year or so, to see a certain doctor. She had always paid the doctor after the service but the problem was still going on despite the fact that some procedures had been performed on her. She was scheduled to come again regularly for follow-up visits and was required to pay some money whenever she accessed services. She was very surprised that this time (because the usual doctor was travelling) she was attended free of charge, informed of her problem and referred to the big hospital for further care.
Sikitu’s story is by no means an exception in Tanzania and in other sub-Saharan African countries that still have user fee policies in place, but is just the tip of the iceberg. Many poor people are unaware of user fee exemption policies. Many people, especially the poor, have been denied access to health care and live now in extreme poverty because of lack of information about user fee exemption policies. Corrupt practitioners take advantage of this knowledge gap, induce demand and ask for informal payments (bribes) from their (mostly poor) clients.
There are several reasons as to why ordinary citizens often lack information on available health policies. The (trademark) top-down approach of policy formulation that denies active participation of ordinary citizens in setting the agenda and overseeing the implementation of policies, contributes to this gap. Moreover, the absence of pressure groups that can hold the government accountable if these policies are not addressing ordinary citizens’ problems plays a major role. These two major reasons are interrelated in Tanzania: the political atmosphere in my country (characterised by the dominance of one political party) has for a long time supported a top-down approach and limited democratic practices – in the past civil society organisations (CSOs) that weren’t affiliated to the ruling party were even banned. However, since the end of the 80s (when there was a severe economic crisis), regulation of CSOs has changed as a result of conditional ties of international aid. The same process also led to the introduction of a multiparty system in 1992.
So the situation is slowly changing, for the better, even if until recently Tanzania could be characterized as a “de facto one party state in a context of multi-party elections”. Little by little, citizens are more empowered (at least in other social sectors) due to actions of CSOs and opposition political parties. In fact, even in the health sector, there have been some active local CSOs that work as ‘health policy entrepreneurs’ such as Sikika, but they have not been vigorous enough to push forward an agenda that promotes poor people’s access to information (in order to empower them to advocate for their health rights). Nevertheless, Sikika has shown the way by using research evidence as an advocacy tool for quality health services in partnership with other local CSOs. Sikika’s activities are geographically confined, though, mainly focusing on urban areas. The capacity of the organization also needs to be improved. Many international NGOs are also working in the country, but it is very complex to understand how they relate to the government and local CSOs, and not the focus of this editorial. More importantly perhaps, the recent emergence of strong opposition political parties that have been challenging the status quo is seen as a window of opportunity. Many of them promote the health sector agenda in their election manifestos for the coming general elections (scheduled for 2015).
It is unfortunate, however, that until now there has never been a serious attempt (and mass movement) to change the current situation that creates major inequalities in the society in terms of access to health care, unlike in other sectors such as education and land rights. This is probably because health activists have never worked in unity to address such issues, and health worker unions are too fragmented to put successful pressure on decision makers and address such inequalities (apart from isolated doctors’ strikes that have typically been suppressed by authorities). The government on the other hand tries to make sure that health issues do not feature in mainstream party politics because of their potential sensitivity; they therefore find ways (sometimes barbaric ones) to suppress initiatives that appear to advocate the right to access health care or that suggest mechanisms which promote equity (not that Tanzania is alone in this – the crackdown on civil society is, unfortunately, a global phenomenon). However, things are finally changing, and it could very well be that the ‘access to health care’ agenda will feature quite prominently in the 2015 general elections, even more so because a series of mediatised actions have happened in the health sector recently such as persistent doctors’ strikes to demand good working conditions and the kidnapping and torture of the frontline leaders of these movements.
Since realities on the ground and research evidence have already demonstrated the inequalities caused by user fee policies and the fact that people are unaware of exemption procedures (or sometimes they are aware but there exists no functioning (social and legal) framework that can support them in the fight for their rights), it seems high time for health activists ( individuals, CSOs and political parties) to join hands and advocate the right to health and work towards boosting citizens’ awareness and empowering them to know their right to health care. They can also start advocating the abolition of user fee policies like in other Sub-Saharan African countries. Obviously, they can and should also jump on the global UHC bandwagon to make universal health coverage a reality in Tanzania.
As Jim Kim noted in his speech at the World Health Assembly earlier this week, “Now is the time to act. WE MUST BE the generation that delivers universal health coverage.”
World Health Assembly
As already mentioned in the introduction, the WHA media centre offers quite some information and material on the Assembly, among others daily notes on proceedings (see here ) and some videos of speeches (like the ones by Margaret Chan & Jim Kim – see below). And of course it offers also the background material and reports that are being discussed. Lots of tweets also on #WHA66. Just a few to give you a flavour: (Richard Horton) “One observation about this year’s WHA: there is a huge move to warmly embrace the private sector. Few voices are raising questions. Why?” Just today, Horton also lamented the Anglo-American hegemony in global health. He wondered how, for example, Europe could help to challenge this.
1. KFF – Public Health Important Focus ‘In These Troubled Times,’ WHO’s Chan Says At World Health Assembly Opening
During her opening remarks at the WHA, Margaret Chan said, “In these troubled times, public health looks more and more like a refuge, a safe harbor of hope that allows, and inspires, all countries to work together for the good of humanity.” She added that nothing reflects this spirit better than the growing commitment to universal health coverage, and she also stressed the need to ensure that health occupies a high place on the global development agenda beyond 2015. Worth to read her speech in full, obviously, but we already flag this conspicuous statement, in which she makes a distinction between Big Tobacco and other private industries (like food, alcohol etc): “WHO will never be on speaking terms with the tobacco industry. At the same time, I do not exclude cooperation with other industries that have a role to play in reducing the risks for NCDs. There are no safe tobacco products. There is no safe level of tobacco consumption. But there are healthier foods and beverages, and in some cultures, alcohol can be consumed at levels that do not harm health.” (my 13-year old son will be glad to hear this).
On IP Watch you find some in-depth coverage about Chan’s opening remarks, part of a nice series of blog posts (by William New & Brittany Ngo) on the ongoing WHA. See for example also here (for an overview of the WHA agenda, before the Assembly started), here and here (reporting on discussions on the R&D system), here and here (on NCD action plan draft). In short: definitely check out IP Watch coverage during the WHA.
Check out also this nice (visual) ‘infographic’ on INIS for some (3) WHO budget trends (proposed budget 2014-15). More on this below – see Laurie Garrett.
2. CSIS – WHO Attempts to Enlist the “Extremely Powerful Forces” of Industry to Combat NCDs
The WHO is in active dialogue with the food, beverage, alcohol, and even sporting goods industries to encourage marketing changes and product formulations to help curb the growing worldwide prevalence of non-communicable diseases. Bristol listened carefully to Chan’s speech and is in favour.
3. World Bank – World Bank Group President Jim Yong Kim’s Speech at World Health Assembly: Poverty, Health and the Human Future
Jim Young Kim;
In a (much anticipated) speech delivered to the WHA, WB president Jim Yong Kim said UHC in all countries can help achieve a goal of ending extreme poverty by 2030. Every country in the world can improve the performance of its health system in the three dimensions of universal coverage: access, quality and affordability. He outlined five specific ways the Bank Group will support countries in their drive toward UHC: ramping up analytic work and support for strengthening health systems; leading an effort to help countries reach MDGs 4 and 5 on maternal and child mortality; developing a monitoring framework for UHC, together with the WHO; deepening work on the science of delivery (see also below for a new Lancet article by Jim Kim on global health care delivery); and stepping up efforts to improve health through action in other sectors that affect whether people lead healthy lives.
Obviously, commentators will scrutinize Kim’s speech in the coming days and months (or even years) – and the quick ones have already done so (like Save the Children’s Simon Wright in a short blog post, happy about the WB’s change of heart about user fees – “As part of a speech which emphatically committed the World Bank to working to support countries to introduce universal health coverage, Jim Yong Kim made a statement that is revolutionary: “Anyone who has provided health care to poor people knows that even tiny out-of-pocket charges can drastically reduce their use of needed services. This is both unjust and unnecessary.” – or this very nice analysis by Todd Summers (CSIS)) who also looks at the future – what are the next steps for the WB?
4. WHO Watchers – before and on the WHA
* The People’s Health Movement, together with experts from collaborating networks and NGOs, prepared a number of comments on items appearing on the agenda of the 66th World Health Assembly. This document is a must-read (unless if you are allergic to a social determinants discourse. If you are, you should probably get another job). By way of example (on NCDs): “NCD targets must explicitly address global and local social determinants and corporate behaviour, including potentially damaging marketing practices.” (not sure all WHA participants got the message)
* Daily reports from WHO Watch you find here, as well as various PHM statements on items like the WHO reform, social determinants of health, MDGs & the post-2015 agenda, UHC. Check out also the somewhat reluctant position of the PHM on a Framework Convention for Global Health.
* You can also find most of these documents and positions on GH Watch (and more).
More on the UHC debate:
* Not directly related to the WHA, but very relevant for the UHC discussions: Remco van de Pas (Wemos & Medicus Mundi)’ recent presentation in Brussels on ‘Interrogating scarcity & the political determinants of UHC’.
* Also not directly related to the WHA, but equally important for the UHC debate in India: check out this new blog post on Oxfam’s Global Health Check website, “Health for all in India- Public, not ‘packaged’. “As world leaders prepare to gather for the 66th World Health Assembly on May 20, social movements are questioning the market-friendly version of universal health coverage (UHC) it is promoting. One organization, Jan Swasthya Abhiyan (JSA), is denouncing India’s emulation of this UHC strategy, as contained in the country’s 12th Five Year Plan, which uncritically endorses the private medical sector and focuses on health insurance schemes. In a recent paper – JSA proposes an alternative UHC model.
5. Series of blog posts by Laurie Garrett on the WHA and global health
Laurie Garrett has already posted 3 blogs this week in a series on the future of global health, coinciding with the 66th World Health Assembly. Discussions must be unbelievably interesting/boring – or else Laurie is on speed this week. More blog posts will follow in the coming days, she promises. Blog posts so far focus on (1) Margaret Chan and the proposed budget – with an apparent shift towards more NCD spending, according to Garrett a “hasty decision to increase spending in non-communicable diseases at the apparent expense of its (=WHO’s) own capacity to respond to outbreaks and epidemics”, (2) the future of global health funding, and (3) the implications of macroeconomic changes for global health. The 4th blog post will zoom in on the global health architecture.
6. BMJ – Non-Communicable Diseases -Targets for non-communicable disease: what has happened since the UN summit?
Joyce K. Ho et al.;
This week’s World Health Assembly again discusses targets for non-communicable diseases. Joyce K Ho and Rajaie Batniji examine the difficulties of getting an agreement.
The BRICS countries pledged in a joint communiqué on the sidelines of the World Health Assembly to strengthen intra-BRICS cooperation in promoting the health of their people. (see a Xinhua article ). The BRICS decided to continue cooperation in the sphere of health through the Technical Working Groups on five thematic issues.
More on the WHA next week.
Access to medicine
7. Indian Journal of Medical ethics – The global impact of Indian generics on access to health
Raffaella M Ravinetto , Thomas PC Dorlo, Jean-Michel Caudron, NS Prashanth
Fascinating article by some of our colleagues on the global impact of Indian generics on access to health. They point out quality is as important as access. “In particular, the recent reports concerning poor regulatory enforcement of medicine quality requirements seem to indicate an unexpected gap between the valuable effort to build on universal access to essential medicines and a parallel effort to guarantee universal quality of all essential medicines. Nevertheless, access and quality need to be achieved simultaneously, to fulfill the basic ethical requirement of equity and to provide adequate and safe treatment to all.”
In case you wondered why this is becoming a very urgent issue, check out this Global Dashboard article on a recent account of the crimes of Indian generic drug maker, Ranbaxy. A quote: “Why hasn’t this been a bigger story? The BBC gave it a couple of hundred words. … Two reasons for the radio silence, I think. The current media narrative focuses heavily on the myriad of sins of Western companies – if this had been GlaxoSmithKline, you can be sure it would have dominated the front pages. There’s much less interest in how lax regulation elsewhere in the world is corrupting globalisation. Second, many – me included – are heavily invested in generic drugs as a vital weapon in the battle to improve health standards in the poorest countries. In 2004, the Guardian carried an interview with Dr Brian Tempest, a Brit who was then Ranbaxy’s CEO (and who Fortune puts at the heart of the company’s reckless cover-up). For the generics industry, AIDS drugs were a route to respectability, with Ranbaxy swiftly becoming an aid industry favourite.”
This is the official reaction from WHO’s Pre Qualification of Medicines program.
8. CGD – Bringing Health to World’s Poor Goes Beyond Drug Price
Glassman comments (in a letter to the FT) on Andrew Jack’s report “GSK and Merck pioneer vaccine deal” (May 10) on a discounted human papillomavirus (HPV) vaccine price for GAVI, which according to her “illustrates a continuing focus on the price, rather than on the value and affordability of a product in a given health system.” Very nice & short blog post. She concludes: “Adoption of new health technologies should be based on the incremental costs and benefits and on immediate and longer-term affordability of a technology in a particular health system, and decisions on price should flow from that starting point.”
You should also read Agnes Binagwo’s angry reaction at criticism of the (HPV) drug deal (in the Guardian). The Rwandan minister of Health is a firm believer in public-private partnerships. According to her, the debate must move on from seeing pharmaceutical companies as evil predators and poor people as hapless victims.
Health Policy & Financing
9. Book – Health in All Policies – Seizing opportunities, implementing policies
Edited by Kimmo Leppo et al..
Health in All Policies is an approach to policies that systematically takes into account the health and health-system implications of decisions, seeks synergies, and avoids harmful health impacts to improve population health and health equity. It is founded on health-related rights and obligations and has great potential to improve population health and equity. However, incorporating health into policies across sectors is often challenging and even when decisions are made, implementation may only be partial or unsustainable. This volume aims to improve our understanding of the dynamics of HiAP policy-making and implementation processes. Drawing on experience from all regions, and from countries at various levels of economic development, it demonstrates that HiAP is feasible in different contexts, and provides fresh insight into how to seize opportunities to promote HiAP and how to implement policies for health across sectors.
By the way, the Eight Global Conference on Health Promotion which is being co-organized by the WHO and the Ministry of Social Affairs and Health of the Government of Finland is coming up. The conference will take place in Helsinki,
Finland, from 10 to 14 June 2013. We hope to have an IHP watcher there.
10. Lancet (early online) – Redefining global health-care delivery
Jim Yong Kim et al.;
This article is a call to harness existing resources and dedicate new ones to the issues of global health-care delivery. Kim et al. put forward a framework and advocate a strategic approach to global health care delivery.
11. Lancet (early online) – Mapping of available health research and development data: what’s there, what’s missing, and what role is there for a global observatory?
John Arne Rottingen et al.;
The need to align investments in health research and development (R&D) with public health demands is one of the most pressing global public health challenges. The authors aim to provide a comprehensive description of available data sources, propose a set of indicators for monitoring the global landscape of health R&D, and present a sample of country indicators on research inputs (investments), processes (clinical trials), and outputs (publications), based on data from international databases. This report confirms that substantial gaps in the global landscape of health R&D remain, especially for and in low-income and middle-income countries. Too few investments are targeted towards the health needs of these countries. Better data are needed to improve priority setting and coordination for health R&D, ultimately to ensure that resources are allocated to diseases and regions where they are needed the most. The authors also advocate the establishment of a global observatory on health R&D, which is being discussed at WHO.
12. CGD (blog) – Who runs the (Global Health) world?
Victoria Fan & Rachel Silverman;
Guess what: it’s not women. The CGD scholars give some stats for global health organizations & American schools of public health. (On the bright side: last week we learned that men are overlooked by the global health architecture & donors. Guess we aren’t taking about the same men, though – Julio Frenk et al. aren’t exactly ‘precariat’.)
In another nice CGD blog post, Kate Almquist Knopf reports on a recent panel hosted by the Kaiser Family Foundation on the US Defense Department’s role in global health. DoD’s work in global health involves, among others, “medical stability operations and partnership engagement”. Knopf is concerned about this category.
13. UNAIDS report – Update
As the African Union held its 21st summit in Addis Ababa, celebrating 50 years of African unity, UNAIDS released “Update”, a new report on the AIDS response in Africa, documenting the remarkable recent progress against HIV on the continent. The report attributes this success to strong leadership and shared responsibility in Africa and among the global community. The report also urges sustained commitment to ensure Africa achieves zero new HIV infections, zero discrimination and zero AIDS-related deaths.
CGD’s Amanda Glassman & Jenny Ottenhoff wrote a blog post on the occasion of the 10th anniversary of PEPFAR.
Meanwhile, reauthorization of PEPFAR is not guaranteed this year.
14. Lancet (Editorial) – Blood: a precious resource
The Lancet pays a lot of attention to blood transfusions in this week’s issue. This editorial introduces three articles of this issue, but it also discusses blood management in LMICs. “A proposed initiative, endorsed by the WHO Blood Regulators Network, to tackle issues of safety, availability, quality, and accessibility of blood products in low-income and middle-income countries, is the addition of whole blood and red blood cells to the WHO Model Lists of Essential Medicines (EML).”
15. Plos – Grand Challenges: Improving HIV Treatment Outcomes by Integrating Interventions for Co-Morbid Mental Illness
Sylvia Kaaya et al.;
In the fourth article of a five-part series providing a global perspective on integrating mental health, Sylvia Kaaya and colleagues discuss the importance of integrating mental health interventions into HIV prevention and treatment platforms.
16. Huffington Post – Government Inks Deal With GlaxoSmithKline To Tackle Drug Resistance, Bioterrorism Threats
The U.S. government has signed an antibiotics development deal worth up to $200 million with GlaxoSmithKline to tackle the dual threats of drug resistance and bioterrorism. The collaboration, the first of its kind between Washington and a drug company, will allow funding to move around GSK’s antibiotics portfolio rather than focusing on a single drug candidate. (guess Obama and co had some money left now that they’re going to be a bit more careful with drones)
17. CGD – The Global Fund opens up
Amanda Glassman & Denizhan Duran;
The Global Fund to Fight AIDS, TB and Malaria recently made it easier to find out where their money is going with the launch of a new, online grant portfolio portal.
18. GF – Global Fund Joins New Innovative Financing Partnership
“The Global Fund agreed to participate in a new partnership to leverage private sector funding to speed delivery and expand access to health supplies such as contraceptives, bed nets, and medicines. The ‘Pledge Guarantee for Health’ is a new financing mechanism that will help increase the impact of each dollar of donor funding and ultimately improve healthcare access and outcomes for millions of people. The initiative was announced at the GBC Health Conference in New York, where leading global health and development experts from the public and private sectors convened.”
In other news, the GF published a report on preventing and detecting possible misuse of funds in countries where Global Fund grants support programs that fight AIDS, tuberculosis and malaria. The report, prepared by Chief Risk Officer Cees Klumper, outlines actions that the Global Fund has taken over the past year to reduce risk and improve oversight.
Global health bits & pieces
* Polio news:
The WHO says the Horn of Africa is experiencing an outbreak of polio with cases confirmed in Kenya and Somali (see the Associated Press/Washington Post ) – yet another worrying development.
And a Scidev.net viewpoint (by Sue Coe) argues that efforts to eradicate polio by 2018 will fail unless people with disabilities are included in elimination strategies.
19. World Development – Institutional Solutions to the Asymmetric Information Problem in Health and Development Services for the Poor
Leonard D. K., Gerry Bloom et al.;
The world’s poorest pay for professional services and thus are in a “market,” whether the services are provided in the public or private sectors. The associated problems of unequal information are particularly acute in undergoverned countries, where state regulation is weak. The authors systematically review the evidence on solutions to these problems in a variety of professions. Payments by clients are more likely to have a positive effect on quality if they are made through locally-managed organizations rather than directly to individual practitioners, particularly if those organizations have an institutionalized history of other—regarding values and incorporate client participation.
* USAID has for the first time a comprehensive strategy to integrate water into all development funding & programs (see Humanosphere).
* The EU goes for ‘basic education for all by 2030’. During a meeting of EU leaders in Brussels, the European Commission announced on Thursday that it will allocate at least 20 percent of its 2014-2020 aid budget for human development and social inclusion, with €2.5 billion for education.