Rio de Janeiro, May 2017 . No 6
WHERE DOES THE MONEY COME FROM? HOW MUCH IS AN ILLNESS WORTH? INTERVIEW: PATRICK PENGEL MINISTER OF HEALTH OF SURINAME
WHAT TO DO WHEN HEALTH PROFESSIONALS DO NOT WANT TO ATTEND THE POOR?
INSTITUTIONAL ISAGS-UNASUR Executive Director: Carina Vance Head of Administration and Human Resources: Gabriela Jaramillo Coordinator of International Relations: Luana Bermudez INFORMATION AND COMUNICATION MANAGEMENT Coordinator: Flávia Bueno Editor-in-Chief: Manoel Giffoni Report: Carina Vance, Félix Rígoli, Flávia Bueno, Manoel Giffoni Collaborators: Beatriz Nascimento, Luana Bermudez, Mariana Faria, Mario Camelo Team: Bruno Macabú y Felippe Amarante Contact: comunicacao@isags-unasur.org Phone: +55 21 2505 4400 This is the report from the South American Institute of Government in Health (ISAGS), the think tank on health of the Union of South American Nations (UNASUR) that aims to contribute to improving South America government quality in health by means of leadership training, knowledge management and technical support to health systems.
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WHERE DOES THE MONEY COME FROM? PRIVATE FINANCING FOR GLOBAL HEALTH ACTIONS IS AN ISSUE THAT CLEARLY HIGHLIGHTS POTENTIAL CONFLICTS OF INTEREST BETWEEN THE GUARANTEE OF THE RIGHT TO HEALTH AND THE GAIN OF PRIVATE ACTORS “Saving newborns is a tender-hearted act of love that also makes hard-headed business sense”. These were Melinda Gates´ words, from the Bill & Melinda Gates Foundation, in a speech to the 67th Session of the World Health Assembly (WHA) in 2014, and reveals that much of what can initially be perceived as simple acts of solidarity can hide clear commercial interests. Of the thousands of agents who interact today in the international system, States can still be considered the main ones, but no longer the only ones with influence on policies. Governments, intergovernmental organizations, non-governmental organizations (NGOs), private funds, foundations, the industry, populations. All of these actors participate in the international arena of public policymaking in one way or another. What we often do not ask ourselves is: who financed it? And what are the reasons that led either actor to make such a great investment? This is a problem that affects many sectors of society and in recent years has been intensively taking the field of global health by more apparent situations of conflicts of interest between corporations and the health of peoples, whether in the realm of medicines, in the purchase of medical equipment, or related to the food industry, among others.
The case of WHO The debate on the relationship between these non-state actors and governmental organizations became an issue discussed in the World Health Organization (WHO), mainly after accusations that it would be losing its independence under the influence of private agents. This prompted a process of reform of the Organization that began in 2010, which already presents some important progresses, such as the approval – after four years of negotiations – of the Framework for Collaboration with Non-State Actors (FENSA) during the 69th edition of the WHA (2016). Some of the main objectives of the Reform are to increase transparency and solve a critical financing problem that significantly affects the conduct of the Organization’s activities. When it was created, WHO’s budget was composed of 80% of contributions from its Member States and 20% from voluntary contributions. Currently, this proportion was reversed. Approximately 75% of its entire budget comes from voluntary contributions, either from its own Member States or from agents such as the Bill & Melinda Gates Foundation, which is its second largest donor, leaving behind only the United States.
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The Emergency of the AH1N1 virus, decreed in 2009 by the Organization, is an emblematic case. The recommendation of the broad use of Tamiflu (Roche) by the Emergency Committee highlighted the lack of transparency and clear conflicts of interest as it was eventually revealed that some of its members were “financially rewarded (by the pharmaceutical industry) for their apology to antivirals”, as Ventura and Perez (2014) emphasize, which in the end was proved unnecessary and ineffective. This underscores the discrepancy between what populations need and what these financiers want. This problem is covered in the FENSA document; however, civil society organizations such as the People’s Health Movement and the IBFAN (International Baby Food Action Network) along with many others, expressed their concern that this framework would legitimize the capacity of intervention of these agents in WHO´s programs and that it puts without distinction, in the same level, those that aim the profit and institutions that work mainly for the defense of health as a right. The Academia also expressed concern with the issue. In an article published in the English academic journal The Lancet in 2016, Kent Buse (UNAIDS) and Sarah Hawkes (University College London) understand that the FENSA can be an insufficient mechanism, even if it is well implemented, to ensure improvements in corporate practices towards the health of people. In an interview for ISAGS´ Special Report of the WHA 2016, Deisy Ventura (University of São Paulo), in addition to recognizing and reinforcing these issues, stated that the FENSA can be a mechanism of visibility and transparency, which “may improve control of relationships that today occur in total opacity”. For Minister Julio Mercado, Argentina’s diplomat responsible for coordinating the FENSA’s discussions, “there is no doubt that the organization (WHO) belongs to the Member States and this was demonstrated by the role we played during the process of creating the FENSA. In all discussions [...] the primacy of Member States was clear and this was never doubted, quite the opposite”. The position of UNASUR During the FENSA negotiations, UNASUR made a joint intervention at the WHA 2015, reinforcing the need for WHO Member States to play a supervisory role in the process of assessing relations with non-state actors, stressing the need to take extreme care in the cases of industries whose activities have an impact on health
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and reiterated the “non-involvement of the private sector in any activity aimed at developing standards and policies of the Organization”, the document concludes. In contrast with the mechanism established by WHO, which makes this type of decision based on the vote of a two-thirds majority of its members, UNASUR has as its founding principle the need for consensus. This means that everything that happens in the bloc is given by common agreement among all its members, which includes the choice of how and with whom to interact in the international arena. The document governing UNASUR’s relationship with third parties lists a number of principles to be followed such as non-conditionality, respect for sovereignty and sustainable development, but also prioritizes its relationship with other international organizations in the region of Latin American and the Caribbean. According to Ricardo Malca, director of International Cooperation and Technical Agenda of the bloc´s General Secretariat, currently UNASUR is only working with other governmental organizations, but explains that although there are still no relations with non-state actors, “it is by no means something that is ruled out, that is, our guidelines allows it, provided there is consensus of the 12 member countries”, he added. Social participation is a constitutive principle and a fundamental part of the regional integration proposed by UNASUR and already has an approved framework for its regulation, so to make an effort to legitimizing the development of its actions and always keep in the horizon for whom and to whom we work. In that sense, Julio Mercado adds: “States have an nondelegable role of leadership in the search for solutions, but their work alone is not enough. The perspective, support and active collaboration of civil society guarantee us not only long-term solutions but also a more complete work in the prevention of problems”.
Flávia Bueno flaviabueno@isags-unasur.org
Much of these resources are allocated for specific actions, programs or projects that are of particular interest to their financiers, that is to say, in some way, the orientation of the Organization’s policies is a lot influenced by those who pay for its activities. This raises strong questions about the independence of the WHO and a concern about its place in the governance of global health.
EXPERTS CORNER The Health Council of UNASUR and the construction of health sovereignty from the exercise of health diplomacy by Mariana Faria Building sanitary sovereignty through regional integration can be a way to strengthen national autonomy, control and legitimacy, while at the same time to expand UNASUR room for acting as an agent in the global system. In the end, health is a privileged arena for cooperation between countries and the exercise of diplomacy. The action of the South American Health Council (SHC) as a global health diplomacy actor projects regional challenges in the area of regional health diplomacy and defends the region as a geostrategic space in the formulation of international policies. In this sense, the actions of the SHC in the World Health Assembly (WHA) through the presentation of joint interventions, initiated in 2010, establishes a historical milestone for the representation of South America in the scenario of global health diplomacy. UNASUR made important progresses in relation to other integration processes in South America. The longer-lived CAN, MERCOSUR and ACTO have not been organized for joint action at the WHA, which resulted in the non-recognition of the South American region as an important player in that arena. The situation began to change in 2010, with UNASUR’s constant and growing performance in the forum. By intervening as a bloc, the Health Council contributes to strengthening the regional integration process in the continent for the formulation of a regional health agenda. Furthermore, it supports the consolidation
The SHC has been active in formulating and negotiating policies in various global forums, such as the PAHO Directing Council and in global conferences made by specialized agencies such as the VI International Conference of Drug Regulatory Authorities (ICDRA) in 2014, The III Global Forum on Human Resources for Health in 2013, the VIII Global Conference on Health Promotion: Health in All Policies; and the World Conference on Social Determinants of Health in 2011.
of UNASUR itself as a global player in the definition of guidelines of the global health agenda which contribute to the reduction of inequities in health. In its first joint intervention at the 63rd WHA, UNASUR addressed the impact of intellectual property rights on access to medicines and the monopoly power of pharmaceutical companies in deciding on pricing and generics. Over the years, in addition to the increase in the number of resolutions, the topics that were subject to common positioning of the Council were diversified. Regional sanitary sovereignty, understood as a shared and negotiated practice between countries, is developed from the perception that integration can increase the ability to decide autonomously and break with the historically established asymmetric conditions of South America in its relation with other regions. The lower the autonomy of a region comparing to the international system, the greater the importance of external factors in the definition of its policies. Based on this concept of regional health sovereignty and the Health Council as an actor in global health diplomacy, it can be said that UNASUR member states have chosen to claim health sovereignty over the relevant agents of the international system, including not only countries and organizations that have notably dictated health policies in the region, but also the market, transnational corporations and, in particular, the pharmaceutical industry. In other words, UNASUR has realized that gathering countries around common interests can strengthen the region’s positions in multilateral international fora and expand the possibilities of defending the interests of South American countries in face of transnational health challenges.
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HOW MUCH IS AN ILLNESS WORTH? In the economic world there is a very popular tool for its versatility, used to guide the decision of its agents. The calculation of the so-called Return on Investment (ROI) is simple: it refers to the difference of the gain obtained and the initial investment on the initial investment; That is, if a company generated a profit of 500 thousand dollars after an initial contribution of 100 thousand, the ROI will have been 4, which means a return of 400% on the amount.
what concerns, for example, programs of global scope, such as those carried out by the World Health Organization or the World Bank.
It is an indicator among a plethora of indicators available in the financial market, although it is advisable to hire a company specialized in the management of this type of calculation due to the complexity of some business models. The so-called risk assessment companies, such as Standard & Poor’s, Moody’s and Fitch, monitor the business environment around companies and countries from a matrix that includes thousands of variables, giving them literally a grade, the rating, in order to guide to the investors on the convenience and opportunity to bet on them. In a world of scarce resources, “maximizing profit and minimizing loss” is a mantra repeated ad nauseam by economists.
In that context, Christopher Murray presented in 1994 the synthetic indicator DALY (Disability Adjusted Life Years) in the article titled Quantifying the burden of disease, with the objective of evaluating the impact of every dollar spent in policies, initiatives or programs to improve the health of the population aggregate. The calculation is made in different stages: it combines the potential years of life lost plus the years lived with disability in the health-disease process. Thus, for example, the deaths because of old age and of disabled individuals contribute less to the overall burden of the estimated disease.
Lately, we have also become accustomed to repeating mantras in Public Health, such as the one that says that allocating funds for this field is not an expense, but an investment; and the one that says that decision-making requires evidence-based support. However, the mantras are more complex than they appear when it comes to their implementation. When a health authority is between providing services to a child with a rare disease with an expensive treatment or conducting an influenza vaccination campaign with the same amount of resources for thousands of people, what kind of rationality can guide that decision? This is a type of dilemma that happens every day and is taken on a much larger scale in
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At the beginning of the 1990’s, a certain rationality intrinsically associated with the neoliberal momentum and the performance of the World Bank, with many conditionalities and cost-effectiveness analysis, favored the elaboration of metrics that could help (or actually, frame) decision-making.
According to Murray, public health statistics previously had the bias of being partial and fragmented, not allowing the authorities to compare the cost-effectiveness of different interventions in different diseases. That is, the new indicator could help the health authorities and global agencies allocate their limited resources for programs and treatment of diseases that have the greatest impact. The Global Burden of Disease Study, conducted by Murray with the collaboration of more than 1,800 researchers from 127 countries, was institutionalized by the World Health Organization and was updated a couple of times since then bythe Institute of Metrics and Health Assessment at the University of Washington (IHME), the organization responsible for it, financed by the Bill & Melinda Gates Foundation.
One of the points mentioned by Rosenberg is regarding the territory that considers the indicator, which places all strata of the population in the same level. “It does not allow identifying, for example, the diseases and pathologies that affect, more specifically in the territory, the socially fragile or excluded populations and that, however, in the territorial average is less frequent”, he says. In addition, it points to the limitations of the system of notification and registration of specific diseases and pathologies in the different Health Systems, sometimes biased by economic interests or by priorities established at the global level, either by the International Health Code or Health Security. On the other hand, in attempting to remedy this insufficiency in addressing inequities in Health, it was proposed to use data referring to poverty and income concentration, such as the Gini coefficient. However, according to a 2001 article by Ugá et al., published in the journal Ciência & Saúde Coletiva (Science & Collective Health, in English) with considerations on the WHO Report of 2000 that compared and
classified the performance of Health Systems, these data refer to the inequality of health in the population, but not necessarily to inequity in the performance of the health system. For these reasons, Rosenberg considers that “the burden of disease indicator reproduces the global priorities (average), not allowing to plan the prevention or correction of those pathologies that affect populations that are more exposed and have less access to health services because of their social condition”. The criticisms mentioned above echo many recommendations of the recently developed Sustainable Development Goals in relation to the lessons learned from the Millennium Agenda. Given the widely debated limitations of the strictly vertical approach and the focus on specific diseases, countries thought of a new Development Agenda that leaves no one behind by disaggregating data and promoting comprehensive initiatives. Therefore, it will be necessary to update the ways in which decisionmaking is evaluated and based on issues such as development and Public Health.
Manoel Giffoni manoelgiffoni@isags-unasur.org
The concept raised ample criticism from the ethical to the methodological spectrum one. On the one hand, it transforms people’s lives into a subjective algorithm based on an arbitrary selection of variables and consideration and some inconsistent extrapolations. “Even recognizing that this is an important indicator for the organization and financing of health services, this indicator is not sufficient and, I may say, distorts reality by reducing it to a process of epidemiological study and strategic prioritization, specially when the objective is to reduce inequities in health based on their social determination”, says the Executive Secretary of the Network of National Institutes of Health (RINS-UNASUR), the Argentine researcher Félix Rosenberg.
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PLENARY There is a Plenary session at the opening of the WHA, which gathers all delegates from member countries and other institutions. The DirectorGeneral of the WHO delivers a speech and the members elect a President, five Vice-Presidents and Chairmen for the main Committees of each edition of the Assembly. These sessions are also held throughout the event for the presentation of reports elaborated by Committees and declarations from Member States and, at the end of the week, to vote the adoption of resolutions negotiated by the Committees.
COMMITTEES A AND B
WHA,
STEP BY STEP The World Health Assembly (WHA) is held annually at the Palais des Nations in Geneva, Switzerland. With an agenda that grows more complex every year, the WHA has turned into a whole universe of meetings, events and negotiations where thousands of delegates from member countries, international organizations, NGOs, the press and the private sector circulate. Among other functions, the Assembly is where agreements, conventions and health regulations, such as the Framework Convention on Tobacco Control and the International Health Regulations are approved. See here the bodies that take the most important decisions in global health every year.
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These Committees are where participants debate items of the agenda and texts of resolutions, and where the representatives of UNASUR’s Health Council present their joint interventions. Committee A generally addresses technical and health subjects, whereas Committee B is focused on financial and management questions, even though this rule is sometimes broken due to programme issues. Once the Committee approves the text, it is sent for voting at the Plenary.
TECHNICAL BRIEFINGS These sessions are carried out in order to facilitate the exchange of information on the newest issues on public health and to support the discussions of Committees and at the Plenary. They are generally composed of a debate table that addresses specific issues, with the presentation of experiences and good practices both by Member States and members of the civil society.
DRAFTING GROUPS Drafting Groups are held when an item of the main agenda has not yet reached a resolution, generally due to controversial points. Every day, the WHA Journal publishes the time and place of sessions, so that countries interested in the subject are able to attend the meetings and debate texts item by item, in sessions that are closed to non-members. In these groups, negotiation and health diplomacy are more evident.
SIDE EVENTS AND MEETINGS When the actors of the Assembly, such as Member States or organizations, want to debate specific issues or negotiate common positions, they may convene meetings which are usually incorporated to the official agenda of side events and meetings of the WHA. One example is the meetings of the South American Health Council (SHC) held before and during the Assembly.
UNASUR at the WHA Since 2010, the South American Health Council has met in an Extraordinary Meeting prior to the opening of the Assembly.
UNASUR HAS ALREADY PRESENTED 35 JOINT INTERVENTIONS AT THE WHA. 14 OF THEM ON MEDICINES NUMBER OF JOINT INTERVENTIONS BY YEAR 12 10 8 6 4 2 0
2010
2011
2012
2013
2014
2015
2016
ISAGS supports the Pro Tempore Presidency of the South American Health Council in the organization of joint interventions. 2017 will be the first time that the new WHO Director-General will be elected during the Assembly. Beforehand, the process culminated during the meetings of the Executive Board.
Listen to the proposals of the 3 candidates for WHO Director-General in an exclusive interview organized by ISAGS during the last meeting of the South American Health Council: http://bit.ly/MesaRedondaCandidatos 9
INTERVIEW:
PATRICK PENGEL
MINISTER OF HEALTH OF SURINAME
“Because we can learn a lot from each other, we should make better use of our experiences. Some countries are doing better with certain initiatives than other countries, and UNASUR is a very good space to carry that out”
Last March, ISAGS was invited to convene and lead a group of high authorities from UNASUR in a course on Child Development carried out at the University of Harvard. During the course, our Executive Director Carina Vance interviewed the Surinamese Minister of Health, Dr. Patrick Pengel. With a background in Engineering, he took office in August 2015.
Carina Vance: What are Suriname’s priorities in Health right now? PATRICK PENGEL: As in most countries, noncommunicable diseases are becoming a very big burden for our health system, but they also have a much bigger impact every year on the productivity of the country. So, I would say NCDs and, particularly, cardiovascular diseases as well as all the risk factors that go along with it, like nutrition, tobacco, alcohol. Infectious diseases would be our number two or actually number three, because we also have mother and child health, whose results in the Millennium Development Goals were not satisfying. It is definitely our second priority, then.
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CV: What role UNASUR can play in addressing these issues? PP: I think we can do a lot in terms of communication. For instance, we have our Pharmaceutical Inspector [Miriam Naarendorp, alternate coordinator of GAUMU-UNASUR] working on a policy to increase the access to medicines. She is quite active in the UNASUR network and ISAGS to our advantage. We have the challenge that Suriname is Dutch-speaking, but a few people speak Spanish in the Ministry, so they can participate more in this network. Because we can learn a lot from each other, like we are learning now from this course, we should be making better use of that experience within the continent and not to reinvent the wheel. Some countries are doing better with certain initiatives than other countries, and UNASUR is a very good space to carry that out. That was the reason for creating UNASUR, but there are still some gaps that we need to fill.
CV: In your your Ministry’s for confronting mentioned?
opinion, what are greatest strengths the problems you
PP: I would say we have a knowledgeable staff, we have many Masters in Public Health, we have a Bureau of Public Health under the Director of Public Health that is a very centralized function. Many initiatives go through the Bureau. Another strength of the system is that Primary Healthcare is 50% managed by a government-owned Institute and the other 50%, in the interior, by an NGO we have an agreement with for more than 30 years now. We also have a good collaboration with the Pan-American Health Organization (PAHO-WHO) as well as other regional networks, like the Caribbean Public Health Agency (CARPHA), ISAGS and UNASUR. I think our staff is familiar with this network, so that is a plus.
CV: How is your Ministry working in terms of Social Determinants and the WHO initiative ‘Health in all Policies’? PP: We have been in this initiative for two years now. Actually, our Secretary went recently all the way to Australia to present the results that we achieved in Suriname, and we have already identified eight interdepartmental policy areas which we will implement this year. We are just waiting for our annual budget round to present them to the Parliament. It’s a simple rule, without a budget, we cannot have it done. The main areas are related to collaboration with the Ministry of Public Works for the construction of parks and upgrading the sidewalks; with the Ministry of Trade and Industry and of Agriculture for the import and use of pesticide chemicals for food safety production; and a few others.
CV: After the course we’ve just taken, which would you say are Suriname’s Early Childhood Health priorities? PP: There are a few things we can improve from conception to the first thousand days. In this course, the discussions were very productive, I was able to learn a lot from my peers. Many countries have already tested many initiatives, so we don’t have to reinvent the wheel. You take this experience and look to your local situation, in order to see how you can scale it into your country. I also learned the difference between leadership and authority, which is a very important success factor. Authority has more to do with law and enforcement, while implementation processes are more successful with a leader.
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TO THE POINT By Carina Vance
HALF WAY THERE The economic growth of the South American region in the last 15 years is undeniable, and so is growing investment in the health sector. This is undoubtedly good news for the population. If we add the implementation of public policies based on the Primary Health Care strategy, a successful recipe to strengthen the right to health of the population is generated. Health indicators, to a large extent, reflect this. However, focusing solely on macro indicators of both economic and health growth can blind us to situations and conditions that require our attention to the extent that our goal is to achieve truly universal health systems and to the extent that we want to continue to improve the health situation of all populations, including those whose reality is not reflected in national indicators. To achieve this goal, it is fundamental to deepen and broaden social participation for the construction of inclusive public policies. We have a way to go on this issue and even more so when it comes to including population groups that remain a target of discrimination and even persecution and criminalization. On the occasion of my participation as part of the Latin American and Caribbean delegation at the last meeting of the Board of Directors of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF), the first week of May in Kigali, Rwanda, I was able to learn more about the process of transition for its departure from many countries of the world, several of them South American. The GF supports actions for the prevention and care of one or more of these three diseases, working with States, civil society organizations and affected communities. According to its strategic plan, the GF proposes a reorientation of its resources (which come mainly from “developed� countries like the United States, United Kingdom, France and Germany, among others, as well as philanthropic organizations such as The Bill & Melinda Gates Foundation), towards countries
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with higher disease burden and lower income, based on the measurement of Gross National Income generated by the World Bank. The most serious consequence of this is that, often, actions that were developing successfully in countries, especially with populations of extreme vulnerability, are discontinued at any moment, worsening their health situation. In our region, the GF has agreements with Bolivia, Colombia, Ecuador, Guyana, Paraguay, Peru and Suriname and is expected to finance projects worth approximately USD $65 million in the 2017-2019 financing round. Of these countries, only Bolivia and Guyana would continue to receive support after 2019. The incidence of HIV, TB and malaria in the region has generally been reduced, but in some countries, for one or even all three diseases, the trend is actually the opposite, and in all countries, there are specific populations with prevalence and incidence greater than national average. Although the budget that the GF allocates to the countries in our region is not especially big in relation to their national health budgets, one aspect that must be taken into account is the type of actions that they finance. In the case of HIV, in several countries, with the consent of the respective Ministries of Health, there are civil society organizations that receive funds to carry out prevention actions involving affected communities that have their direct participation. Some of the populations active in these processes are men who have sex with men (MSM), transgender people, intravenous drug users and sex workers, that is to say, populations that according to several studies have a higher HIV prevalence than the general population, are discriminated and even criminalized and are largely left out of the construction process of public policies that directly impact them.
In the field of HIV/AIDS prevention, the withdrawal of the GF from several countries worldwide has been followed by a surge in the incidence of the disease, and these experiences must be analyzed in depth to avoid similar situations in our region. In countries such as Mexico, Serbia, and Thailand, the withdrawal was followed by significant reductions in budgets for prevention actions for key populations, which could cause a decline in health. In Romania, for example, one study shows that HIV prevalence among injecting drug users rose from 2 per cent in 2000 to over 50 per cent in 2013. Another example is Jamaica, which will no longer receive GF resources in the next years. It is estimated that the MSM population has an HIV prevalence of more than 30%, and in this country homosexuality is criminalized with imprisonment. It is difficult to imagine specific and effective prevention actions for this group from a State that penalizes them. This very particular topic brings to light a subject of great relevance. When we talk about social participation in the health field, how far are we willing to go? To think that communities should adapt to the schedules of bureaucracy or health services, hoping that a few representatives of the various populations will sit down for a “dialogue� is not enough. Generating effective prevention strategies requires knowing and respecting the dynamics, particularities and problems of populations. It is imperative to include the most vulnerable groups in decision-making processes, both in terms of building public policies and defining national strategies, and in the implementation of localized and targeted actions for them. From the health sector, we have the great opportunity to demonstrate the value of inclusion, equity and justice that we so much aspire to, for the sake of millions of lives, we simply cannot miss this opportunity, for the life of millions, we cannot let it pass.
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WHAT TO DO WHEN HEALTH PROFESSIONALS DO NOT WANT TO ATTEND THE POOR? What are the main gaps in health education in our region and what countries are doing to contain the problem Health systems that rely on the right of all citizens to be cared for equally face many challenges, but one of them occurs in both “rich” and “poor” countries like many in South America. This challenge is to get health professionals and mainly physicians to live and work where the most vulnerable citizens need them. This problem occurs both in remote regions of the country (whether in Brazil, Colombia, Canada or Australia) and in populations living in regions with violence or lack of infrastructure such as the marginal regions of many cities in South America (as well as in “rich” regions like the United States). The largest scale program in Primary Care in the world, the Family Health Strategy in Brazil, was not able to reach 40,000 health teams due to shortage of doctors and other professionals, partially resolved through the importation of Cuban doctors. Paradoxically, many of these professionals have been trained through state funding, sometimes in public and free universities. However when deciding where to work, very few choose to serve where they are most needed. In 1925, Raymond Pearl (JAMA 84, 14, 1925), analyzing how doctors in the United States concentrated on wealthy 14
cities, concluded ironically: “Doctors are intelligent people who want to work in places where there is money and people can pay for their services”. In addition to this propensity for financial success, there are other factors acting in maintaining this situation that creates serious problems for equity in health systems. In countries like Australia and Canada huge investments are made in tele-health technology and air and naval transport systems to be able to offer services to populations in remote areas. The challenges to work in urban areas with problems of violence and deficits transportation are less susceptible to technological solutions. Once again it is proven that resolving universal health care is part of the challenges of expanding citizenship rights to all. Some trends are specific barriers that go against the good intentions of pro-equity health policies, such as university vocational training systems, which have a technological bias that is difficult to correct. Sometimes it presents itself to health action in poor communities as a way for those with poor qualifications. This presumption is often accompanied by the reality that salaries reward
Another factor is training and accreditation systems (schools and professional training) that have a tendency to restrict supply below what is necessary, under the pretext of high quality. This means that there are not enough professionals in many countries. On the contrary, if there was an oversupply of professionals due to a more extensive training (more universities, scholarship systems) or to the entry of professionals from abroad; this set of professionals could be willing to work in places where it is more uncomfortable or sometimes dangerous, since the alternative would be to remain unemployed. This strategy of “flooding the market” has been widely used but has the counterpart of the discontent of a group of professionals who stay unemployed for long periods of time. Other countries sometimes open work permits for immigrant foreign professionals only in regions in need of health care. Several policies are being implemented in South America to correct this trend. The most well-known is the creation of “professional performance cycles” also called Social Service, such as in Chile, Ecuador and Peru, generally with compulsory residences in distant regions or remote areas. This is an
effective and temporary solution, however it has been observed that it reinforces the image of this type of work as a punishment from which one must exit quickly (usually one or two years). Another strategy is the creation of an expanded market for those who want to work in areas with deficiencies through the expansion of jobs with adequate salaries, which worked very well in Brazil in the creation of more than 100 thousand positions of doctors, nurses and dentists in the Family Health Program. Several countries are also experiencing formal or informal migration programs for professionals within the region, either by encouraging (or tolerating) the entry of foreign professionals or by promoting the return of professionals who have emigrated, on the condition of providing services in regions that need them with more urgency. Some very special regions, such as areas of jungle or very difficult access, require regimes similar to military service, such as Peace Corps, which benefit from the communications infrastructure and the state’s logistical support in those regions. In many cases, an access option is the use of tele-health for clinical teleconsultation, continuing education as well as to increase the efficiency of patient referral and counter-referral systems.
All these strategies have demonstrated that what can really have some impact is a “package” of interventions that are coherent and oriented towards the same end. Unfortunately, many countries implement contradictory measures: they create compulsory residences in unprotected areas, and on the other hand, they reward graduates who get high grades with scholarships and research funds in high technology areas. Finally, it is important to emphasize that this problem must first be seen as a crucial condition of universal health systems: if our countries have a commitment to the attention of all citizens in all regions, this commitment has an unavoidable step: create conditions for health workers to understand and accept their role in guaranteeing this right for all.
Félix Rigoli felixrigoli@isags-unasur.org
those in large hospitals and handle the high technologies. In addition to that, professional prestige scales are created by closed and often self-selected groups that keep those working for the neediest populations in the lowest positions at the scientific and professional levels.
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PILLS #ISAGSENLAAMS
Since the beginning of May, ISAGS has been analyzing and commenting on themes that will be on the agenda of the 70 th Session of the World Health Assembly. The event will be held from May 22 to 31 in Geneva, Switzerland, and the next “Health to the South” will have a special edition with a South American perspective on the debates. During the Assembly, follow the event coverage with the hashtag #ISAGSenlaAMS on ISAGS´ Social Medias.
INSTITUTIONAL
ISAGS ORGANIZES 6 MEETING OF ITS CONSULTATIVE COUNCIL TO DISCUSS CHALLENGES AND PROPOSALS TH
THE ANNUAL APPOINTMENT HAS THE ROLE OF EVALUATING AND PROPOSING THE INSTITUTE´S WORKING THEMES Representatives of the Technical Groups and the Structuring Networks of the UNASUR Health Council were at ISAGS headquarters on April 19 and 20 for the 6th meeting of its Consultative Council. The members of the Council and ISAGS team gathered to formulate recommendations regarding the planning, management, implementation and evaluation of the actions developed by the Institute last year, in addition to discussing future projects. “We reviewed the activities planned for 2017, making sure that we are linked to the technical groups, the ministries of health of the region and the structuring networks”, commented ISAGS Executive Director, Carina Vance, who chaired the meeting. On the occasion, ISAGS presented to the Council a report on its core achievements and challenges, mainly the incorporation of international employees and the implementation of policies on savings and greater efficiency in spending. “We are planning this year’s tasks and we are already projecting for 2018 to ensure that our work can be transformed into tangible results and benefits for the South American population”, Vance added. Among the issues that Council members considered relevant for the development of actions under UNASUR’ goals and in preparation for the ISAGS AOP 2018 are, for example, the need to establish permanent lines of work, in addition to the importance of including the environmental theme and the intercultural perspective in the studies of the Social Determinants of Health area. Some other issues that the members of the Consultative Council emphasized were: the perspective on the human resources training as a transverse axis to the activities of the Institute; the support in the development of policies for addressing non-communicable chronic diseases; following the processes of joint negotiations of drug prices and possible acquisition strategies, in addition to the International Health Regulations. The ISAGS Consultative Council is a permanent body and meets ordinarily once a year. Its functions include proposing strategic lines of action, formulating recommendations, suggesting programs and projects and supporting the identification of opportunities and mobilization of resources.
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ISAGS PUBLISHES RESULTS OF ROUNDTABLE WITH WHO DG CANDIDATES
On March 31, Ministers of Health and representatives of UNASUR countries attended a forum organized by ISAGS at the bloc´s General Secretariat with the participation of the candidates for Director-General of the World Health Organization: David Nabarro (United Kingdom), Sania Nishtar (Pakistan) and Tedros Ghebreyesus (Ethiopia). During the previous weeks, the ISAGS team consolidated five questions among the members of the South American Health Council to be answered by the candidates. The transcript of the answers is available in a publication on our website. You can watch the video at http://bit.ly/ MesaRedondaCandidatos and download the transcript at http://bit.ly/MesaRedondaCandidatosTranscript.
NEW COLLABORATION AGREEMENT
ISAGS and the National Health Institute of Colombia (INS) celebrated a collaboration agreement to promote and strengthen relations between the two institutions. ISAGS’ specialist in Medicines and Health Technologies, Ángela Acosta, represented the institute in a meeting with Martha Ospina, INS director, and expressed her satisfaction with the document: “We are framing collaboration and technical support to strengthen relations between institutions and also to help promote the activities of the Network of National Health Institutes of UNASUR (RINS-UNASUR)”, she said. Dr. Ospina commented on the importance for the INS to become an ISAGS partner and highlighted key issues in the region in which the Colombian Institute is a reference to provide technical support and knowledge.
SECOND INTERNATIONAL COURSE PUBLIC POLICIES IN HUMAN RIGHTS
ON
It is now open the call for the Second International Course on Public Policies in Human Rights, organized by the International School of the Institute of Public Policies on Human Rights (IPPDH) of MERCOSUR. The classes are from June to November this year and candidates can apply until May 21 at http://bit.ly/ IPPDH. The course is aimed at employees responsible for the design, management, implementation and evaluation of public policies, as well as civil society actors involved in this issue.