Rio de Janeiro, July 2017 . No 8
THE CRISIS CHALLENGES SOCIAL PROTECTION A CRISIS
ON THE PATH TO 2030
CHECKMATE: WHEN HEALTH EXPENDITURES WIN INTERVIEW: CARISSA ETIENNE DIRECTOR OF THE PAN-AMERICAN HEALTH ORGANIZATION
INDIGENOUS HEALTH: A LONG WAY TO GO
INSTITUTIONAL ISAGS-UNASUR Executive Director: Carina Vance Head of Administration and Human Resources: Gabriela Jaramillo Coordinator of International Relations: Luana Bermudez INFORMATION AND COMMUNICATION MANAGEMENT Coordinator: Flávia Bueno Editor-in-Chief: Manoel Giffoni Report: Carina Vance, Flavia Bueno, Manoel Giffoni, Mario Camelo Collaborators: Angela Acosta, Francisco Armada, Gabriela Jaramillo, Luana Bermudez Team: Bruno Macabú y Rakel Cogliatti 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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A CRISIS ON THE PATH TO 2030 The year is 2008. The subprime crisis in the United States, in a sort of ‘domino effect’, smashes the country’s fourth largest investment bank and sparks a series of bad economic news around the world – the debacle spares no one. Additionally, uncertainties in Spain bursts the real estate bubble generating a banking crisis, which is reflected in several indicators that directly affect the population, such as inflation and unemployment. The country, however, has a social protection system that initially does a fairly good job reducing harm. A health system, for instance, with the best primary healthcare program among European countries, and that is considered the 7th best in the world by the controversial study published in 2000 by the World Health Organization (WHO). “The whole system cushioned a truly terrible crisis, there is no other way to put it; a crisis that left 50% of the youth unemployed”, says Pedro Brito, a researcher at the Andalusian School of Public Health (EASP). In fact, this is no minor achievement. Based on studies conducted in the midst of Argentina’s 2001 economic-political-institutional crisis, when poverty levels reached 54%, GDP plummeted almost 11% and unemployment rates soared at more than 30%, it is not hard to infer how such an event affects the functioning of the health system and, consequently, the lives of people. According to the report of the Pan American Health Organization (PAHO), “Argentina: Socio-Economic Impact of the Crisis, 2001-2003”, being unable to pay for private insurance, people flooded public health facilities at an extraordinary rate (up to 56% more in emergency consultations and 173% in clinical and specialty ONES). It basically took place adding to widespread deterioration that included a critical increase in malnutrition, and in morbidity and mortality rates among the
most vulnerable populations, such as children, pregnant women and the elderly. “There are studies that also show a significant increase in drug and alcohol abuse in the country, as well as in mental disorders”, says Ligia Giovanella from the Brazilian National School of Public Health (ENSP-Fiocruz). Despite some identifiable effects of the crisis among Spaniards, such as an increase in smoking rates, in the prevalence of obesity and drug consumption, like anxiolytics and antidepressants, the situation cannot be said to be calamitous. “Social protection is a countercyclical policy”, explains Brito. It was precisely to discuss the effects of the economic turmoil on the health of the population and the role of protection systems in mitigating these effects that ISAGS held a meeting between June 28 and 29 with representatives of the UNASUR countries and specialists. The Seminar discussed the “Data Panel on Health Systems Asymmetries. Equity, regulation and public funding issues during fiscal crises”. It was aimed at defining parameters for establishing a joint monitoring mechanism of the health system response to conjunctural changes of the regional economies. The discussion, however, led to an alert. “Can you turn back on social achievements?”, asked Luis Andrés López, colleague of Brito at the EASP. “Unfortunately, yes”, he anticipated. Encouraged by funding agencies such as the World Bank and the International Monetary Fund, austerity policies in Spain eventually weakened the country’s health system, with changes in legislation, lower funding and a consequent increase in waiting lists, emigration of health personnel and lower patient satisfaction. With even more consequences for the future, legislation stopped considering citizens as subjects of rights, and calls them “insured”, opening space for other cuts in the universality of the system. 3
At the beginning of 2016, ECLAC had already issued a similar alarm to our region in its ‘Social Panorama’, affirming that it was “imperative to protect the core of social spending by defining policies and programs that are considered priorities - particularly those against poverty and social exclusion, and those aimed at protecting the most vulnerable population against the economic cycle”. The Report depicts the South American economic and social crisis, which has only increased since then. In a graph showing a strict correlation between the rise/fall of GDP and poverty levels, Brito reinforced the warning: “when GDP falls, social spending decreases, weakening the protection system right when it is most necessary”.
RECOVERY AT THE POVERTY LEVEL: 25 years versus RECOVERY OF GDP PER CAPITA 15 years
INCIDENCE OF POVERTY
GDP PER CAPITA
Latin America and the Caribbean: Comparison between GDP per capita and incidence of poverty, 1980-2015
A JOINT ACTION PROPOSAL: MONITORING IMPACTS AND RESPONSES TO THE CRISIS With the tool proposed in the ISAGS Seminar, the idea is to monitor in real time the impact of both the crisis, the response and the health effects among the population. Therefore, the discussions also focused on the selection of indicators and categories of analysis. Brazilian researcher Ligia Giovanella, one of the organizers of the book “Health Systems in South America”, published by ISAGS in 2012, recommended, for example, that, besides economic indicators, three dimensions of universality should also be considered:
I) Extent of coverage of the population by the public system (number of people who can access services) II) Depth of public coverage (health care covered by the system)
Source: Economic Commission for Latin America and the Caribbean (ECLAC), on the basis of official information
Sustainable Development Agenda Amidst various consensuses among the representatives of the countries, the invited researchers and ISAGS staff present at the Seminar, one stood out: the concern with the achievement of the Sustainable Development Goals (SDGs) set for 2030.
III) Level of coverage of public financing (public budget dedicated to the health sector) On the other hand, the Seminar suggested that attention should be paid to both quantitative and qualitative indicators that broadly monitor the impacts of the crisis on health conditions, such as increased alcohol and drug abuse, some contagious infectious diseases, among others.
Today, it is not uncommon to see cases where recommendations based on scientific evidence are ignored (see the US abandonment of the Paris Agreement announced by President Donald Trump while the most respected scientists warn of the catastrophic effects of global warming). In a South America committed with reducing inequalities and deepening the progresses made at the times of the Millennium Development Goals (2000-2015), the implementation of austerity measures in social protection systems could lead to setbacks in the health and well-being of the population, as evidence shows in other parts of the world.
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Manoel Giffoni manoelgiffoni@isags-unasur.org
Established in 2015, the second global journey towards a world with less inequality, better health, education and a more sustainable way of life had a troubled start in South America, with several countries (particularly, one of its greatest economies, Brazil) presenting negative growth, rising unemployment and inflation.
EXPERTS CORNER HEALTH TECHNOLOGY ASSESSMENTS, ALERTS AND UNANSWERED QUESTIONS by Angela Acosta, ISAGS’ specialist in Medicines and Health Technologies
Although recent publications show high expectations regarding the implementation of health technology assessments (HTA) in South America1,2, there are also other instances that alert about what is still to be solved, almost 20 years after institutional experiences such as the National Institute of Health and Clinical Excellence of England (NICE) and other more recent ones like the experiences of Germany, Sweden and Canada3,4,5. With the creation of NICE in 1999, its work has contributed to the recognition of HTAs as a tool to establish health priorities, relying mainly on methods related to evidence-based medicine and economic evaluations such as comparative effectiveness studies, cost-effectiveness and budget impact analysis. Regarding the efforts made by countries such as Colombia in relation to the creation of HTA Agencies, by 2012 some references projected that these instances could become the cornerstone that would provide information regarding challenges such as budget constraints, increases of health costs demographic transitions towards population ageing, as well as social and market pressures to allow the entry of new technologies; meanwhile, a call was also made to develop a balanced exercise of HTAs, giving a fair measure to the access to individual services versus public health services. Cost-effectiveness, which assesses disease frequency, safety and efficacy of interventions, outcomes reported by patients, and costs in order to assess short- and long-term consequences, is currently one of the most prominent decisionmaking criterium on HTA programs. Nevertheless, current evidence demonstrates that a health technology cannot prove its effectiveness until its availability, acceptability, safety and supply conditions have been followed and assessed in several segments of the population. Clinical efficacy and effectiveness are only half the history of HTA. More important still, the other responses the HTA process is aimed at giving are related to equity. In this regard, even longstanding experiences such as NICE show that they have not taken this other dimension into account. Components such as social, ethical and legal aspects, which theoretically should be among variables in HTAs1, have not been incorporated yet. An alert of our regional reality indicates problems in the South American health systems related to both equity and efficiency, and also one well known in countries like Argentina, Brazil and Colombia: judicial means to access medicines coverage5,6. While more than 50% of South American countries report that HTA processes have not been formally incorporated in their legislation, there is also limited availability of local data to develop economic assessments with costs linked to our
realities. In this sense, regional projects such as the Medicines Price Bank of UNASUR is a source that can provide more accurate inputs to our realities. Another theoretical component that has been excluded from HTA are the structures of service delivery within health systems. While they are related to technology assessments1, national programs do not address them. Many low- and middleincome countries have focused important efforts to strengthen and sustain their population health; research such as that coordinated by ISAGS in 2012 on the structure of our health systems7 must undergo updating processes in a systematic way, so as to provide inputs for specific contexts such as this. Today, the challenges mentioned in relation to the development of HTAs lies in the fragmentation between the decisions of entry, coverage and financing, particularly for medicines within the health systems.
“Health Technology Assessments are perhaps the most powerful arm of England’s national health research program” (The Lancet, 2013) In 2013, Sally Davies, England’s leading health adviser on health issues, formulated the incorporation of equity as a turning point in the history of the HTA program in England3. The goal is to incorporate it in the next 20 years. The same target must be considered today in the development of HTA programs of South American countries, a region that still has deep and, sometimes, growing inequalities. References 1. Lifschitz, E (Ed), Martich E, Tobar S, Watman R. Agencias de evaluación de tecnologías sanitarias, Lecciones aprendidas em países de Latinoamérica y Europa. Fundación Guemes, Argentina, 2017. 2. Rosselli D, Quirland-Lazo C, Csanádi M, etal. HTA Implementation in Latin American Countries: Comparison of Current and Preferred Status. Value in Health. Volume 14, pag 20-27. 2017. 3. Harton R. Offline: The error of our health technology assessment ways. The Lancet, comment. Vol 382 October 19, 2013. 4. Godman B, Oortwijn W, DeWaure C, etal. Links between pharmaceutical R&D models and access to affordable medicines. European Union, PE587.321EN.IP/A/ ENVI/2015-06.2016. 5. Oortwijn W, Determann D, Schiffers K, etal. Towards Integrated Health Technology Assessment for Improving Decision Making in Selected Countries. Value in Health (2 0 1 7), article in press. 6. Castro, H. (2012). Agencias de evaluación de tecnologías en salud ¿moda o necesidad? Vía Salud, 16 (1), 12-17. 7. Giovanella L, Feo O, Faria M, Tobar S. Sistemas de salud en Suramérica: desafíos para la universalidad, la intergralidady la equidad. ISAGS, 2012.
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CHECKMATE:
WHEN HEALTH EXPENDITURES WIN Catastrophic health expenditures are responsible for the impoverishment of thousands of families every year, pointing to the need for urgent measures to protect their right to health The scenario is one of despair, the household faces a double calamity. From one day to the other, the family loses much of what was built over generations right when it is affected by the illness of a loved one. This is an extreme reality, but it is more common than one can imagine. Estimates from the World Health Organization1 suggest that every year about 150 million people suffer financial catastrophe for health spending and that thousands are pushed into poverty. This reveals what catastrophic health expenditures represent, spending that exceeds 40% of family income after subsistence needs are met2. They are closely linked to the way health is funded, ie through the payment of taxes, some state subsidies or are direct expenditures made by users. These expenses are, according to WHO, those payments by individuals to health care providers at the time of use, excluding taxes and also health insurance, without the possibility for reimbursement. Since the publication of the World Health Report 2010 “Financing health systems: the road to universal
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coverage�, WHO and its office in the Americas, the Pan American Health Organization (PAHO), have been working to promote the universal access and/or coverage as one of the ways to reduce the risks of catastrophic expenses. Universal health coverage is a broad concept that mainly refers to the structure of health systems, ranging from those based on insurance with minimum packages, to those recognized as universal health systems. Despite the lack of specificity of the concept, this policy gained even more prominence with the launch of the United Nations Sustainable Development Goals (SDG), in which its member countries agreed to reach universal health coverage by 2030. The target 3.8 (part of the SDG 3 - Health) has as indicators the coverage of essential health services and the insufficiency of financial protection, that is, the proportion of the population with health expenses exceeding 25% of their total income. In fact, studies comparing the prevalence of catastrophic expenditures apply very different methodologies and, in addition, the primary
Perticara, who carried out a study on health expenditures in seven countries (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico and Uruguay) for CEPAL3, found data that may seem contradictory, but which has even more devastating explanations. The proportion of households with zero health expenditures is, in relative terms, higher among low-income groups (with the exception of Ecuador and Colombia), that is, the most vulnerable people do not spend in health. This, explains the researcher, is due to the fact that many of these people are covered in some way by social insurance, but in addition, there is a more worrying conclusion: these groups simply do not have the resources to spend. In a 20164 study, the researcher from the Fiocruz National School of Public Health, Vera Lucia Luiza, and colleagues report that 5.3% of Brazilian households are extremely affected by catastrophic health expenditures and 3.2%; Main promoter of this situation. Brazil has one In a 20164 study, researcher Fiocruz National School of Public Health Vera Lucia Luiza and colleagues point out that 5.3% of Brazilian households are extremely affected by catastrophic health expenditures and in 3.2% spending on medicines was the main cause of this situation. Brazil has a universal health system that covers all its territorial extension and seeks the equity and integrality of health care; however, much of the drug costs are private5. In Argentina, important data show that 1.7% of households fell into poverty due to direct health expenditure6. To mitigate these effects, in recent years the country has developed “regulations that have put a stop to increases in health plans and improved the rights of patients, [which]may also have reduced the incidence of catastrophic expenses”, added Marcela Perticara. In order to mitigate these risks, other countries in the region have been implementing reforms in their systems. Chile is an important case with the recent approval of the law Ricarte Soto, which was
presented by the country during the World Health Assembly this year. According to the Chilean Minister of Health, Carmen Castillo, in an interview for Health to the South, this is a law that “ includes high-cost treatments, devices and foods, that would ruin a family with out-of-pocket expenditure”. In the case of the AUGE (Universal Access Plan for Explicit Guarantees), which covers chronic diseases of the highest prevalence in the population, expectations for improvements are even greater. WHO points to many ways to mitigate and reduce these costs, such as abolishing payments in public services, exempting vulnerable populations from payments, and offering free services such as maternal and child care. This, in fact, indicates that structural changes in health systems are needed, with the redesign of policies in a broad way. Hence, the challenges for health systems of our region are multiple to achieve the financial protection of the people; however, we cannot lose sight of the quest for equity in a comprehensive manner and the guarantee of the right to health for all populations.
Referencias 1. OMS. Financiación de los sistemas de salud: el camino hacia la cobertura universal. 2010. 2. XU Ke, et al. Designing Health Financing Systems to Reduce Catastrophic Health Expenditure. Technical Briefs for Policy-Makers, OMS, 2005. 3. PERTICARA, M. Incidencia de los gastos de bolsillo en salud en siete países latinoamericanos, v. 50, supl. 2, 15s, 2008. 4. LUIZA, VL et al . Gasto catastrófico com medicamentos no Brasil. Rev Saúde Pública 2016;50(supl 2):15s. 5. Boing AC, et al. Acesso a medicamentos no setor público: análise de usuários do Sistema Único de Saúde no Brasil. Cad Saude Publica. 2013; 29(4):691-701. 6. ABELDANO, RA. Análisis del gasto de los hogares en salud en Argentina, como componente de la cobertura universal de salud. Ciênc. saúde coletiva, Rio de Janeiro , v. 22, n. 5, p. 1631-1640, May 2017.
Flávia Bueno flaviabueno@isags-unasur.org
information sources used, in general by household surveys in each country, have important variants such as the structure of the health system itself and “the way people ask in these spending surveys, [which] can make people report differently”, adds Marcela Perticara, professor at the Universidad Alberto Hurtado in Chile.
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Sexual Health
and Reproductive Health Venezuela
Ecuador
Guyana
2.5 mniulnldieor n16
suriname
wome ch year give birth ea
colombia
16) (GSWCAH, 20
PerĂş
Brasil Bolivia Paraguay
chile
Argentina
uruguay
Number of liv e births per 1,000 adolesc ent women from 15 to 19 years old 40 to 55 55,1 to 70 70,1 to 85 85,1 to 90 Source: Health
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in the America
s 2016 (PAHO/W
HO)
Number of live births per 1,000 women from 15 to 19 years old
Adolescent fertility in Latin America 90 85 80 75 70 1990
2000
2010
year
Source: United Nations
Statistical Division: Mill ennium Development Goal Indicators Databas e.
Several recomendations for preventing undesired teen pregnancy
1
2
3
Strengthen sexual education within a sexual and reproductive rights framework Enable the access to contraceptives for teenagers Reduce unsafe abortion among teenagers
4
5
Action against sexual violence Limit marriage before 18 years of age
6 Favour friendly sexual health and
reproductive health services for teenagers
Target 3.7 of the SDGs a n a y u G d n a y a u g u Ur
can South Ameri are the only is ere abortion th eek countries wh 12 w law until the permitted by ance any circumst in y c n a n g re of p
By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes
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INTERVIEW:
CARISSA ETIENNE
DIRECTOR OF THE PAN-AMERICAN HEALTH ORGANIZATION (PAHO) Appointed in 2013 to the highest position in the Pan American Health Organization, Dominican Carissa Etienne is running for a second term. As a single candidate, she will surely be re-elected at the Pan American Sanitary Conference in late September. She spoke with our Executive Director, Carina Vance, about working with other intergovernmental organizations, with non-state actors and her priorities for the future. 10
CARINA VANCE: There are many political and trade agreements in the Americas - such as UNASUR, MERCOSUR, ORAS-CONHU, CARICOM and COMISCA - that have their own sub-regional agendas. As PAHO Director, how would you define a roadmap to combine and synergize all these different agendas and priorities? CARISSA ETIENNE: There is a lot of diversity in the Americas, whether cultural or socio-economic, and PAHO, as an intergovernmental organization, has a duty to recognize the specificities and needs of countries and regional groups. South America, for example, is a highly developed region as far as integration processes are concerned, and I find it vital to work with them. On the one hand, we have a lot of knowledge and experience; therefore, we should share much more in the framework of South-South cooperation, triangular cooperation, etc. On the other, PAHO can function as a link between sub-regions.
CV: How do you see the role of the new PAHO office in Lima for sub-regional coordination? CE: We have a long-standing regional office in the Caribbean Community (CARICOM) region. It is an initiative to get closer to the sub-region and to sub-regional agencies, not from the point of view of selling our agenda, but from the point of view of collaborating and improving the work we do with technical cooperation or other activities. Again, they depend on the specificities of each country and subregion. I am very encouraged by the fact that we have so much solidarity on our continent and it seems entirely possible that we can come together to define a common agenda to bring our efforts together. Ultimately, we exist to serve the Member States, so the best we can do is to make our work more efficient, never from a position of opposition or competition.
CV: What is your position regarding non-state actors, which, nowadays, play such an important role in Global Health? How is PAHO implementing the Framework of Engagement with Non-State Actors (FENSA) and what are the next steps? CE: As you know, the entire global discussion at the WHO on FENSA took about four years, because there is an important dichotomy in how countries understand the role of the private sector and non-state actors. Many countries of the continent, particularly the countries of the South, had many concerns about the influence of the private sector and non-State actors in WHO’s decisionmaking. They were concerned about the need to safeguard WHO’s role in setting norms and standards and, therefore, wanted to block the influence of non-State actors. Other groups have a different point of view. The FENSA was then developed, which was accepted by the Member States. PAHO had difficulties with this, because we have our own constitution and we had to make them compatible. For example, the one who decides who the non-state actors with whom PAHO collaborates is not the WHO’s director-
general, but PAHO itself through its director. My view is that, because of the Sustainable Development agenda, the 2030 Agenda, governments and intergovernmental organizations alone will not be able to do the work. We will need the collaboration of the private sector, including foundations and civil society. However, we must be careful. The goals and challenges of non-state actors are not necessarily the same as ours, so we must be very careful about relationships and our principles.
CV: In your opinion, what were the most important achievements of your first term as a director? What were the adversities? CE: Building up on the work that had been developed before, we had very good news the past 5 years, like the announcement of the elimination of measles and congenital rubella syndrome, which is a great achievement. We are working with some countries that eventually managed to eliminate onchocerciasis and trachoma - the first countries in the world to do so. Cuba was the first country in the world to interrupt mother-tochild transmission of HIV/AIDS. In turn, malaria cases fell dramatically and we are already looking for an elimination agenda particularly in Central America, but also in South America. That is, in terms of neglected infectious diseases we did a lot. As you know, one of my priorities is universal access to health and universal coverage. We revitalized the issue of strengthening health systems with a focus on primary care, with the adoption of a resolution in 2014 - it was one of the happiest days of my life - but there is still a lot to be done. As far as Noncommunicable Diseases are concerned, it is very frustrating that we do not have enough funding from either governments or donors, although we were able to do some things. We included medicines for NCDs in the Strategic Fund, which 30 countries are part of nowadays. We even made an agreement with MERCOSUR for negotiations on high-cost drugs. The purchases will be made through the Fund. We also work with countries on NCD prevention issues such as tobacco control, implementation of food labeling, physical activity, among others. Another important work we did was with the International Health Regulations. In a total of 28 missions, we were able to find out the status of the main capabilities, identify gaps and offer help to fill them. With regard to vaccines, we had many challenges with the new vaccines. About 41 countries buy vaccines through our vaccine program, saving millions of dollars for countries. This amount should actually be quantified. Another great success, something unprecedented in PAHO’s history: the support we gave to Brazil in the More Doctors Program to increase access to primary health care services in rural areas. We acted as middlemen between the country and Cuba, which sent 12,000 doctors through the program. We also act in continuous evaluation and managing the funds. A great challenge with a spectacular result, as we could extend the attention to 63 million people in Brazil. 11
TO THE POINT By Carina Vance
HEALTH IN ALL POLICIES, INCLUDING TRADE... In a few months, Buenos Aires will host the 11th Ministerial Conference of the World Trade Organization (WTO), the highest-level meeting of the institution, convened every two years to discuss and decide on world trade issues, some of which with enormous implications for health. It is the first time it is convened in a country in South America. In WTO meetings, member countries agree on decisions related to such issues as access to medicines, the application of flexibilities on the Trade-Related Aspects of Intellectual Property Rights Agreement (TRIPS) for the granting of compulsory licenses; debate about policies like those related to the control of tobacco products, such as those implemented in Uruguay and other countries in the region; and discuss policies such as the processed food labeling implemented by Chile 12
and Ecuador. In this arena where public health interests and economic interests are many times in dispute, although interdependent, the interests of the world’s largest transnational corporations are often backed by the most powerful countries sometimes in opposition to arguments from the health field. It is a scenario in which global health would benefit from the greater substantive involvement of representatives of the health sector from the different countries. The Ministries of Health participate actively in the World Health Assembly and in international and regional conferences held by integration mechanisms or organizations that work directly with health. Disputes between diverging interests also occur here, without a doubt, but here the court is more inclined towards the interests
of public health and many times, despite the particularities or nuances held in the various positions regarding health, we often find ourselves “preaching to the choir”. This is not to say that this exercise is not valuable, it allows us to share ideas and experiences that strengthen arguments and negotiation strategies, but the agreements and resolutions that emerge from these encounters must be complemented by agreements in other fields of work, if we hope to be effective. The processed food labeling implemented by Ecuador in 2014 is widely recognized, but it is less well known that there was a subsequent process in the WTO, where, among others, the European Union, the United States and Switzerland, raised a “concern” that the measure could be a “technical obstacle to trade.” The Ecuadorian Government successfully defended its labelling policy, indicating that it was a measure that sought to protect the health of its population and demonstrating that it did not contravene any of the WTO agreements. It is quite possible that the defense strategy would not have been successful had there not been a close articulation between the State Portfolios responsible for health, foreign trade and production, as was the case. Also, it draws attention that Ecuador received requests for cooperation related to the implementation
of the food labelling policy from the health ministries of several countries, while at the same time having to defend this same policy from the objections presented to the WTO by foreign trade sector representatives of some of the same countries. The example clearly shows a situation that is repeated when dealing with this and other issues within countries: contradictory positions between the health and the trade sectors. Ever since the Helsinki Declaration of 2013, the “health in all policies” approach is mentioned in almost all summits and meetings where health issues are discussed. It proposes an intersectoral approach that takes into account the impact on health of all public policies. Frequently shared, are successful experiences of articulation between health and the education, social development or economic inclusion sectors, all undoubtedly essential to improving the health situation of the population. As are these sectors, the trade sector, is equally critical to health. It would be strategic, therefore, for the countries participating in the WTO Conference to do so with contributions from their Ministries of Health in their areas of responsibility. If we truly expect health to be considered in all policies, we must play in its favor on all courts.
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A LONG WAY TO GO What countries are doing to overcome the challenges of the region in Indigenous Health Long before the arrival of Europeans, indigenous peoples populated vast tracts of South America. It is estimated that, in 1492, the indigenous population in the region reached about 20 million1. Because of voracious colonialism, many of these populations were decimated. However, after the 19th century, the number of indigenous people grew again and their needs, slowly, began to integrate the agendas of public health policies. According to a population analysis of the Economic Commission for Latin America and the Caribbean (ECLAC) in 2014, it is estimated that the indigenous population accounts for about 45 million people, or 8.3% of the population of the region. It is assumed that this growth is the result of a greater ethnic awareness, and of “the revitalization of indigenous identity in recent years, which consequently materializes an increase of self-identification”2. Despite the space conquered in public health policy agendas, today the needs of these peoples are much more complex than before and go beyond issues such as interculturalism and the differences between traditional medicine and occidental medicine. There are new diseases, disorders and other conditions introduced into their lives. The anthropologist and co-director of the Center for Anthropology Studies at the National University of San Martin in Argentina (CEA/UNSM), Silvia Hirsch, says that, lately, there has been an increase in cases of NonCommunicable Diseases (NCDs), for example. “Diabetes, obesity and the consequent disorders of these problems are growing a lot”, states the specialist, who along with Mariana Lorenzetti just launched the book “Public Health and Indigenous Peoples in Argentina”.
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For her, these new needs are reflected in many aspects that require adjustments in public health management, such as primary care and the effectiveness of systems. In
general, throughout Latin America there are public health policies that “more or less” reach those populations. “But many things happen. In some communities, programs work better, in others don’t. Sometimes doctors do not come often. Access to medicines is also an issue and the cultural dimension is something that must be greatly improved in public policies, not only in Argentina but throughout all the region. There are important differences and tensions, but if many are looking for systems is because there are serious diseases to treat as well”, she said. In general, in South America, almost all Ministries of Health have programs, directions or secretariats that deal exclusively with the subject of Indigenous or intercultural Health. Brazil, for example, which has the biggest diversity in the region with 305 different indigenous populations, created in 2010 the Special Secretariat of Indigenous Health (Sesai, in Portuguese). Since then, important actions have been taken, such as combating indigenous child mortality. According to the Ministry, the nutritional coverage of children under the age of five increased from 61.9% in 2013 to 67.9% in 2014. In addition, a program named “More Doctors” increased by 344 the number of doctors in the 34 Special Indigenous Health Districts (DSEI). In Peru, the country with the largest indigenous population in the region (7 million), in April of this year, the Directorate of indigenous or native peoples was reincorporated into the Ministry of Health, but now as part of the strategic interventions in public health. With the new norm is expected to generate more attention in Health to the communities of the country with policies adapted to their reality and needs.
COLOMBIA: In May 2017, the Ministry of Health announced a strategic plan against tuberculosis. The Sub-Director of Communicable Diseases, Diego Alejandro Garcia Londoño, said that within the framework of the plan “strategic lines should be strengthened in vulnerable populations, especially indigenous people”; ARGENTINA: In 2016, the country created the first Health Program for Indigenous Peoples, within the scope of the National Department of Community Health Care of the Ministry of Health of the Nation; BOLIVIA: In August 2016, at the seminar “Health of Indigenous Peoples”, Bolivia committed itself to strengthening Intercultural Community Family Health; CHILE: In April of this year, after two years of intense negotiations, Chile approved the new regulation that establishes the right of native people to receive health care with cultural relevance; VENEZUELA: In 2010, Venezuela started the “Cacique Nigale” project, whose mission is to direct young students from indigenous communities to careers in the Health area, reducing intercultural gaps in the system.
In South America, there are many initiatives and regional organizations that are very significant for the work in health of native peoples, since they have the difficult mission to overcome the borders and to create a joint view at the decisions of the governments. The Andean Regional Health Agency-Convention Hipólito Unanue (ORAS-CONHU), for example, that since 1971 works for the health of Andean peoples, has many policies in this regard. One of the most important is the “Andean Intercultural Health Policy”, launched in 2014. Another example of cooperation is a training in malaria coordinated by the Amazon Cooperation Treaty Organization (ACTO) in countries such as Bolivia, Peru and Ecuador, which will train its technicians in indigenous affairs. Many of the participants are members of these communities. “ACTO as an organization has among its functions to create structures that lead to collective decisions and that allow countries to develop collective visions that will become tools for national and regional decisions”, said the organization’s Executive Director, César Augusto de las Casas Díaz. Despite the advances, there are still many difficulties on the way towards comprehensive health care for these populations. ACTO´s Regional Health Coordinator, Luis Francisco Sánchez Otero, tells some of the many challenges that have been presented, such as the introduction of sexually transmitted diseases as AIDS and hepatitis in their environment, vector-borne diseases, resistance to antibiotics, illegal mining and the interests of the private sector, among others. “The Amazon is a heterogeneous region. The
situation and risks are different. From the point of view of information, for example, the indigenous people are often closed, isolated or the next health station is three days away by boat. Such information, which would allow us to make a better characterization for the interventions, we do not have. There is a lot of work, a lot of perspectives and a lot of interesting things to do, but you cannot look at the problems separately”, he concludes. Currently, ISAGS is also working on the development of an intercultural health policy survey of South American countries coordinated by the Institute´s Specialist on Social Determination of Health, Francisco Armada. The study responds to a request from Bolivia, approved by consensus by the all the Ministries of Health of UNASUR. “The enormous South American cultural diversity, as well as its multiethnic and multicultural character, represents at the same time a challenge and an excellent opportunity for the formulation of public policies”, says Armada. References 1. Steward, Julian H. A população nativa da América do Sul. Revista do Museu de Arqueologia e Etnologia, São Paulo, v.10, p. 303-315, 2000. 2. NU. CEPAL. Los pueblos indígenas en América Latina. Avances en el último decenio y retos pendientes para la garantía de sus derechos. Síntesis. 2014.
Mario Camelo mariocamelo@isags-unasur.org
OTHER GOOD PRACTICES IN COUNTRIES OF THE REGION
The importance of intergovernmental organizations
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INSTITUTIONAL DIALOGUES FROM THE SOUTH: THE SECOND EDITION OF THE CYCLE OF DEBATES ON INTEGRATION IN HEALTH HIGHLIGHTS ASPECTS OF THE INTERNATIONAL HEALTH REGULATIONS (IHR) The second edition of Dialogues from the South - the cycle of debates that practically and dynamically discusses Health issues as a point of convergence in the countries of South America - took place last June 13 at ISAGS headquarters and had the debate within the framework the International Health Regulations (IHR), which has just completed ten years since its implementation. “Between the individual right and the protection of Public Health: Epidemics and the role of the State” was the rountable main theme, which was moderated by the specialist in Health Surveillance of ISAGS, Eduardo Hage, and with the participation of the PhD In International Law, Deisy Ventura, from the Institute of International Relations of the University of São Paulo (IRI/USP); and PhD in Public Health, Fernando Aith, Department of Preventive Medicine, University of São Paulo Medical School (DMPFM/USP).
PILLS CALL FOR CASE STUDIES: HEALTHY AGING ISAGS Call for Case Studies on the Healthy Aging will be open until July 23. Three studies on interventions in countries of South American region will be selected, and will receive support in organization and dissemination. The Institute will also offer assistance in the processes of information collection and publication of the studies. The objective is to characterize the aging process in the region with an emphasis on the impact on health systems and strategies aimed at improving the living conditions of the elderly population. Those interested should access ISAGS website to register: www.isags-unasur.org
ENSP AND ISAGS REAFFIRM COLLABORATION AGREEMENT FOR TRAINING IN PUBLIC HEALTH
Hage and the specialists discussed the changes and challenges for the South American countries in the adoption of the IHR measures, in terms of their legal structures. In addition, specific surveillance measures planned for public health emergencies, especially epidemics and their relationship with the right to health. Individual and collective rights and freedoms were also subjects of the agenda. Dialogues from the South continues until the end of the year and its next edition will be in September.
WORLD NO TOBACCO DAY: ISAGS ORGANIZES EVENT TO DISCUSS IMPACTS OF THE SUBSTANCE USE IN THE REGION On June 1st, as part of the date established by the World Health Organization, ISAGS organized (with Brazilian institutions related to the theme) the event “World No Tobacco Day - Costs for Development in South America”, calling attention to the fight against the use of tobacco, which kills about six million people a year, according to WHO. The headquarters of the Institute received researchers, specialists and representatives of relevant institutions for a debate led by our specialist in Social Determination of Health, Francisco Armada. The unpublished study: “Burden of diseases attributable to tobacco use in Brazil and the potential impact of price increase by means of taxes” was also presented by researcher Márcia Pinto, Instituto Fernandes Figueira (IFF/Fiocruz) and collaborators. The evaluation, developed in 2013 and updated this year, covers data on some diseases related to tobacco use and the cost of these diseases for health systems in Brazil and other countries in South America. Topics such as the advances and challenges of the National Tobacco Control Program in Brazil, the contribution of regulatory agencies for sustainable development through tobacco control; and the Tobacco Control in the Agenda 2030 for Sustainable Development were some of the points addressed by specialists. Other organizations such as The National Commission for the Implementation of the Framework Convention on Tobacco Control (CONICQ/Brazil); The Brazilian National Health Surveillance Agency (ANVISA); The National Cancer Institute of Brazil (INCA), the Tobacco Control Alliance (ACT), the Cancer Foundation, and the Center for Tobacco and Health Studies (CETAB/Fiocruz) also supported the event. 16
ISAGS executive director, Carina Vance, and its International Relations team met with officials of the Sergio Arouca National School of Public Health (ENSP/Fiocruz) - which is the Executive Secretary of the UNASUR Network of Public Health Schools (RESP/UNASUR) - to discuss themes of the common agenda of work between the two institutions. At the meeting, the organisms pledged to continue with updating the mapping of the South American public health training, a project that is already under development. ENSP director, Hermano Castro, and Vance also emphasized the intention to increase the participation of both institutions in common activities.
NEW REPORT ON CHILDREN ADOLESCENTS OF MERCOSUR
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The Institute of Public Policies on Human Rights of MERCOSUR (IPPDH) has just launched the report “Children and adolescents across the MERCOSUR borders”, which presents and discusses the results of a research carried out during 2014 together with the regional office for South America of the International Organization for Migration (IOM) in order to contribute to a better understanding of the reasons and procedures by which children and adolescents cross international borders. Access the full study on the Organization’s website: www.ippdh.mercosur.int.