The Civil Society Forum on the African Charter on the Rights and Welfare of the Child (ACRWC) has written this open letter to G8 Countries to urge them to meet their promises for external funding to African countries, noting that countries have failed to fulfil their promise for increased aid allocation to Africa – with assistance from France and Germany increasing by just 25%, while Italy is actually set to reduce its contribution by 6% this year. They also urge for continued commitment within Africa to pledges made by leaders. The members note that while domestic allocations are difficult to achieve with all the pressures on very limited resources, they are critical for the health sector if we are to meet the MDGs. The letter draws special attention to the need for investing in maternal, newborn and child health. ACRWC is urging African leaders to endorse the letter. They ask readers to circulate the letter through networks and for those connected, directly to the Africa leaders.
Editorial
We remember you in Maputo, in the 1980s, from that time you spent as a political refugee in Mozambique. Often our paths crossed on Julius Nyerere Avenue and we would greet each other with the casual friendliness of neighbours. Often I imagined the fears that you must have felt, as a person persecuted by the apartheid regime. I imagined the nightmares you must have experienced at night when you thought of the ambushes plotted against you and against your comrades in the struggle. But I don’t remember ever seeing you with a bodyguard. In fact it was we Mozambicans who acted as your bodyguards. For years we gave you more than a refuge. We offered you a house and we gave you security at the cost of our security. You cannot possibly have forgotten this generosity.
We haven’t forgotten it. Perhaps more than any other neighboring country, Mozambique paid a high price for the support we gave to the liberation of South Africa. The fragile Mozambican economy was wrecked. Our territory was invaded and bombed. Mozambicans died in defence of their brothers on the other side of the border. For us, Mr President, there was no border, there was no nationality. We were all brothers in the same cause, and when apartheid fell, our festivities were the same, on either side of the border.
For centuries Mozambican migrants, miners and peasants, worked in neighbouring South Africa under conditions that were not far short of slavery. These workers helped build the South African economy. There is no wealth in your country that does not carry the contribution of those who today are coming under attack.
For all these reasons, it is not possible to imagine what is going on in your country. It is not possible to imagine that these same South African brothers have chosen us as a target for hatred and persecution. It is not possible that Mozambicans are persecuted in the streets of South Africa with the same cruelty that the apartheid police persecuted freedom fighters, inside and outside the country. The nightmare we are living is more serious than that visited upon you when you were politically persecuted. For you were the victim of a choice, of an ideal that you had embraced. But those who are persecuted in your country today are guilty merely of having a different nationality. Their only crime is that they are Mozambicans. Their only offence is that they are not South Africans.
Mr President, the xenophobia expressed today in South Africa is not merely a barbaric and cowardly attack against “the others”. It is also aggression against South Africa itself. It is an attack against the “Rainbow Nation” which South Africans proudly proclaimed a decade or more ago. Some South Africans are staining the name of their motherland. They are attacking the feelings of gratitude and solidarity between nations and peoples. It is sad that your country today is in the news across the world for such inhuman reasons.
Certainly measures are being taken. But they are proving inadequate, and above all they have come late. The rulers of South Africa can argue everything except that they were taken by surprise. History was allowed to repeat itself. Voices were heard spreading hatred with impunity. That is why we are joining our indignation to that of our fellow Mozambicans and urging you: put an immediate end to this situation, which is a fire that can spread across the entire region, with feelings of revenge being created beyond South Africa’s borders. Tough, immediate and total measures are needed which may include the mobilization of the armed forces. For, at the end of the day, it is South Africa itself which is under attack.
Mr President, you know, better than we do, that police actions can contain this crime but, in the current context, other preventive measures must be taken. So that these criminal events are never again repeated.
For this, it is necessary to take measures on another scale, measures that work over the long term. Measures of civic education, and of exalting the recent past in which we were so close, are urgently needed. It is necessary to recreate the feelings of solidarity between our peoples and to rescue the memory of a time of shared struggles. As artists, as makers of culture and of social values, we are available so that, together with South African artists, we can face this new challenge, in unity with the countless expressions of revulsion born within South African society. We can still transform this pain and this shame into something which expresses the nobility and dignity of our peoples and our nations. As artists and writers, we want to declare our willingness to support a spirit of neighbourliness which is born, not from geography, but from a kinship of our common soul and shared history.
This editorial is reproduced from Brittle Paper and is an open letter addressed to President Zuma, written by award-winning Mozambican novelist Mia Couto.
This month's editorial draws our attention to the shift the profile on universal coverage has brought in the international debate on global health. Much of this dialogue on universal coverage has been focused on financing issues. However universal policies cannot be only technical, or financial. A December 2010 World Conference on Universal Social Security Systems in Brazil put it simply - universal policies are the means to deliver on rights based guarantees that citizens are entitled to and that states have a duty to ensure, including access to health care. At national and global level there is a huge gap in how this is delivered on. Researchers from Africa, Asia and the Americas observed in a statement at the final plenary of the first Global Symposium on health systems research: “Equity is the central goal. Universal health coverage is the means of achieving equity”. As experience has taught in many places, closing this gap, nationally and globally, calls, beyond technical options, on political leadership and social power and action. What we say and do within and across all our different constituencies will be pivotal in realising universal policies in health. We wish you a safe, healthy and peaceful new year and look forward to our interaction towards equity in 2011.
Social health insurance schemes, introduced in the name of universal health coverage (UHC), are excluding the majority of people and leaving the poor behind. So argues a new report from Oxfam ‘Universal health coverage: why health insurance schemes are leaving the poor behind’.
The growing momentum for universal health coverage (UHC) is certainly cause for celebration. But in some cases health financing reforms are widening inequality by prioritising already advantaged groups in the formal sector and leaving the most poor and marginalised people – especially women – as last in line to benefit.
This raises the question of why there is an almost exclusive focus on contributory-based health insurance schemes as the way to achieve UHC. Although no country in the world has achieved anything close to UHC using voluntary insurance, private and community-based voluntary schemes are still being promoted by governments and external funders. India’s voluntary India’s voluntary Rashtriya Swasthya Bima Yojana insurance scheme for people below the poverty line is widely praised as a success. However evidence cited in the Oxfam report indicates that the scheme offers limited financial protection against impoverishing out of pocket spending on health and has skewed public resources to curative rather than preventative care.
For those who recognise the pitfalls of voluntary schemes, social health insurance (SHI) has emerged as the model of choice. SHI has worked to achieve UHC in a number of high-income countries. However attempts to replicate the same kind of employment-based models in low- and middle-income countries have proved unsuccessful. Even high-income countries struggled to achieve rapid scale up via SHI. In Germany UHC took 127 years to achieve using a SHI model. Surely people in low and middle income countries (LMICs) should not have to wait that long!
In low and middle income countries SHI schemes are typically characterised by large-scale exclusion. Ten years after the introduction of SHI schemes in Tanzania, according to a National Health Insurance Fund 2011 report, coverage had reached only 17 per cent. Kenya’s National Hospital Insurance Fund – established nearly 50 years ago – today insures just 18 per cent of Kenyans. Ghana’s National Health Insurance Scheme (NHIS), widely promoted as an SHI success story, covers only 36 per cent of the population.
Hopes that insurance contributions from those outside of formal employment would raise significant revenue have not been realised. In Ghana, cash premiums paid directly by those in the informal sector contribute just five per cent towards the cost of the NHIS, that also draws funds from earmarked tax and other sources. Governments also face huge bills to cover the SHI contributions of their workers. According to 2010 National Health Insurance Fund Tanzania and WHO evidence cited in the report, the Government of Tanzania spent $33m on employer contributions in 2009/10; this equated to $83 per employee – six times more than it spent per person, per year on health for the general population.
Instead of importing inappropriate health financing models from high-income countries, governments in LMICs should surely learn from the increasing number of home-grown UHC success stories in other, more comparable countries.
The countries making most progress towards UHC agree that entitlement to health care should be based on citizenship and/or residency and not on employment status or financial contributions. While their specific journeys differ, these countries fall into two broad camps. First there are examples of countries at all income levels, including Sri Lanka, Malaysia, and Brazil, which use tax revenues to fund UHC. Crucially, the 2009 report of a Task Force on Global Action for Health System Strengthening found that the only low-income countries to achieve universal and equitable health coverage did so by relying mainly on tax financing. A second option increasingly being adopted by another set of successful UHC countries, including Thailand, Mexico, and Kyrgyzstan, is to collect insurance premiums only from those in formal salaried employment, and to pool these where possible with tax revenues to finance health coverage for the entire population.
The growing momentum for UHC is welcome, exciting, and challenging. UHC has the potential to transform the lives of millions of people by bringing life-saving health care to those who need it most. But rather than focus efforts on collecting contributions from people who are too poor to pay, governments and external funders should focus on financing options that will work to deliver universal and equitable health care for all. The preoccupation with health insurance as the ‘default’ UHC model has left the crucial question of how to generate more tax revenues for health largely unexplored. This blind spot should be urgently addressed.
At its core, UHC is about the right to health. This means moving away from the idea of an employment or contributory basis for entitlement. People must be entitled to receive benefits by virtue of their citizenship and/or residency and not because they are formally employed or have paid to join a scheme. Women and men living in poverty must benefit at least as much as the better off every step of the way.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please see the Oxfam report ‘Universal health coverage: why health insurance schemes are leaving the poor behind’ at www.oxfam.org/uhc
In 2008, Members of Parliament from twelve countries in East and Southern Africa pledged to advance health equity and sexual and reproductive health in the region. How much progress had been made a year later? This was the question that was in focus in a follow up regional meeting in September 2009.
At a meeting in September 2008 hosted by Partners in Population and Development Africa Regional Office (PPD ARO), Regional Network for Equity in Health in East and Southern Africa (EQUINET), African Population Health Research Centre (APHRC) and Southern and East African Parliamentary Alliance of Committees of Health (SEAPACOH) with international partners, the members of parliamentary committees on health made commitments to promote primary health care, health equity and reproductive health.
These reflected the fact that parliaments can and do play a key role in promoting health and health equity through their representative, legislative and oversight roles, including budget oversight. EQUINET reports have documented examples of how these roles have been exercised in East and Southern Africa (ESA) to prioritise health in budgets, to monitor the performance of the executive, to strengthen laws protecting health and to keep the need to redress inequity in health and to promote sexual and reproductive health high on the public agenda.
As a unique measure to consolidate this, members of the health committees came together in the Southern and East African Parliamentary Alliance of Committees of Health (SEAPACOH) in 2005, to build a more consistent collaboration of the committees towards achieving individual and regional goals of health equity and effective responses to HIV and AIDS. The committee members carried out field visits to local governments at districts and lower levels to appraise themselves with the prevailing health needs, and mobilised and sensitised leaders at local government levels, in civil society and in communities on health and reproductive health issues. The parliamentary committees on health have met to review this work on health with EQUINET and various partners in 2003, 2005, 2008, and most recently in September 2009. In April 2009 with PPD support SEAPACOH developed and adopted a Strategic Plan for 2009 – 2013. The three main areas of focus identified include: ensuring needs-based resourcing of the health sector; ensuring effective domestication, implementation and compliance with agreed upon commitments in the health sector by governments; and ensuring sustainability of the alliance.
The follow up meeting in September 2009, hosted by the same organizations provided an opportunity to review progress, share experiences and lessons learnt over the past one year on the implementation of the resolutions of the September 2008 meeting.
Parliamentarians shared information on their progress, challenges, and on how to move commitments further forward. Progress had indeed been made since September 2008. For example:
• The East Africa Legislative Assembly have developed model laws on HIV, AIDS and female genital mutilation and is working to develop pooled procurement of drug, medical supplies and medical equipment; to review health insurance schemes, and to explore options for contracting health workers.
• In Kenya, the Parliament is scrutinizing the government budget through interrogating line ministries’ budgets. They have promoted an economic stimulus package, which provides for model health centers to be set up across the country and for twenty nurses to be hired in each constituency. In Kenya, a parliamentary taskforce has been set up to monitor and oversee action on socio-economic inequalities, including inequality in health and access to health care. The health committee have sensitized fellow MPs and the Ministers of Health and Finance on health issues, leading to legal provisions for Health Committees to be include in the budget process.
• In Malawi, Parliamentarians have moved a motion to persuade government to draft legislation on research activities to prevent abuse of citizens in clinical research trials.
• Namibia’s Committee on Human Resources, Social and Community Development were trained in gender based violence, reproductive health and HIV and AIDS in 2009. They undertook field visits to assess the implementation of government policies and programmes with regard to health and education issues; and revised and costed the national roadmap that outlines strategies and guidelines for improving maternal and child health, as a contribution to reducing illness and mortality in 2009.
• The Parliament of Swaziland reported implementing capacity building work on sexual and reproductive health for members. Members have also moved several motions, including on access to health services, and to promote investigation into the increase in abortions among young people and into the increase in maternal mortality.
• In Uganda, Parliamentarians have engaged Ministries of Health and Finance and the media on the need to fund sexual and reproductive health issues and recommended policy changes in the management and administration of the budget for drugs, including for reproductive health commodities. The committee has with the executive allocated additional government resources for reproductive health and HIV and AIDS. The committee has successfully advocated for a budget line of 200 million Uganda shillings (US$105 000) for activities to address female genital mutilation and prepared and presented a private member’s bill entitled “The Prohibition of Female Genital Mutilation Bill, 2009.
• In Zimbabwe, the Parliament has improved the allocation of resources to health in the budget. The committee on health has tabled a motion on the need to link sexual and reproductive health and HIV in programmes and policies that address vulnerabilities of women and children, has lobbied for the provision of appropriate, affordable, accessible and friendly adolescent and reproductive health services and are currently crafting a policy on male circumcision as one of the added strategies to reduce HIV infection. This was supported by a number of research studies in areas of sexual and reproductive health.
With these areas of progress taking place, the need to network regionally to share progress and experience was evident. In agreeing on a way forward over the next year, the committees agreed to operationalize the SEAPACOH Strategic Plan, including strengthening their own networking and communication across the region. This will enable those making progress in key areas of health to share information on achievements, to exchange experiences in their oversight of regional commitments and international agreements and to support new and innovative programmes to enhance health, including reproductive health. The adoption of common platforms and a regional agenda can only make the work of the individual committees stronger.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed and the regional parliamentary meeting please visit the websites of PPD ARO: www.ppdafrica.org; EQUINET: www.equinetafrica.org; and APHRC: www.aphrc.org. The SEAPACOH strategic plan is at http://www.equinetafrica.org/bibl/docs/SEAPACOHstrategicplan09.pdf. The 2009 commitments are included in this newsletter and are also at http://www.equinetafrica.org/bibl/docs/RegParl%20mtg09%20res.pdf. The resolutions and report of the 2008 meeting are at http://www.equinetafrica.org/bibl/docs/REPMET0908parl.pdf and http://www.equinetafrica.org/bibl/docs/RESsep2008parl.pdf.
The 56th World Health Assembly - the annual health meeting at which the World Health Organisation's (WHO) directives are set for the year - ended last week in Geneva after a long round of discussions on the continuing SARS saga. Press coverage of the Assembly also focused on the completion of a tobacco control resolution, which the U.S. delegation agreed to sign in exchange for deals that will secure a future pact on sugar imports. But the resolution receiving the longest debate among the delegates of the 192 member governments attending the WHO's Assembly received little attention outside of the business press.
The controversy was over a resolution mandating the WHO to advise governments about patent rules and access to medicines. Patent laws in many developing countries are now set through a combination of World Trade Organisation (WTO) directives, World Intellectual Property Organization (WIPO) advice, and U.S. bilateral trade pressure. But because the WTO's Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement requires developing countries to pass national legislation guaranteeing patent terms of two decades for pharmaceuticals, the prices of new drugs for both common and rare conditions is expected to double soon after January 2005. The TRIPS Agreement, passed more than a decade ago under the aegis of the WTO, was described as a "free trade" measure by its key architect, Pfizer CEO (and Ronald Reagan trade advisor) Edmund Pratt. By definition, it is the complete opposite of competition-based trade: it grants pharmaceutical companies a monopoly on any new product they produce, and therefore allows drug prices to be set to the purchasing standards of the elite, to the obvious detriment of the poor.
Joint Statement by Oxfam, Treatment Action Campaign, Consumer Project on Technology (CPT), Médecins Sans Frontières (MSF) and Health GAP NGOs which are treating people with AIDS and working to improve access to medicines say patents block affordable, easier-to-take medicines from reaching people who need them. This is in sharp contrast to a 17 October communication co-authored by Amir Attaran of the Harvard Center for International Development and Lee Gillespie-White of the International Intellectual Property Institute, "Do Patents for Antiretroviral Drugs Constrain Access to AIDS Treatment in Africa". The publication claims that "patents in Africa have generally not been a factor in either pharmaceutical economics and antiretroviral drug treatment access."
The findings of this paper have been extensively used by industry to back their claim that patents are not an issue. The pharmaceutical company Merck has also funded one of the authors.
The NGOs agree with the "special communication's" claim that many barriers impede access to health care in Africa, and support their call for international financial aid to fund antiretroviral treatment.
However, they believe that the data presented in the paper do not support the conclusions drawn, but actually shed light on the extent of patent barriers to treatment. In African countries, the most practical and sought after combinations include fixed dose medicines (2 drugs in one pill) and affordable non-nucleosides. The most popular combination of AZT/3TC is patented in 37 out of 53 countries and the only affordable non-nucleoside (nevirapine in generic form) is patented in 25 out of 53 countries.
Many of the non-patented drugs listed in the study, including some of the protease inhibitors, are not practical as first-line treatments in resource-poor settings because of side effects (which need to be monitored) and cumbersome dietary requirements. The study data show that patents are concentrated in countries where pharmaceutical markets are the largest. In South Africa, which has 4.7 million people living with HIV/AIDS and represents half of the pharmaceutical market in Africa, 13 out of 15 antiretroviral treatments are patent protected. In fact, half of the people with HIV/AIDS in Africa live in countries with significant patent barriers on antiretroviral drugs.
The authors claim that even if prices of patented ARVs come down, African countries cannot afford them. But since generic triple therapies can now cost as little as US$ 30 a month, significant numbers of individuals and employers can afford the treatment, if it were not for patents. Patented prices are still three times higher than generic prices. This means that for a given amount of international aid, three times as many people can be treated if generic production is allowed.
This misleading "communication" seems to be an attempt to sabotage a process initiated by the developing world, which seeks to ensure that patents will no longer be a barrier for access to medicines. A draft declaration calling for a pro-public health interpretation of TRIPS was put forward by 60 developing countries in the September 2001 TRIPS council session on access to medicines. The declaration, signed by 41 African nations, states that "nothing in the TRIPS agreements shall prevent members from taking measures to protect public health." The declaration, which will be considered at the next WTO ministerial conference, has been opposed by the United States, Switzerland, Japan and Canada.
If nothing changes, beginning in 2006, all WTO Members will be obligated to grant twenty-year minimum patents for medicines. For this reason, it is critical that the false conclusions drawn from the data do not lead people to believe that patents are not an issue in access to life-saving medicines.
The attacks against foreigners in KwaZulu Natal, Johannesburg and other parts of our country are shameful. If we close our eyes, or turn away, we bring shame on ourselves. The attacks present South Africans to the world as a barbaric, violent and murderous nation. We are not. Our march will show another South Africa to ourselves and the world. We are the country of Nelson Mandela, Oliver Tambo and all people who gave their lives for freedom. In our freedom struggle we had vital help from our sisters, brothers and comrades throughout Africa and the World. In 1994 we voted for peace, not war. We have the fairest Constitution in the world - that protects ALL who live here.
We link arms with our sisters and brothers from other countries who live with us here in South Africa. We are proud our extended family transcends national borders, languages, cultures and religions - because we need each other, because we are one! We will march to celebrate our solidarity with everyone from other countries living amongst us - particularly the poor, people seeking refuge, and political and economic migrants who have come to our country to try and survive. We will march to show our deep concern and solidarity to all poor communities where chronic unemployment, inadequate housing, rising crime and bad schools have become the norm. We will march to appeal to people who live in poor communities not to resort to violence. Do not to be distracted by blaming people from other countries who are also poor. The poor of the world must unite!
We will march to expose employers who play one group of workers off against another in order to maximize their profit. They are part of the problem right across our Africa. Workers, do not to be fooled: recognize that it is only by uniting workers and communities within and across national borders that a real challenge to poverty, pay and conditions can be fought and won.
International solidarity helped end apartheid. Likewise, we must build unity within and across our national boundaries. Our struggle against all forms of oppression continues. Authorities must listen to our pleas, and improve and protect our communities and respond positively.
We are all human beings. We must be treat one another with respect, and live our lives in dignity. It is time for all good people to come together. We are the majority. We reject division, and it is time for real change! Don't turn away. Don't make excuses. Join us! Come from your school, workplace, union, your church, your university, your business, your community. Take three hours to march for life, dignity and equality. Together, let us show the world and our countrymen and women that another South Africa exists - where solidarity defeats xenophobia!
This call was made by South Africans for a march on 23 April that involved about 30,000 people through Johannesburg, to demand an end to a recent wave of xenophobic attacks.
Over the last eight years there has been an increased interest in the use of performance based funding to ‘strengthen’ African health systems. Performance based funding has been used in different ways in the past within countries. With its growing popularity at global level, we need to be clearer about how these funding models work in practice and how far the performance based agenda being advanced at global level integrates meaningful participation and partnership in building health systems in Africa. How much are African actors setting and shaping this emerging global agenda?
Performance based funding refers to the idea of transferring resources (money, material goods) for health on condition that measurable action will be taken to achieve predefined health system performance targets. These performance targets may relate to particular health outcomes, to indicators of delivery of effective interventions (such as immunization coverage), to the utilization of certain services (like HIV counseling and testing), or to meeting targets in relation to quality of care. Because performance based financing offers incentives for positive action, many global institutions promote it as a way to efficiently and effectively reform the way that health systems are planned, financed, coordinated and steered. This is particularly true of external funding in many low and middle-income African countries, where there is growing evidence to suggest that performance based funding is being championed by global and bilateral funders as a key innovation in health financing. Funding agencies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank claim that performance based funding promotes reform in a way that can also be locally owned and accountable. This argument is based on a claim that performance targets and indicators will be developed through the active participation of local actors from within various African states, rather than being set by global agencies from the top-down.
Despite increasing use of these arguments for performance based funding within global health policy, there is still a lack of consensus about what performance based funding actually means, and little evidence to support the assumed causal pathways through which diverse African health systems theoretically achieve the governance outcomes claimed. There is also limited evidence about the extent of local participation in the design of performance based initiatives, and particularly in how far African actors – governments, civil society, health services, individuals and the private sector – have participated in the design, implementation and delivery of performance based funding initiatives. It is thus not clear who is participating in shaping, deciding and adopting performance based funding agendas and goals and how these decision-making processes work. There are questions about how targets are set, who sets these targets, as well as about how ‘performance’ is measured, and what exactly constitutes ‘good’ performance.
These ambiguities raise concern about how performance based funding complements other key processes that aim to broaden participation within ‘global health partnerships.’ Partnership has, for example, become a key concept within the Global Fund, World Bank and WHO processes. Millennium Development Goal 8 refers to developing a partnership for development, and the Paris Declaration aims to increase the ability of national and local governments and stakeholders to engage with and shape health policy at national, regional and global levels. However, if we don’t know how far African actors do actually participate in the formulation, implementation and evaluation of initiatives such as performance base funding, it is unclear how far they meet these commitments towards more cooperative processes, where all stakeholders engage with and shape health policy. Given that participation is a key normative aim in debates about furthering more equitable health diplomacy, it is important to know whether and how far performance based funding, as it is currently being practiced, fulfills these normative aims and is (or is not) an effective strategy for reforming health system governance in a participatory and equitable manner.
These questions are being explored in collaborative research currently underway in EQUINET, through the University of Sheffield, Queen Mary University, the University of Zambia, the University of Dar es Salaam, the Ministry of Health Zambia and the University of Kwazulu-Natal, as one input to regional dialogue on global health partnership and equitable health system strengthening.
Performance based financing initiatives have potentially powerful effects on health systems. Their agendas and preferred performance targets become embedded in, and potentially shape, local and national forms of state governance, participation and authority. The current context of global actors devising and advancing such models makes it is critical for African actors to proactively and effectively access and engage in the processes that shape these emerging global health policies: from design (agenda setting) through to implementation and delivery. It is equally critical to know the possibilities and limits of the spaces and places for such participation, especially those provided for by global actors such as the WHO, World Bank and Global Fund .
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit www.equinetafrica.org
The poorest countries in the world have been unable to reach agreement at the World Trade Organisation (WTO) on relief from global rules that would allow access to much needed medicines for their citizens. The 16 October 2015 meeting to resolve the impasse has been suspended indefinitely according to reports by IP-Watch in Geneva.
At the forefront of resistance to this application from least developed countries (LDCs) were the United States, Canada and Australia, in positions raised in June and again on 16 October. The LDCs have a two-fold demand that amounts to a request for a waiver from the application of WTO rules on intellectual property (IP) rights, such as patents (which protect owners of new medicines), data and marketing rights. Firstly, they have requested an extension of the 2013 waiver related to pharmaceutical products, currently expiring on 1 January 2016. Secondly, they have petitioned through Uganda, as LDC representative, for a general exemption from applying the WTO intellectual property rights agreement (TRIPS), granted until 2021. Their position is that it ought to be granted for as long as countries remain designated as least developed according to the United Nations. Most LDCs are in Africa.
Over 140 non-governmental organisations have come out in support of the LDC petition. Médecins Sans Frontières accused the US, Australia and Canada of seeking to worsen access to medicines in LDCs by weakening the exceptions granted to them.
Some reports imply that LDCs were ‘collateral damage’ for other IP interests for the US. The US Trade Representative failed to reach the high standards of protection sought in the mega-regional trade and regulatory agreement called the Trans-Pacific Partnership (TPP). Commercial US stakeholders were reported in an October 2015 paper by Knowledge Ecology International (KEI) to be upset with the concessions made in this flagship trade deal, with an informed but unnamed source stating, "the TPP did not deliver as expected on IP [Intellectual Property] and so we are under a lot of pressure not to give in more on IP."
In contrast, the LDCs’ proposals were supported by developing countries, including Cambodia, Cuba, Brazil, China, Uruguay and by the Africa Group. Norway and the European Commission also supported the LDCs request, as did the World Health Organization (WHO), the United Nations Development Programme and UNAIDS.
The costly nature of pharmaceutical drug production and the complex rules on production for export to countries with public health needs requires the certainty of a permanent waiver. According to James Love of KEI, "A permanent waiver of drug patent obligations is needed. No country will amend its patent laws if the waiver is limited in time, like the previous extensions...”
The public health basis for the LDC application is also evident. In a statement in June 2015, Uganda’s representative put the case to WTO members that 63% of people living with HIV in LDC countries still had no access to appropriate treatments. The United Nations Office of the High Representative for the Least Developed Countries, Landlocked Developing Countries and Small Island Developing States in its 2014 report indicated that most LDCs had not yet met the Millennium Development Goals on health, stating that LDCs “also need financial and technological support to derive maximum development benefits from the waivers granted under the WTO TRIPS agreement.”
LDCs, as the poorest countries in the world, serve as some measure of the level of civilisation of the global economic order. These countries are in effect asked to repeatedly expend scarce domestic resources and diplomatic capital supplicating rich countries at the WTO for exemptions from international rules that clearly do not take their interests into account. It is refreshing that the WHO is taking the side of the LDCs and access to medicines in this instance as the position has been less clear in the past. For example, Third World Network raised in 2010 that the WHO initiatives on “counterfeit” drugs threatened medicines access by conflating legitimately produced generic drugs with drugs that were illegally produced or traded, given that the term ‘counterfeit’ is used to denote trademark infringements in intellectual property rules.
The LDCs request for a waiver signals that the access to medicines activism that secured the 2001 WTO Doha Declaration on Public Health was just the start of a battle against vested interests pursuing profits at the expense of human life. The 2001 Declaration was in fact a statement of legal rights that all countries enjoyed already, but over which poor countries had to ensure legal certainty at global level as they were under threat. For example, the US Special 301 list designated countries deemed to violate intellectual property rights, as unilaterally imposed sanctions with negative economic and reputational effects. Given that the WTO disciplines unilateral action by states that affects multilateral trade, the US undertook to not use Special 301 in violation of the WTO, according to Chakravarthi Raghavan in 2000. However the US repeatedly breached this undertaking, such as in its placement of Thailand on the 2007 watch list for issuing compulsory licenses for patented pharmaceutical products.
The industry has significant lobbying power and the preponderantly US-based branded products pharmaceutical industry is one of the most profitable in the world. According to a 2014 BBC report, the sector made a 42% margin of profit in 2013 in the US, compared to about 29% for the banks. Many US pharmaceutical companies held tens of billions of dollars offshore to avoid US taxes, according to Bloomberg’s Richard Rubin on 4 March 2014.The cost of such concentrated corporate power is evident in the fact that US medicines prices are almost twice that compared to other developed countries. US policies are rationalised with ideas of free trade, competition and the full functioning of markets. The super-profits being made by branded pharmaceutical companies should lead even free trade proponents to be concerned about the enormous rents they extract from the market. The suspension of discussions on the LDC waiver on Friday coincided with the US and developed countries stating they would also not make binding commitments for special treatment of LDCs on other issues at the next WTO Ministerial meeting scheduled for 15 to 18 December in Nairobi.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org.