Please find below my answers to the questions on The EU role in global health

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1 Jean-Pierre Unger, MD, MPH, PhD Professor of Public Health Institute of Tropical Medicine Antwerp, Belgium Tel Antwerp, November the 18 th, 2009 Dear Sir, Please find below my answers to the questions on The EU role in global health With best wishes Jean-Pierre Unger

2 Question 1: In your opinion, does the proposed concept global health cover the most relevant dimensions? If not, which other essential factors would you suggest? Access to comprehensive health care is needed if diseases are to be successfully controlled (J.-P. Unger. How could disease specific programs strengthen health systems delivering comprehensive health care? Strategic and technical guidelines. European Commission, 30 Sept 2008, Brussels). Global health should explicitly address the challenge of universal access to comprehensive care. Question 2: Are the effects of globalisation on health, on the spread of diseases (whether communicable or life-style non-communicable) and on equitable access to health care sufficiently described? International trade agreements may threat access to health care by preventing signatory countries to finance their public health services (Unger J.-P., De Paepe P., Ghilbert P., De Groote T. Letter. Public health implications of world trade negotiations. Lancet 2004; 363: 83). This pivotal, undesirable effect of globalisation is not addressed in the European Commission paper submitted to our consideration. International loans (e.g. IMF and WB) and access to bilateral cooperation projects were often conditioned on similar requirements of LMIC giving up the delivery of comprehensive health care in public services. Question 3: Do you consider the health-related MDGs a sufficient framework for a global health approach? If not, what else should also be considered? The failure to make progresses on MDG is now acknowledged by WHO (Chan M. (2008). Return to Alma-Ata. Lancet, 372 (9642), pp ). Access to family medicine (possibly delivered by non doctors but clinical officers and/or nurses) in first line services and to general hospitals are pivotal to significantly improve life expectancy. Such access should become two additional MDGs. They could be monitored with simple indicators such as the number of sickness episodes (presented to outpatient consultations) per year per

3 inhabitant and the hospital admission rate. In the early 80 s, this used to be international policy goals. Question 4: In your opinion, which are the main strengths and weaknesses of the current EU policy on health and development cooperation, and which dimensions should be given greater attention in order to face the challenges ahead? Three weaknesses are worth being singled out: - the EU budget for cooperation in the health sector is extremely limited; - Experience suggests that budget support plus policy dialogue is not likely to improve the public health budget of recipient countries. This should be carefully evaluated and results be made public; - There is too much emphasis on disease control programs and not enough on health systems strengthening. Question 5: Could you identify health problems that have been neglected by the EU and international health research agenda and propose the best means to support innovation to address them, especially in low- and middle-income countries? The international coalition 1 (established on the basis of working on the disease burden ) has largely managed to evade the need for scientifically based definitions of priorities (Bossyns, 1997; Shiffman et al., 2002; Shiffman, 2006; Sridhar & Batniji, 2008): Acute respiratory infection (ARI) represented 25% of the world s burden of disease. but receives funds corresponding to 3% of total health related overseas development aid; HIV/AIDS, which represents 5% of the burden, received in a share accounting for almost one third (32%) of health aid (and this proportion is sharply on the rise, see figure 2.1) (England et al., 2007; MacKellar, 2005; Norad, 2008); Shigellosis alone yielded up to 165 million cases annually and kills up to 1,100,000 (Kotloff et al., 1999) people a year probably more than malaria (900,000 in Africa) (Stratton et al., 2008) but receives no ear-marked funds at all; 1 Major donors including the World Bank, the IMF and the WHO.

4 Cardiovascular diseases killed much more than TB (World Health Organization, 2008) (figure 2.1) and receive little or no funds in LMIC (notice that close to 70% of the world s elderly live in these countries). Instead of defining disease specific worldwide priorities, international aid and health policies should equip countries to identify local priorities while strengthening rather than weakening health systems (Unger J.- P., De Paepe P., Green A. A code of best practice for disease control programmes to avoid damaging health care services in developing countries Int J Health Planning and Management 2003; 18: S27-S39.). Question 6: Do you think that ODA commitments for health should increase, and how do you think that other sources of financing could contribute to addressing global health and universal access? The EU and EU countries should use their contribution to WB and IMF to avoid these organisations limiting public expenditure on health in LMIC (e.g. through conditionalities). They should rather aim at increasing such expenditure in LMIC through policy dialogue. Question 7: How do you think fragmentation of aid for health could be reduced, with a view to increasing aid effectiveness and preventing detrimental health spending? The EU should - evaluate the efficiency of channeling aid through a myriad of NGOs - avoid using NGOs to channel aid to LMIC until such information is gathered - promote a health care sector with a social mission (gathering all the organizations which would be managed according to ad hoc criteria (contracts may specify such ad hoc criteria for health care management and delivery) Question 8: In the context of aid effectiveness and alignment of financing to national priorities, what can be done to make sure that adequate attention is paid to health priorities and to strengthening health systems? Budget support is not enough: effective technical assistance to health system strengthening is badly needed.

5 The alignment with national financing priorities is a requirement which is contradictory with health system strengthening. There wouldn t be a problem if health system strengthening was a national priority in LMIC. The huge variance of demographic outcome in countries sharing similar income per capita and public expenditure on health suggests that much can be done to improve health systems efficiency. Question 9: What are your suggestions for striking the right balance between addressing health priorities and providing support for developing health systems? International health and aid policies should support health systems capacity to delivery comprehensive care defined as family and community medicine + general hospital care. Question 10: What are the main opportunities for increasing the level and enhancing the effectiveness of health aid from the EU? European companies investing in LMIC outside the health sector are quite concerned with the political and social stability of these countries. Mere disease control does not improve such stability because it does not answer to the demand of the people. Rather, access to polyvalent care is what is needed. Question 11: In your opinion, what are the links between health, governance, democracy, stability and security and how could the right to health be put into operation? In EU countries, health sector stakes often scored high on electoral agendas. Several European governments resigned on this issue. To my knowledge this never happened in Africa probably not because this is of a lower priority to Africans Question 12: What impact will the global crisis (climate change, food prices and economic downturn) have on global health and what could be done to help mitigate their ill effects? The impact is likely to be more catastrophic health expenditure and less access to health care. As a solution, there is a need to develop a public health care sector whereby users could face less catastrophic health expenditure.

6 Question 13: What should be the role of civil society in the health sector, at national and local levels? Question 14: Which action do you think the EU should take to stem the brain drain of health workers, while respecting their freedom of movement? - Establish some communication between SANCO and AIDCO: the former financed studies of the international brain drain and has a clear view of specific situations in the European countries. - Contribute to a decentralized production of nurses and midwives at the level of district and regional hospitals in LMIC. - Tackle the internal brain drain whereby the best professionals are removed from government services by NGOs and aid (disease specific) projects. In Senegal and Zambia, for instance, almost no young doctor would want to embark in a clinical career and study surgery or gynecology because this is much less profitable than public health. - Co-finance the production of good quality doctors in LMIC - Contribute to improve standards in licensing doctors in LMIC Question 15: What role do you see for new technologies (including telemedicine) in enabling developing countries to provide access to care even in remote areas and to allow better sharing of knowledge and expertise between health professionals, and how can the EU support this? There is a need to develop access to internet in LMIC rural hospitals and telephone or radio communications between health centers and hospitals. Question 16: What are the keys to ensuring equitable access to medicine and how could the EU help to do more on this, including by supporting innovation and management of intellectual property rights? The EU should contribute to the development of public drugs distribution systems in LMIC whereby generic and essential drugs would be channeled to health care services belonging to the non commercial, socially oriented health sector.

7 Question 17: What could the EU do to improve the research funding for global health? The EU should fund research on access to comprehensive health care, on strategies to improve quality of care in the realms of family and hospital medicine. It should finance action research and not separate radically health development projects from research projects. It should avoid over-planning financed researches in the domain of public health. Question 18: How, in your opinion, could the EU research funding effectively address the systemic weaknesses of health systems worldwide? See answer to question 18 Question 19: How do you think national capacity and local scientists in low-income countries could be empowered to conduct research relevant to their countries priorities? There is a need to use targeted budget support if these scientists are to become more independent from international research initiatives and devote more time to local health system problems. There is also a need to finance links between LMIC academics and health care services (transport, research costs, etc). Finally, there should be some contribution to their salaries. Question 20: Which kinds of global public goods for health should be given priority and how should they be financed and managed? Access to polyvalent health care should be made a public health good. More than 30 million people die each year because of not accessing first line health care Question 21: Which do you think are the priority areas for coherence on global health policies, and how should they be addressed? See answer to question 20.

8 Question 22: How could the legitimacy and efficiency of the present global health governance be improved and which role should the EU play in this? Such legitimacy could be enhanced by addressing also health problems that are not a priority for industrialized countries. Question 23: Do you think a definition of a universal minimum health service package would facilitate a rights approach and progress towards more equitable coverage of services? If so, how could such a universal minimum standard be defined? It depends on how package is defined. If this concept only encompasses diseases and health conditions, the answer is no because there is no evidence that such an approach improves access to care. Rather, historically, such a use of the notion of package has been used to limit and ration access to care. If the concept of package includes family medicine and hospital medical care, then the answer could be yes. Question 24: What, in your opinion, should be the main principles guiding equitable social protection for health? 1. Avoid exporting our European health system principles. History cannot be exported. The development of Bismarkian health systems is linked to a particular history. There is no evidence from LMIC that such structures would work in these countries. 2. Develop health care systems. 3. Develop health systems with a public orientation that is with a social rather than commercial mission. Question 25: Which fair financing principles and mechanisms should apply to health system financing to ensure equitable and universal coverage of basic health care? 1. Avoid privatization of health care financing. There is no evidence that this can improve access to health care for the majority of LMIC dwellers. Evidence from Colombia, Chile and other countries suggest that private health insurances reduces national solidarity in health. 2. Avoid health care systems for the poor. Those countries like Costa Rica and Sri Lanka which managed to improve significantly universal access to care have developed a national system instead.

9 Question 26: What is the role of civil society in global and national health governance and how can potential conflicts of interest between advocacy and service provision be avoided? Question 27: What, in your view, is the main added value offered by the EU in the field of global health? Question 28: Do you think that an EU social model could inspire global health equity? See answer question 24

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