1. - IP/Prices + Funding + Health - IMF Systems = Access to Medicines Prof. Brook K. Baker, Health GAP, Northeastern U. School of Law UKZN IP and Access to Medicines 2010

2. Overview of Presentation  Growth of the untreated HIV/AIDS pandemic  Access to medicines = right to life  Reducing drug prices  Increasing funding  Building health system capacity  Attacking IMF macroeconomic constraints

3. HIV/AIDS Pandemic Estimated number of adults and children living with HIV, by region, 1990–2007 Year Millio ns 0 10 20 30 40 199019911992199319941995199619971998199920002001200220032004200520062007 Oceania Middle East & North Africa Eastern Europe & Central Asia Latin America and Caribbean North America and W & C Europe Asia Sub-Saharan Africa

4. Why Focus on Access to Medicines?  Human right to health  Equity – effective medicines are available  Impact mitigation  Medicines/treatment access → testing, knowing your status, behavioral change  Treatment ↓ infectivity  Treatment creates cadre of health activists

5. Early AIDS Movement Focused on Quick Access & New Medicines  Gay activists in the US fought for drug development, fast-track registration, and compassionate access to experimental medicines.  US activists also fought for government support for treatment access (Ryan White)  Brazil was the first developing country to offer universal, free access.

6. The $10,000 Dilemma  2000: The price of the new, highly active antiretroviral therapy (HAART) was the same in Durban as it was in New York City - $10,439.  Drug companies had refused to reduce prices for antiretroviral medicines in Africa.  Only 30,000 Africans (rich elites) out of 20 million infected and 8 million needing treatment were receiving HAART.

7. The Impact of Generic Competition: A Penny on the Dollar

8. Treatment Access

9. The Treatment Gap  Latest UNAID/WHO figures show that 5 million PWAs are receiving treatment.  Under the new WHO treatment guidelines (start at 350 CD4 cell count), 15 million need treatment.  1/3 is not good enough.

10. Funding Needs HIV/AIDS

11. Health Spending in Developing Countries (92% of Global Disease Burden) is Anemic  2004, global health spending $4.1 trillion  2003, developing countries health spending $410 billion, 12% of global total  This was 5.7% of developing country GDP (84% global population, 92% global disease burden). World Bank Strategy for HNP Results 2007.  2005, health spending in Sub-Saharan Africa only $27 billion (11% population; 24% disease burden). GHWA Education (2008).

12. Health Spending by Region

13. Most African Countries Fail to Meet their 15% Abuja Commitment  In 2001 African leaders committed to spending 15% of government budgets on health (from domestic resources, not including donor aid). Abuja Declaration  At the end of 2009, only six African countries had ever met their Abuja commitment

14. Would Meeting Abuja 15% Make a Difference? USAID Roundtable (2008) New Task Force on Innovative Financing Target $51

15. Do Poor African Countries Have Fiscal Space? AU, Health Financing in Africa 2006

16. Donor Assistance for Health has also been Anemic  DAH accounted for only 3% of total developing country health spending in 2003.  However, DAH as a percentage of all official development assistance grew from 8% in 1990 to nearly 16% in 2006.  In Africa DAH accounts for 15% of health spending, and more than 30% in 12 countries.

17. Donor Assistance for Health 2000-2007 Ravishankar, et al., Financing for Global Health, 373 Lancet 2113-24 (2009)

18. DAH by Disease

19. Sub-Sector Spending Kaiser (different estimate of total DAH)

20. What Goes to Medicines/Treatment?  Harder to estimate but  Global Fund spends approximately 27% of its budget on medicines, 45% overall on health commodities  U.S. PEPFAR program spent $5 billion on treatment 2004-2008, now 85% of its purchases are generic medicines

21. Crisis ahead: The costs of improved therapies

22. Crisis ahead: Out-of-pocket costs of medicines  Most developing country health spending is out-of-pocket (70% in low income countries 50% in African countries)  Many countries impose user fees, especially re medicines (cost recovery)  Transportation costs  User fees and costs = less usage

23. Crisis ahead: Human resources for health

24. Brain Drain  Structural adjustment and its impact on health workforce Wage ceilings, fractional wages, poor working conditions  External brain drain – push/pull  Internal brain drain Public to private/NGO Rural to urban

25. Minimum Densities  WHO estimates that countries need 2.3 doctors, nurses, and trained midwives per 1000 people.  WHO estimates that an additional 1.8/1000 auxiliary health workers are needed (pharmacists, lab techs, managers, community health workers, etc.)  The combined estimate, 4.1 HCWs/1000 pop., may be low in high disease contexts and is based on immunization and maternal health requirements only.

26. Task Shifting  Rational reassignment of tasks to mid-level cadre  Allowing nurses to prescribe standard ARVs and other medicines accordingly to simplified and standardized treatment protocols  Incorporate community health workers  Does not substitute re need for new professionals, expanded medical education capacity and pre- service training

27. Other Health System Weaknesses Affecting Access to Medicines  Procurement and supply systems Corruption, inefficiencies, stock-outs Resource allocation/prices  Inadequate health infrastructure Health facilities (mobile clinics?) Medical/lab equipment and supplies  Health information systems Operational information Patient information

28. Inequitable access and patient support  Inequities in access Rural and vulnerable populations  Testing & treatment literacy, adherence supports

29. Crisis of care at the community level  Services are ultimately delivered at the community level  Public sector service delivery dries up at the local level  Peri-urban and rural care is neglected  Vulnerable populations are often neglected

30. Crisis of care within families  Poor access to formal health care  Household care of the ill and dying  Household and community care for orphans and vulnerable children  Home-based care is being provided, the vast majority by women, though children also provide significant care labor

31. The gendered economy of care  Being a care “giver” is women’s assigned role, culturally, and now by donor and national policy.  Uncompensated care removes women from remunerative or subsistence work  Over-burdened and now poorer women have increased vulnerability to HIV because of their growing impoverishment

32. Ubuntu/Solidarity and the Ethic of Care  Compensation vs. volunteerism  Commodification of care vs. communal solidarity  Cultural barriers to paying family members  Wage seekers vs. compassionate carers

33. Bottom Line: CHWs must be paid a living wage  The AIDS pandemic and the response to HIV/AIDS are creating an economy that can perpetuate the economic disempowerment and increased HIV vulnerability of women or not.  If women are paid for their care labor, they gain resources and status that reduce rather than exacerbate their economic and health risks.  CHW task-shifting study – CHWs must be paid  To pay women, the funding crisis must be addressed.

34. Civil society roles in health systems Community mobilization for comprehensive health services Needs-based advocacy Hands-on experience of what works ID practical challenges & gaps in health service delivery Independent oversight, monitoring Services for excluded and vulnerable populations Community-led implementation: health promotion, care and support

35. Community System Strengthening Community systems strengthening Enabling cultural, legal and socio- political environment Access to predictable and sufficient funding Training and capacity for management, advocacy, oversight, service delivery Building linkages and networks with other CBOs and public entities

36. Costs for Educating Health Workers and Doubling Salaries (billions) WHO 2007 YearAfricaDev. Countries 2009 $6.7$58 2010 $7.5$64 2011 $8.0$66 2012 $9.2$69 2013$10.9$74 2014$12.7$80 2015$14.6$86 Total $69.6 $497

37. TOTAL DEVELOPING COUNTRY HEALTH RESOURCE NEEDS & RESOURCE GAPS: 2009-2015 (Baker, 2010)

38. Can you spend health financing? IMF Macroeconomic Policies  IMF targets debt repayment, export earnings, low inflation (>5%), low fiscal deficits (>3%), financial and labor market liberalization.  Results: public sector spending caps health and education.  Threatens use of domestic and donor resources for universal access and HRH/HSS.

39. IMF: Aid Substitution/Fungibility

40. Health Care Worker and India Medicines Protests