NGO "ANOTHER WAY" (STICHTING BAKENS VERZET), NETHERLANDS, SUSTAINABLE INTEGRATED SELF-FINANCING DEVELOPMENT PROJECTS AND ADVANCED DEVELOPMENT TECHNOLOGIES

On health in general review your notes on section 1 of block 1 analysis : health and sanitation and in-depth analysis health and sanitation of the course. See also section 04. Reduce child mortality, which covers amongst other things the issues of malaria and measles.

For a good general reference on an integrated approach to health issues refer to Costello A. et al, Managing the health effects of climate change, Lancet (The) Vol. 373, Issue 9676, pp. 1693-1733 with University College London (Institute for Global Health Commission), London, 2009. [Registration is required for free access].

The Millennium Development goals omit any mention of NCDs [non-communicable diseases].

“…the global burden and threat of non-communicable diseases constitutes one of the major challenges for development in the twenty-first century, which undermines social and economic development throughout the world, and threatens the achievement of internationally agreed development goals.” (Paragraph 1 of the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, Agenda Item 117, Follow up to the outcome of the Millennium Summit, Declaration A/66/L.1, New York, 16 September, 2011.)

Yet non-communicable diseases together cause nearly two out of three deaths in the world !

“ … according to WHO, in 2008, an estimated 36 million of the 57 million global deaths were due to non-communicable diseases, principally cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, including about 9 million before the age of 60, and that nearly 80 per cent of those deaths occurred in developing countries ” (Paragraph 14 of the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, Agenda Item 117, Follow up to the outcome of the Millennium Summit, Declaration A/66/L.1, New York, 16 September, 2011.)

For children under 5, the leading non-communicable disease risk factors world-wide in 2010 were still childhood underweight 12.4% of disability-adjusted life-years (DALYs), non-exclusive or discontinued breast-feeding (7.6%) and household air pollution from solid fuels (6.3%). For adults world-wide high blood pressure, overweight, diabetes, alcohol use, and dietary risks have been steadily increasing in relative importance. (S.Lin et al, A comparative assessment of burden of disease attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010 : a systematic analysis for the Global Burden of Disease Study 2010, The Lancet, Vol. 380, Issue 9859, pp. 2226-2260, London 15 December 2012. [Registration for free copy required.]) .

The UNDP Report on Human Development for 2007/2008 provides the following tables :

In connection with the number of births attended by qualified personnel :

06 Commitment to health : percentage immunised against tuberculosis and measles; contraceptive prevalence rate.

08 Inequalities in maternal and child health. : children totally immunised

09. HIV Prevalence; anti-malaria measures; condom use at last high-risk sex

Millennium Goal 6 contains 2 targets (HIV/aids, and the other diseases), and 7 indicators.

1. Opinion.

On one page, taking into consideration your earlier work, explain why you think so much attention seems to be dedicated to this goal.

Millennium goal 6 is covered in Articles 53-57 in section VI : « Health and sustainable development», of the Plan of Implementation of the Millennium Goals.

Article 53 was already discussed in section 04. Reduce child mortality.

It reads :

“53. The goals of sustainable development can only be achieved in the absence of a high prevalence of debilitating diseases, while obtaining health gains for the whole population requires poverty eradication. There is an urgent need to address the causes of ill health, including environmental causes, and their impact on development, with particular emphasis on women and children, as well as vulnerable groups of society, such as people with disabilities, elderly persons and indigenous people.”

Paragraphs b) and g) read:

«(b) Promote equitable and improved access to affordable and efficient health-care services, including prevention, at all levels of the health system, essential and safe drugs at affordable prices, immunization services and safe vaccines and medical technology;

…

(g) Target research efforts and apply research results to priority public health issues, in particular those affecting susceptible and vulnerable populations, through the development of new vaccines, reducing exposures to health risks, building on equal access to health-care services, education, training and medical treatment and technology and addressing the secondary effects of poor health; “

Paragraph 55 of the Plan of Implementation of the Millennium Goals refers to target 7 on HIV/aids :

“55. Implement, within the agreed time frames, all commitments agreed in the Declaration of Commitment on HIV/AIDS adopted by the General Assembly at its twenty-sixth special session, emphasizing in particular the reduction of HIV prevalence among young men and women aged 15 to 24 by 25 per cent in the most affected countries by 2005, and globally by 2010, as well as combat malaria, tuberculosis and other diseases by, inter alia:

(a) Implementing national preventive and treatment strategies, regional and international cooperation measures and the development of international initiatives to provide special assistance to children orphaned by HIV/AIDS;

(b) Fulfilling commitments for the provision of sufficient resources to support the Global Fund to Fight AIDS, Tuberculosis and Malaria, while promoting access to the Fund by countries most in need;

(c) Protecting the health of workers and promoting occupational safety, by, inter alia, taking into account, as appropriate, the voluntary Code of Practice on HIV/AIDS and the World of Work of the International Labour Organization, to improve conditions of the workplace;

(d) Mobilizing adequate public, and encouraging private, financial resources for research and development on diseases of the poor, such as HIV/AIDS, malaria, and tuberculosis, directed at biomedical and health research, as well as new vaccine and drug development. ”

2. Opinion.

On one page, describe why, in your opinion, the descriptions of actions concerning HIV/ aids appear, when compared with the descriptions of other goals and targets, to be so detailed.

Articles 53 and 55 on their own were apparently not considered sufficient. Section 64 b) of section VIII of the Plan of Implementation of the Millennium Goals which is more specifically dedicated to sustainable development in Africa provides :

“(b) Make available necessary drugs and technology in a sustainable and affordable manner to fight and control communicable diseases, including HIV/AIDS, malaria and tuberculosis, and trypanosomiasis, as well as non-communicable diseases, including those caused by poverty”

“Since 2000, more than $70 billion of overseas development assistance has been spent for mass drug treatments and other allied health interventions, such as antimalarial bednets, health education, and other health system strengthening measures.” (Hoetz, P. : Millennium Development Goal 6 : Measuring Progress, PLOS Medical Journals’ Blog, San Francisco, 02 August, 2014.)

Imported malaria treatments paid for directly by patients in poverty seriously reduce the patients’ purchasing power and cause financial leakage from the areas where they live. Imported medicines paid for by the national government form an indirect financial leakage from the country and reduce the funds available to the government to pay for (other) social services. Since anti-malarial medicines and nets provide protection for a limited period, their supply must be continued over time with serious, on-going financial leakage as a result. This causes more poverty rather than reducing it. Furthermore, the more the medicines distributed, the greater the probability of development of protist immunity (especially that of Plasmodium Falciparum) to malaria treatment as described by A. Costello in her contribution Bed Nets for Malaria : Losing the Arms Race, Public Radio International (PRI), Minneapolis, July 16, 2103, where she also deals with the very poor quality of the bed nets supplied by the international aid industry.

Whatever section 64 b) may say in the interests of the pharmaceuticals industry, basic domestic and local public health measures are therefore the most effective and the cheapest way of fighting many infectious diseases and malaria in particular. They include removal of stagnant waters, including water collection in recipients such as flower pots and saucers and open ditches. The development cycle of mosquitoes varies from five days to a few weeks depending on the species and the environment. If there is no water for them to breed in in residential areas, they have to fly in from outlying areas. Their range of flight can reach a few kilometres depending on the species, but most types do not go more than a few hundred metres from the point of breeding, especially where there is not much wind. Several types of fish will eat mosquito eggs and larvae in stagnant parts of rivers, lakes and water reserves. Fish species used for this purpose must, however, be native to the area.

Strong pesticide-free bed nets cannot be locally produced in each integrated development project area.

These measures are easy to carry out under the local money systems set up in an early phase of the execution of integrated development projects, in principle without the need for any formal money payments in Euros or Dollars at all. That may be why the Plan of Implementation fails to take account of effective local action to reduce the number of cases of malaria. Poverty reduction is about reducing the number of cases, not treating as many of them as possible using imported “drugs and technologies”.

According to the World Health Organization, there were 219 million (registered ?) cases of malaria in 2010, with 660.000 deaths. Bacteria are already becoming resistant to artesiminin-based combination therapies (ACTs). “Without an effective alternative treatment, widespread resistance to both components of ACTs would be disastrous….Further spread of resistant strains of malaria parasites, or the independent emergence of artesiminin resistance in other regions [outside the Mekong Delta region[ could jeopardize all recent gains in malaria control and have major implications for public health. ” (Antimicrobial Resistance : Global Report on Surveillance, World Health Organization, Geneva, 2014, p. 51.)

Note that the foregoing comments are not intended to imply medicines should never be used to treat malaria !

For enlightening information on just how this is actually being done, see Audit of USAid/Benin’s Efforts to Treat and Prevent Malaria, Office of the Inspector General, Audit Report 7-680-13-001-P, Dakar, 09 November, 2012.

The project described is part of the President’s [George W. Bush] Malaria Initiative which was launched in 2008. For Benin, a country with 4.5 million inhabitants, some US$ 76.1 million was awarded to John Snow Inc., Boston (41,6 million), Management Sciences for Health (MSH), Cambridge, Massachusetts (4.5 million) and Medical Care Development International (MCDI), Augusta, Maine (30 million).

The summary of results states (on p. 2) :

“In FY 2011 the mission met its goals as defined in its performance plan report by purchasing 17,000 malaria treatment kits that were used by public and private hospitals and by more than 250 health workers. In support of comprehensive diagnostics, USAID/Benin contributed 600,000 rapid diagnostic tests toward the 3 million total national need, and 509,100 ACTs for uncomplicated malaria treatment to health facilities……

“…Additionally, results from Benin’s 2011-2012 Demographic Health Survey confirmed that USAID and donor efforts in the fight against malaria are having a significant impact. The number of households that own a bed net has increased from 25 to 80 percent in 5 years. The number of children under 5 who reported having a fever dropped by more than two-thirds, from 29 to 9 percent, indicating that prevention activities are reducing the number of new infections among children effectively.”

This does not seem to correlate well with the body of the report.

“All [of its] 1,048 community health workers were trained to treat simple cases of malaria, diarrhea (sic), and acute respiratory infections in children under 5. However, only 102 workers were taught how to use diagnostic tests. In 2011 none of the 39,259 suspected cases of malaria treated by the program’s community health workers were confirmed through diagnostic tests before the administration of antimalarial medication. This is not surprising since the 102 workers who knew how to use the tests were trained in January 2012—only 5 months before the project ended.” (p. 4)

“We were unable to verify any reported results for BASICS’ [Basic Support for Institutionalizing Child Survival ] malaria-related activities because neither MSH nor its five subpartners maintained records.” Of 29259 claimed treatments, 0 were verified. (p. 5)

“Some health centers do not report their inventory and consumption levels as required when they ask for more drugs…. inventory and consumption levels are not reviewed to determine whether the request is reasonable.” (p. 7)

“At Sikecodji Health Center in Cotonou, the director said she did not understand why the mission continued to deliver bed nets if she and her staff could not distribute them to beneficiaries.” (p. 7).

“In some cases, stock cards were inaccurate.”(p. 8)

“In response to the February 2011 audit—which also discovered that nets were missing, diverted, or sold for profit—the mission was supposed to improve its monitoring and perform quarterly site visits. The former commodities logistics specialist reportedly visited the sites to monitor the project, but the mission could not provide documentation of these visits.” (p. 8)

“The bags in which the bed nets were packed were not disposed of promptly… bags are collecting at health centers and could pose health and environmental risks.” (p.8)

“Activities Either Started Late or Not at All.” (p. 9)

“USAID/Benin has not worked intensively with MCDI and partners from the other projects to ensure that there is adequate collaboration.” (p. 10)

“the government [of Benin] had not been able to reimburse health centers because it was still putting a system in place to verify that only expenses for legitimate malaria cases qualified for reimbursement. The mission was aware of the possible adverse effects of this policy before it took effect and advised government officials to first study its implications, but the government did not. Failure to address the reimbursement problem will hinder PMI goals and jeopardize the program’s sustainability.” (p. 12)

The amount “spent” on this part of the anti-malaria campaign in tiny Benin alone could have financed the integrated development of nearly 1 million people, more than 20% of the population of Benin. One might also wonder why, if the bags bed nets were packed in could pose a health hazard, the nets were distributed for use with small children.

Report GAO-13-688, Washington, July 2013, by the United States’ Government Accountablity Office (GAO) on PEPFAR, the President’s Emergency Plan for AIDS relief : Millions Being Treated, but Better Information Needed to Further Improve and Expand Treatment, is also very revealing. PEPFAR is the giant anti-AIDS initiative introduced by president George Bush Jr and re-financed to the tune of US$ 48 billion in 2008 for a period of 5 years. This is a high level official report. It is damning, but the document must be read between the lines to see this. GAO found that “GAO’s reviews of PEPFAR Treatment costs, results, and ARV drug supply chains have revealed limitations in the completeness, timeliness, and consistency of key program information. GAO also found important information lacking in PEPFAR program evaluations plans and results reporting.” While “Fully functioning monitoring and evaluation (M&E) systems are critical for tracking results and ensuring treatment program effectiveness…. OGAC [ Office of the U.S. Global AIDS Coordinator] has not yet established minimum standards [after some 10 years!] for partner countries’ M&E systems, particularly relating to completeness and timeliness” (p. 14) confirming that “Evaluation of partner country supply chains reflect weaknesses in inventory controls and record keeping….”. Detailed cost studies have been carried out in just 8 partner countries at a small number of sites. (p. 17).

The PEPFAR definition of programme retention is unbelievable. “Retention, defined as the percentage of adults and children known to be alive and on treatment 12 months after starting treatment is used by OGAC and PEPFAR as a proxy for treatment program quality.” (p. 15) As if most patients with AIDS would not be alive for those 12 months without treatment anyway. The report continues that 20 of the 23 PEPFAR country teams provided data on “this” and 10 of those report retention rates at or above 80%, but even the “data for this indicator are not always complete and have other limitations.” These limitations include “differing ways of ascertaining and defining treatment retention; lack of data for key populations at risk of contracting…. And minimal data on long-term retention (24 months after starting treatment.” Finally GAO reports, “We provided a copy of this report [to the agencies involved] for review. We received limited technical information.”

The fight against tuberculosis.

“TB is terrifying. According to the WHO, it is the biggest infectious-disease killer, taking more lives than AIDS, cholera and other pandemics combined. But we have made matters worse. We have created Drug Resistant TB by our failure to ensure the complete six months of treatment. Incomplete and irregular treatment has led to successively worsening of disease forms, each more deadly than the last…..The EU spent $700 million on TB in one year alone. By 2015, there will be 1.3 million drug resistant cases, needing $16 billion to treat. 10 million children will be orphaned. In the next decade, the loss to the world's economy, due to TB in 22 high burden countries, will be $3.4 trillion. The brunt of the burden will be borne by low and middle countries… Huge amounts of funds have been poured into a bottomless pit. Global fund gave $3.8 billion to TB in 2012 alone. India revived $10 million from the Global Fund for increasing awareness. This funding should have led to better outcomes, i.e. improved case detection and decreased deaths. Unfortunately, this has not been so. Processes are documented, but not the results nor impact.” .” (Batre, s. Where Has All the Money Gone for Fighting Tuberculosis ?, Blog, Huffington Post, New York, 05 June, 2014.)

As a last “supplement”, article 100 of section X the Plan of Implementation of the Millennium Goals, which is about the “means of implementation” provides :

“100. Address the public health problems affecting many developing and least developed countries, especially those resulting from HIV/AIDS, tuberculosis, malaria and other epidemics, while noting the importance of the Doha Declaration on the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement) and public health, in which it was agreed that the TRIPS Agreement does not and should not prevent WTO members from taking measures to protect public health. Accordingly, while reiterating our commitment to the TRIPS Agreement, we reaffirm that the Agreement can and should be interpreted and implemented in a manner supportive of WTO members' right to protect public health and, in particular, to promote access to medicines for all.”

“The declaration on the TRIPS agreement and public health” was adopted in Doha on 20th November 2001, at the close of a Ministerial Conference of the World Trade Organisation. On 8th December 2005, it was followed up by amendment ADIPC WT/L/641 , which introduced a new article 31 bis to the agreement on Trade related aspects of intellectual property rights, part of the Uruguay Round, reproduced as Annexe C to the Marrakech Agreement instituting the World Trade Organisation signed Marrakech, Morocco on 15th April, 1994.

In practice amendment ADIPC WT/L/641 makes it possible for poor countries to import pharmaceutical products made under licence in other countries (India, for example) in partial derogation of the original licences between the technology owners and the manufacturers in question. The result is that medicines can, at least in theory, be made available to poor countries at a lower price.

3. Opinion.

On two pages write a dialogue between the manager international affairs of a pharmaceuticals multinational with a partner producing medicines under licence in India ,and the Minister of Health from one of the least developed countries who is not convinced of his possibilities of access to Indian-made medicines from India under the amendment ADIPC WT/L/641.

Pages 112- 123 of the UNIFEM Report Making the MDGs Work for All cover Millennium goal 6.

In respect of HIV/aids, women are believed to make up half of the people suffering from HIV/aids.

“Because most men who buy sex either are married or will get married, significant numbers of ostensibly ‘low-risk’ women who only have sex with their husbands are exposed to HIV.” (p. 112)

“Women's risk of exposure to HIV/AIDS is increased by poverty, poor nutrition, low levels of education, illiteracy, lack of information on HIV/AIDS, lack of knowledge about sexuality and inability to discuss it with sexual partners, and lack of empowerment among women in general and sex workers in particular to negotiate safe sex with partners and clients. “ (p. 121)

“The majority of primary caregivers are women, including girls and grandmothers. The physical burden of care is so heavy that it leaves little time or energy for economic activity to provide a livelihood for the family.” (p.123)

Malaria.

Each year, some 50.000.000 women get pregnant in areas where malaria is endemic. Half of them live in tropical Africa. Malarial infection in pregnant women leads to the death of about 10.000 women and 200.000 children each year. More than half of these deaths are caused by serious malarial anaemia. (See «Where and why are 10 million children dying every year » (The Lancet, Vol. 361, edition 9376, pp 2226-2234, June 2003) and «Knowledge into action for child survival » , The Bellagio Study Group on Child Survival, The Lancet, Vol. 363, edition 9380, pp. 323-327, July 2003, which were both cited in the section of the course on the reduction of child mortality.

Tuberculosis.

"In Africa, tuberculosis is the most important cause of death of people suffering from HIV/aids. More women die each year of tuberculosis than of all maternal mortality causes combined. Biologically, women are at greater risk of tuberculosis than men, and they progress faster from infection to active tuberculosis. Tuberculosis is the single biggest killer of young women. ” ( Report Making the MDGs Work for All, p. 114)

Dominating social structures often make it difficult for women to get access to medical centres.

4. Opinion.

On one page, try to organise three columns, one for HIV/aids, one for malaria, and one for tuberculosis. In each column list local actions you think could be taken in your project area to substantially reduce the number of cases of death due to HIV/aids, malaria, and tuberculosis.

◄ ►

◄ Second block : Problems to be solved.

◄ Index : Diploma in Integrated Development (Dip. Int. Dev)

◄ List of key words.

◄ List of references.

◄ Course chart.

◄ Technical aspects.

◄ Courses available.

◄ Homepage Bakens Verzet.

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