Rio de Janeiro, November 2014
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Marmor: “Health as a right is a political aspiration” Healthcare, cross national researches, regulation and the reforms of the sector were the main issues addressed during the conference “Challenges for universal health systems in the 21st century”, presented on November 12 by Theodore Marmor, professor emeritus at Yale University. Marmor came to Rio de Janeiro after an invitation from the South American Institute of Government in Health (ISAGS) to open the workshop “Strengthening the State, Regulating the Market: Challenges for UNASUR national health systems”. The conference was presented in English with live Internet transmission and counted with simultaneous translation to Spanish and Portuguese. Marmor began his exposition by presenting various approaches on cross national health researches, highlighting the danger of “naive transplantation”, which would be equivalent to the reproduction of successful health system models from other countries. On the other hand, he also mentioned the “intellectual fallacy”, which can be explained as the negative of learning through the exchange of experiences. Public Health vs. Private insurance The academic pointed out the fundamental differences between the private health insurance and the principles of public health, arguing that, for the logic of private health, there is a selection in the base, with the separation between those who are healthy and those who are not. With regard to the values of public health, he highlighted the commitment with no financial barriers, for an accessible healthcare to all the population. When talking about the private sector, Marmor identified the growth of a promarket conception in the contexts of political discussions, pointing out an approach that sees health as merchandise. The lecturer was ironic: “From the neoliberal perspective, if bread were free, no bakery would have any bread left. They talk about ill and injured people as people who are buying bread”.
Fabiano Veneza
Specialist stated that there is a tension between the programs for the extension of coverage and the commitment with the claims for equal access
In his conference, Ted Marmor talked about regulation, healthcare and cross national investigation
Ted Marmor briefly presented the Obamacare – North American healthcare programme, initiated this year – exploring its complexities and critical aspects. Marmor affirmed that the initiative, developed by traditional economists, could be seen as a “patchwork”.
“From the neoliberal perspective, if bread were free, no bakery would have any bread left. They talk about ill and injured people as people who are buying bread” Right to health, regulation and financing In an interview for ISAGS, Marmor affirmed that “health as a right is a political aspiration” and that the efforts for the extension of coverage reflect this thought. The academic observed that, however, there is “a tension between the multiple programmes for the extension of coverage and the commitment with the claims for equal access and citizenship”.
Concerning the aspects of the regulatory health market, the professor affirmed that public authorities must impose restrictions to prices and define clear rules about conducts that should be avoided. When talking about financing, he declared: “If a programme is not sustainable in the long term, it should not be sustained”. The conference and the complete interview with Ted Marmor will be available at ISAGS’ website in a few weeks.
READ MORE Workshop evaluates regulation of private health sector Page. 2 ISAGS participates in debate about global health and south-south cooperation in Washington Page. 3 “There is no use in a safe, effective, quality medicine, which is inaccessible”, says Tomás Pippo Page. 4
Workshop evaluates regulation of private health sector in UNASUR countries
Fabiano Veneza
During the event organized by ISAGS, countries representatives presented their models for regulation of the private sector and debated partnerships
Representatives of UNASUR countries evaluate policies for the regulation of the private health sector
Different health systems and different ways of integrating the public and private sector, but the common intention of fighting for quality in service provision, whether public or private. This is the scenario of South America that was evaluated by the participants of the Workshop “Strengthening the State, Regulating the Market: challenges for UNASUR national health systems”, promoted by ISAGS. From November 12 to 14, the event gathered representatives from eight South American countries at the Institute’s headquarters, in Brazil. The participants presented the main characteristics of their health systems, emphasizing on the state’s regulation tools, on the dimension of the private market, the financing sources and the composition of public and private expenditure in health. Concerning the regulation of financing institutions, health service providers and private insurance companies, each country has its own model, which varies according
to their legal frameworks and specific needs. Some countries focus on the regulation of health system financing institutions, such as Peru and Suriname, while others emphasize on the regulation of service pricing – such as Colombia. There are, still, those who strongly regulate the companies that offer health insurances, like Brazil and Argentina. “Each one of us has different strategies and means, but the aims are the same: to fight for the quality of services provided. We work to guarantee the accessibility for the population, the sustainability of health expenditure and the strengthening of the State’s leadership, so that our populations are always benefited”, explained the representative for Uruguay’s Ministry of Public Health, Elena Clavell. Common values and challenges The establishment of institutional and legal frameworks that guarantee the right to health was highlighted as a common value – so much so that the protection of health
as a human fundamental right is determined by the national constitutions of Argentina, Brazil, Colombia, Ecuador, Uruguay, Paraguay, Suriname and Peru, although they might have different approaches. “Still, we face difficulties for the transformation of legal provision in practical actions”, stressed the representative for Ecuador’s ministry of Health, Nilda Villacres. Other challenges pointed out by the participants were the questions related to health provision in border regions. The participants even proposed it that ISAGS could develop a study about the issue, in order to facilitate decision making. “The different providers and the varied financing and healthcare models, sometimes generate problems for the population. We need to act beyond the borders of the State, in order to create adequate solutions”, highlighted the representative for Paraguay, Gustavo Cristaldo. The participants exalted the initiative of promoting cooperation activities with repercussion on the internal dynamics of the countries. “I would like to highlight ISAGS’ role as an international space for discussion, which helps us identify the opportunities to enhance our systems. It was extremely positive to meet representatives from other South American nations and to exchange experiences. I believe this workshop will have positive repercussions on our work”, concluded the representative for Argentina, Mariano Fernández Lerena.
“Tax deductions strengthen health inequities”, defends Ipea researcher Conference “Tax deductions for health expenses: the experiences of Australia, Canada and the United States” was presented on second day of ISAGS’ workshop age was adopted. From another point of view, he talked about the Canadian experience, characterized by the incentive to the public system, the private health insurance being supplementary. He counterpointed this vision with the Brazilian scenario, marked by the duplication of expenses, considering that the unified health system and the private plans offer similar services. The specialist pointed out the importance of rethinking the relation between the
State and the market from the South American perspective, taking into account the current discussion about coverage and universal health systems: “Considering that universality and equity may not be guaranteed, once the coverage strategy includes the purchase and sale of services, wouldn’t it be better to allocate those resources in the public systems, instead of extending the subsidy to the market?” he questioned.
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Tax deduction as a background for the debate on mixed public-private health system models was the theme of the conference presented by the technician in Planning and Research at Brazil’s Institute for Applied Economic Research (Ipea), Carlos Ocké, during the workshop “Strengthen the State, Regulate the Market”, held by ISAGS. Ocké, who coordinated ISAGS’ thematic workshop, talked about the varied approaches on tax deductions, emphasizing that the taxes that the State does not collect, allowing individuals to deduct their expenses with private health insurance and services, reinforce the existence of inequities, once the State ceases to allocate resources in the public health sector. With regard to the Australian case, the researcher explained that there is an incentive for the use of the private system since 2000, when a policy that stimulates the purchase of insurances for population under 30 years of
Carlos Ocké presents conference about tax deductions during ISAGS’ workshop
Global health and south-south cooperation are debated in Washington “UNASUR is an integration project, built upon the possibility of reducing inequalities. The 12 countries have united themselves because they believe that together they can do better in order to reach this goal, inclusively in the field of health.” With these words, ISAGS head of office, Mariana Faria, has put South America in the core of the debate on global health in the 21st century. Faria participated in the session about global health, held during the Global SouthSouth Development Expo (GSSD Expo), which took place in Washington (USA), on november, 19th. The event was promoted by the United Nations Office for South-South Cooperation (UNOSSC), with the support of the Organization of American States (OAS). During the GSSD Expo, different issues concerning South-South cooperation were addressed, such as green energy, the eradication of child labor, development programs, poverty reduction and the Ebola epidemics. Global health was one of the highlights and it was the theme of a special session composed by two panels, in which there was an evaluation of projects with possibilities of extension and reproduction in different parts of the world. In the event, UNASUR was represented by the South American Institute of Government inHealth. ISAGS participated in the first panel about global health, alongside the Pan-American Health Organization (PAHO), the Global Fund to Fight AIDS, Tuberculosis
ISAGS Collection
During the event, ISAGS’Head od Office received an award for the institute’s actions in cooperation initiatives in South America
ISAGS head of office presented the South-South cooperation initiatives developed by the Institute
and Malaria, the Federal Commission for the Protection against Sanitary Risks, Government of Mexico (COFEPRIS) and the Department of Public Health of Angola. For the director of the Health Systems and Services Department of the Pan-American Health Organization (PAHO), James Fitzgerald, health is one of the pillars for South-South cooperation. “The current scenario shows that innovation in health through South-South cooperation is not only real, but is rapidly growing. This is extraordinary, especially if we take into account the diversity of the countries in cultural, social, economic and political aspects. Such interactions are only possible when there is political engagement and commitment”, he affirmed. Institute receives award The relation between ISAGS and the UNOSSC is established on the Institute’s Annual Operative Plan 2014, which introduces the possibility of intersectoral articulation with other international organisms and congener institutions. Within the context of South-South cooperation, other important international
institutions also took part in the GSSD Expo, such as the Economic Commission for Latin American and the Caribbean (ECLAC), the United Nations Development Program (UNDP) and the United Nations Environment Programme (UNEP). At the end of the session, ISAGS representative received an award in recognition of its social contribution to South-South cooperation and triangular cooperation in the field of health. The award was also given to the other participants of the two panels about health. ISAGS was invited to do the closing speech of the session. In the occasion, Mariana Faria highlighted the importance of developing joint actions in the field of health in order to guarantee the enhancement of the quality of life of the populations, especially those of Southern countries. “Health cannot be reached with simple or superficial solutions: it is necessary to have a systemic and multisectoral approach. In this sense, cooperation is fundamental, for we live in a global world and diseases know no borders. Without health, there is no sustainable development”, she concluded.
ISAGS hosts workshop for the construction of indicators on public health policies Monitoring of policies will be focused on the issues of medicines, primary healthcare, schools of public health and surveillance she complimented UNASUR’s performance: “The bloc has progressed a lot in a short period of time, especially with regards to the right and development of health. Therefore, it is necessary to investigate the positive synergies between international organizations and poverty reduction”, she declared. The Associate Director at the United Nations University’s Institute on Comparative Regional Integration Studies, Philippe de Lombaerde, defended that the monitoring system should go beyond the technical aspect and also contemplate political and management aspects, thus observing the importance of the work with institutional mandates of the Five-Year Plan of the South American Health Council (SHC). The meeting also debated the fact that some tangible elements for the evaluation of UNASUR’s health sector are not included in the SHC’s Plan. The specialist Andrés
Coitiño mentioned the example of the work plans of the structuring networks and technical groups of the Council. The group agreed on the construction of governance indicators in four areas of focus: medicines, primary healthcare, schools of public health and surveillance. The researchers will elaborate a document with the description of the aims of the monitoring and evaluation, its critical aspects and expected results.
ISAGS Collection
The 1st Workshop for the Construction of Indicators to Measure the Progress of UNASUR Health Policies was held on November 10, at the headquarters of the South American Institute of Government in Health (ISAGS). The meeting, which is part of the activities of the project “Poverty reduction and regional integration – a comparative analysis of the Southern Africa Development Community (SADC) and the Union of the South American Nations”, counted with the participation of researchers and specialists in health of South America. The project is coordinated by the United Nations University and the University of Southampton, in England. The researcher and coordinator of the project, Pia Riggirozzi, from the English university, opened the event by highlighting the role of international organizations in the maximization of public policies. In this context,
Participants of the workshop work on the construction of indicators to evaluate public health policies
Interview: Tomás Pippo
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There is no use in a safe, effective, quality medicine, which is inaccessible
Tomás Pippo is the coordinator of the Technical Group on Universal Access to Medicines of the South American Health Council (GAUMU) and the director of Health Economy at the ministry of Health of Argentina. In this interview, he talks about how the power relations between countries and laboratories can influence the prices of medicines, defends the importance of universal access to pharmaceuticals and addresses the dichotomy between the protection of intellectual property and the right to health. Regarding the latter, he highlights the importance of the Seminar “Public Health, Innovation and Intellectual Property: Perspectives for UNASUR”, which will be held by ISAGS on December 3 and 4, in Buenos Aires, Argentina. What are the expectations for the Seminar on Intellectual Property that will take place in Buenos Aires? In the ambit of UNASUR, this is the first time we have a specific workshop to address the issue and, therefore, we have very high expectations. The issue is not only interesting for the ministries of Health, but also for the ministries of Science and Technology, as we will address the access to medicines and the protection of intellectual property.
The perspectives of the scientifictechnological sector are not always the same perspectives of the health sector. Hence, it is fundamental to establish a dialogue between these sectors in order to understand their points of view and, starting from that, be able to strengthen the construction of common positions. An event like this, which intends to gather representatives of both ministries, should be of great importance for that matter. In your opinion, which is the boundary between the right to health and intellectual property? We, from the health area, keep a premise as an unnegotiable value and ideal: first comes public health, and after that, commercial interests. This is laid down in many international agreements. We also recognize it that intellectual property has been the engine of many important research and development projects in the health area. Nonetheless, we need consider that, in many cases, the protection of intellectual property does not work as a sufficient incentive to development. We want to focus on specific situations, which require alternative systems, with the engagement of other actors and the search for other mechanisms. The final aim is not the search for the patent, but the access to health.
What were the main activities of the GAUMU in 2014 and what are the perspectives for 2015? In 2014, we worked intensely for the construction of UNASUR common positions on the access to essential medicines and to similar biotherapeutic products. The articulations carried out by the GAUMU have enabled us to reach a common position for the 12 countries of South American on the 67 th World Health Assembly. We have succeeded in the inclusion of this dimension of the access: evidently, we need to fight for safety, quality and efficacy, but there is no use in a safe, effective, quality medicine, which is inaccessible. In 2015, we intend to work even more intensely in the two projects of UNASUR’s Common Initiatives Fund, which are being developed by the Group, in a partnership with ISAGS: the medicines price bank and the mapping of the regional capacity for the production of medicines and health inputs. After the signature of the letters of commitment by the SecretaryGeneral Ernesto Samper and by ISAGS Executive Director José Temporão, we can think of new policies and strategies to continue with the work. How can these two projects be useful to the countries? These are processes based on information sharing. Each country will decide how to use this information, and they can all define a common use, if they wish to do so. The most interesting part is that the mere sharing of data can make the production and purchase processes much more efficient in the countries. Nowadays, the prices can vary a lot from one State to another, and this variation is much more associated to the negotiation power of the country towards laboratories, than to the production costs specifically. The prices are the result of a power relation. Therefore, the access to these data can be used as a tool for the countries to negotiate the prices more transparently. I believe that the initiatives will bring results to the populations in the short term already.
INSTITUTIONAL ISAGS-UNASUR Executive Director: José Gomes Temporão Head of Office: Mariana Faria Technical Coordinator: Henri Jouval INFORMATION AND KNOWLEDGE MANAGEMENT Coordinator: Camilla Ibiapina ISAGS Report Editor: Beatriz Nascimento Report: Beatriz Nascimento and Mariana Moreno Team: Bruno Macabú, Felippe Amarante, Flávia Bueno and Nanci Miranda 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.