Health to the South - September 2017

Rio de Janeiro, September 2017 . No 10

PRODUCTION OF ANTIVENOMS: EXPERIENCES AND CHALLENGES OF BRAZIL AND COLOMBIA INTERFERENCE OF THE FOOD INDUSTRY IN THE COLLECTIVE HEALTH?

Interview: BERNARD PÉCOUL EXECUTIVE-DIRECTOR OF THE DRUGS FOR NEGLECTED DISEASES INITIATIVE (DNDI)

WHEN WILL THE BARRIERS GO?

INSTITUTIONAL ISAGS-UNASUR Executive Director: Carina Vance Head of Administration and Human Resources: Gabriela Jaramillo Coordinator of International Relations: Luana Bermudez INFORMATION AND COMMUNICATION MANAGEMENT Coordinator: Flávia Bueno Editor-in-Chief: Manoel Giffoni Report: Carina Vance, Carla Magda Allan Santos, Flávia Bueno, Francisco Armada, Manoel Giffoni, Mario Camelo, Martha Lucía Ospina, Néstor Fernando Mondragón, Ricardo Gadelha de Abreu Collaborators: Angela Acosta, Caroline Ignácio, Eduardo Hage Team: Carlos de Lima 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.

Photo: INS Colombia

PRODUCTION OF

ANTIVENOMS: EXPERIENCES AND CHALLENGES OF BRAZIL AND COLOMBIA Although it is not a widely debated issue on the global public health agenda, snake-bite accidents have a major impact worldwide. So much so that the World Health Organization (WHO) has again included those in the list of the top 20 neglected tropical diseases, aiming at developing a global intervention strategy. Deaths from poisonings of this type are easily preventable, provided that specific antivenoms are available; however, therein lies the problem.

Despite progress in meeting the current regulatory and quality requirements, the sera production sector has undergone rapid and profound changes. The level of production has not yet been able to meet all the demands of both Brazil and Colombia as well as many other countries in South America, demanding a reorganization of the process of distribution and use of sera to ensure supply.

Given these conditions, the need to strengthen the production of antivenoms by means of strategic alliances that allow for the development of drugs with high neutralizing power to meet the needs of the region is evident.

In Brazil, for example, accidents involving venomous animals and, in particular snake-bite accidents were included in its Compulsory Notification List of the “Information System for Notifiable Diseases” (SINAN, in Portuguese) since 2010, being one of the top reported cases in the system. Based on the analysis of these data, epidemiological surveillance is able to identify the quantity of antivenom sera to be distributed to the Federated Units, determine strategic points of surveillance, structure care units for the victims and develop control strategies.

In the past five years (2012 to 2016), the incidence rate of accidents by venomous animals varied in the country from 73 to 80 per 100 thousand people, as well as the mortality rate: from 0.13 to 0.15 per 100 thousand people.

IN 2016, THERE WERE AROUND

173,165 ACCIDENTS scorpions: 53% spider: 17% serpent: 15% bee: 7% caterpillar: 2% other: 6% 311 DEATHS

scorpions: 41% spider: 36% serpent: 10% bee: 8% caterpillar: 1% other: 3% Currently, Brazil is self-sufficient in the production of antivenom sera and has three public laboratories: Ezequiel Dias Foundation, in Minas Gerais; Instituto Butantan, in São Paulo; and Instituto Vital Brazil, in Rio de Janeiro. In 2016, about 480 thousand bottles of sera were acquired for various types of accidents to meet the needs of the country’s 27 Federative Units.

The sustainability policy of the country’s National Immunization Program (PNI) is based on the strengthening of the industrial health complex, where the main strategic inputs are produced by public laboratories, in order to guarantee the self-

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sufficiency of national production, the maintenance of high vaccine coverage and access to resources, such as sera, in all Brazilian municipalities.

This strategy aims to avoid the shortage of products and submission to market law. Two main mechanisms have been adopted to foment domestic production: stimulation of internal development of products or seeking technology transfer to public laboratories through partnerships with private laboratories. This action has allowed for the production of the main strategic inputs by public laboratories, as required by the National Health Surveillance Agency (ANVISA), have adequate their infrastructure to Good Manufacturing Practices, further guaranteeing the quality of products used in the Unified Health System (SUS) network.

significant resources for the adaptation and physical improvement of the hyperimmune sera production plant in order to improve the quality of the product and to comply with the Good Manufacturing Practices.

This improved the production of antivenoms and the efficiency of the pharmaceutical process in such a way that the INS currently has the capacity to produce up to 60,000 polyvalent antiophidic serum vials every year and to develop the micrurus antivenom in such a way that the country also has the specific medication to give timely attention to accidents caused by coral snakes.

CHALLENGES In both countries, efforts have been made to improve the management of the use of sera in health units, but there remain bit challenges.

In Colombia, since 2004, snake accidents have been recognized as an event of interest for Public Health, therefore, health professionals are required to report cases to the Epidemiological Surveillance System (Sivigila, in Spanish), which makes the collection of annual information possible In order to follow the behavior of such events and also to make informed decisions to approach prevention and control. During 2016, 4,704 snake accidents were reported, with a national incidence of 9.6 cases per 100,000 people. 34 cases resulted in death, representing a mortality rate of 0.6 per 1,000,000 people. In 2016, notification increased compared to previous years, with a 69.7% increase in the incidence rate when compared to 2008. Regarding accidents caused by other venomous animals such as scorpions, spiders and caterpillars do not have general data because they are not under mandatory reporting to the surveillance system; however, in recent years, they have become more important since there have been reported deaths associated with these types of events.

Likewise, for the country, this type of accident has been of great importance and that is why one of the main goals of Colombia´s National Health Institute (INS, in Spanish) is the production of goods and provision of services of interest for Public Health , which has allowed the Institute to allocate part of its human and economic resources for more than 50 years in order to guarantee the production of high quality antiophidic serum with excellent neutralizing capacity and an efficient production cost to treat ophidian accidents.

Taking into account that these events are a priority for the Colombian State, the INS recently invested

Carla Magda Allan Santos Domingues, General Coordinator of the National Immunization Program of Brazil 4

Effective management of the records of sera production and use in order to avoid wastage and ensure timely access to the population.

Improvement of notifications in surveillance systems so that appropriate measures are taken, avoiding deaths; The shortage of sera in many countries of the region, such as the anti-monomeric to treat accidents caused by venomous caterpillars, and anti-corpionic, causing deaths especially of children; Biodiversity of the countries, so that the species involved in scorpionic and lonomic accidents are different from those used in the countries where these antivenoms are produced, such as Brazil and Mexico for the manufacture of antivenoms (generating insufficient production that meets all regional needs).

In order to overcome these challenges, South American countries are structuring agreements through international cooperation, such as the one Colombia is doing with the governments of Ecuador and Peru to promote technological exchange and use their production capacity in order to guarantee the availability of the antiophidic sera in the neighboring countries, thus consolidating a regional response to provide timely attention to such important events in Public Health.

It is crucial, therefore, to create strategic alliances that respond to these challenges. This gives the opportunity for Colombia and Brazil to join forces and share their strengths to lead the region in order to provide these medicines of vital importance for the entire region.

Ricardo Gadelha de Abreu,

Martha Lucía Ospina,

Néstor Fernando Mondragón,

Technical Manager of Resources Management of the National Immunization Program of Brazil

General Director of the National Health Institute of Colombia

Director of Production of the National Health Institute of Colombia

EXPERTS CORNER THE 29th PAN AMERICAN SANITARY CONFERENCE OF THE PAN AMERICAN HEALTH ORGANIZATION

by Piedad Huerta Arneros, MPH - Senior Advisor, Bureau of Governing Bodies-Panamerican Health Organization, Regional Office for the World Health Organization

In order to understand the importance of the Pan American Sanitary Conference, it is necessary to know its historical context. The first International Sanitary Convention of the American Republics took place on December 2, 1902, in Washington, USA, as a result of a resolution adopted by the International Conference of American States, organized by the International Union of American Republics of the American States (predecessor to the Organization of American States [OAS]) between the end of 1901 and the beginning of 1902.

the relationship by signing an agreement between the Organizations on May 23, 1950.

In this resolution, the governments represented their commitment to cooperate with the others to guarantee and maintain modern and efficient sanitary conditions in all their ports and territories. In addition, they agreed to convene the First International Sanitary Convention - to reach agreements and sanitary regulations that would serve the interests of the republics represented - and also to choose an International Sanitary Bureau, whose permanent center should be established in that same city, in order to provide services to the nations present at the convention. Thus, during the first meeting, held on December 2, 1902, the Office, now known as the Pan American Health Organization (PAHO), was established.

The Conference has a very important mandate to elect the director of the Pan American Sanitary Bureau, which is the sole responsibility of that body. The name of the person elected as director is presented to the WHO Executive Board to be nominated for its office in the Americas. It is also before the Conference that the report “Health in the Americas” is presented, a flagship publication that compiles information on prevalent health conditions and trends in the countries and territories of the region, as a result of a resolution (CD7.R23), adopted by the Seventh Directing Council, in 1953.

For 115 years, Ministers of Health and other delegates from the American Republics and their territories have met periodically to discuss relevant regional public health issues, to reach agreements through resolutions and decisions; and adopt policies, strategies and action plans that serve as a framework for improving the health of the peoples of the Americas.

With the establishment of the World Health Organization (WHO) in 1948, on May 24, 1949, PAHO and WHO signed an agreement which established that the Pan American Sanitary Bureau would serve as the WHO Regional Office in the Americas. In addition, its governing bodies, the Pan American Sanitary Conference and the Directing Council, would serve as the WHO Regional Committee for the region. Since then, each meeting of these bodies has assumed the role of sessions of the WHO Regional Committee. At that time, although PAHO was already the specialized health agency for the OAS, it was decided to formalize

PAHO´s highest governance body is the Pan American Sanitary Conference, which meets every five years, followed by the Directing Council whose meetings are held each year, except for the year of the Conference. The Organization also has an Executive Committee and, in addition, the Pan American Sanitary Bureau, which serves as the secretariat of the Organization, and it is also recognized as an organ of PAHO.

During the 29th Pan American Sanitary Conference, PAHO´s Director will be elected for the next 5-year period (February 2018 to January 2023). Considering that the Rules of Procedure include the possibility that a current Director may be reelected for an additional period, Dominica presented the candidacy of Dr. Carissa Etienne, and she is the only candidate in the current election process.

In addition, the Conference will review some 40 topics, ranging from the adoption of resolutions on important technical topics, to the review of progress reports on resolutions adopted in previous years, as well as other administrative and regulatory issues. The 29th Pan American Sanitary Conference is expected to approve around 15 resolutions this year.

The 29th Pan American Sanitary Conference of the Pan American Health Organization will take place from September 25 to 29, 2017 in Washington, United States, at the same time as the 69th Session of the WHO Regional Committee for the Americas.

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INTERFERENCE OF THE FOOD INDUSTRY IN THE COLLECTIVE HEALTH? One of the main challenges of public health is the constant interference of industry in the formulation of its policies and the consequences that this generates. The power they have can lead to many health problems that impact health systems, as is the case of obesity, hypertension and diabetes, heavily influenced by food, for instance. To address this problem, countries in South America such as Bolivia, Chile, Ecuador, Peru, and Uruguay implemented or are in process of implementing innovative interventions as part of a comprehensive strategy: food labeling.

Last August, the Government of Chile, with the participation of the Pan American Health Organization (PAHO/WHO), the Food and Agriculture Organization of the United Nations (FAO) and the United Nations Children’s Fund (UNICEF) organized the conference “Towards a Healthier World: Promoting Alliances for the Regulation of Food Environments” to address the issue from an intersectoral perspective. One of the challenges discussed was the need to deal with the interference of the food industry in these policy processes for the promotion of healthy eating, whose mechanisms have been extensively studied in the case of tobacco control.

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New labeling initiatives include much clearer

and easier to understand warnings at the time of product selection, for girls and boys often have great influence in food choice, using different models of public warning about high content of fats, sugar, calories or salt. Ecuador implemented warnings that are linked to the common knowledge of a traffic light, while Chile opted for black and white symbols that also recall traffic signals. Models, size, messages, location, and other technical details have been the subject of a number of studies, the evidence of which served as the basis for the main recommendations to countries implementing these initiatives.

UNASUR countries have expressed their interest in the study of these initiatives in different scenarios. ISAGS-UNASUR with the participation of PAHO/WHO organized an International Conference on “Integrated Policies and regulation in food and nutritional security” in 2016, where the main initiatives of the region and the challenges for their implementation were discussed. This is the topic of a project currently being developed

by ISAGS-UNASUR with the aim of outlining a set of recommendations for countries on how to deal with these practices of the industry. The study has already identified both the successful strategies employed by the ministries of health

Another strategy used by the industry has been the general questioning of the necessity or usefulness of labeling, usually based on lack of knowledge, or discredit of existing evidence. To address this practice, countries used available information on the characteristics of obesity in the country where the policy was proposed.

“The Food Labeling Law we implement is not only an obligation to make the actual content of harmful elements present in the products that the population consume. It is also an action that seeks to mobilize people regarding the seriousness of the problem of malnutrition, and to put the issue at the center of society discussion, in the media, in homes, in schools.”

Michelle Bachelet, president of Chile The economic issue is one of the most used arguments, with an astonishing parallel to that of the tobacco industry. Catastrophic economic scenarios of job losses, economic downturns were frequently presented by the industry, despite not having evidence in this regard. Even after the implementation of innovative labeling alternatives in some countries, similar negative consequences for the national economy were not documented.

The analysis of the experiences of the implementation of innovative labeling in South America, complemented by findings published in scientific literature, allowed us to outline a first group of recommendations to deal with the interference of the industry in the process of adoption of these policies of healthier diets, as follows:

a) Use of evidence and robust epidemiological data: before, during and after implementation of the policy.

This is valid to characterize the situation of obesity and to support technically the measures to be taken.

b) Consolidate a multidisciplinary team in the Ministry of Health with specialists from different areas was important for the success of the experiences analyzed. c) Strategic alliances with international organizations, particularly PAHO/WHO, ISAGS/UNASUR, FAO and UNICEF, were very useful in discussing the policy and its subsequent implementation. (d) Multiple national alliances with consumer associations, community groups, professional associations and academia were also very useful in successfully implementing the new labellings.

Although measures and actions need to be adapted to each specific context and circumstance, understanding the way of some sectors of the food industry act to interfere with these new initiatives and studying the successful mechanisms to respond to these interventions represent an opportunity for the initiatives already implemented and also to the ones that are in progress of navigating more fluidly in the political and technical processes of policy development that will promote a healthier diet for all.

“Why do they sell junk food? Because they can put garbage in containers that seem healthy, because nobody understood the labeling and there is asymmetry in the handling of information. That is why it is very important that Chile has been able to advance in a public policy to fight globally against obesity and non-communicable diseases – heart attacks, vascular accidents and cancers - that are the most transmissible of all “- Guido Girardi, VicePresident of the Senate in Chile Francisco Armada franciscoarmada@isags-unasur.org

and other driving institutions for innovative policies in the countries, as well as some of the mechanisms employed by the industry, including the active participation of its representatives trying to influence the design and implementation of such measures. In some cases, these individuals succeeded in halting or delaying implementation, in others, weakening some of the proposed interventions. In Ecuador, it was suggested that industry interference influenced the abandonment of the initial intention of front labeling. Industry activities interfering with labeling policies have been reported even some time after the measure was approved. In Chile, after the implementation of labeling, the industry financed a publicity piece on television where local artists questioned the effectiveness of the measure.

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CHAGAS

A neglected disease The infection is transmitted by contact with feces and urine of triatomine insects such as the kissing bug, shortly after its bite.

Caused by the protozoan parasite Trypanosoma cruzi (TC), discovered in 1908 by Carlos Ribeiro Justiniano Chagas, a Brazilian doctor who named the microorganism in honor of Oswaldo Cruz.

The fact was considered unique in the history of Medicine, since the same investigator identified the vector, the parasite and a new disease, named with his last name.

The insect lives in holes and gaps of adobe houses, mainly, and has nocturnal habits, when it feeds on human blood.

In addition, it can also be transmitted by contaminated food, blood transfusion/ laboratory accidents, by vertical transmission or organ transplants of infected persons.

In 2006, there was a significant increase in cases of Chagas in the State of Pará in Brazil, when it was found the cause to be the consumption of unpasteurized açaí (a fruit from a palm common in the region).

1 ACUTE PHASE

Of the 6/7 million people infected with TC worldwide, the majority is in Latin America and it is present in the 12 countries of South America.

It is the parasitic disease that kills the most in Latin America.

During the acute phase, which lasts approximately 2 months after infection, the parasites circulate through the bloodstream and may be asymptomatic, present mild or non-specific symptoms.

One of the signs that the bite leaves is a skin lesion or a swelling in the eyelid.

Symptoms The disease has 2 distinct phases

There is no vaccine against Chagas’ disease.

Although vector control is one of the ways to control transmission, access to housing which would not facilitate the installation of the insect, as well as the conservation of forests are essential to prevent the spread of this disease.

2 CHRONIC PHASE In the chronic phase, which can last for many years, the parasites are hidden in the heart and digestive muscle and in about 30% of cases, those infected suffer from heart problems and 10%, digestive, neurological or mixed ones.

However, the available treatment is poorly effective in the chronic phase of the disease, it lasts too long (60-90 days) and has side effects that contribute to the lack patient adherence.

Treatment Early treatment is crucial for the cure of Chagas disease

In 2009, the DNDi (Drugs for Neglected Diseases Initiative) and collaborators launched the Chagas Disease Clinical Research Platform, which brings together experts and patients in the search for new treatments and diagnostic strategies for the Trypanosoma cruzi infection and advocacy actions to increase the numbers of patients being treated.

Sources: • OMS, 2017. La enfermedad de Chagas (tripanosomiasis americana). Nota descriptiva. Available at: http://www.who.int/mediacentre/factsheets/fs340/es/ • IOC, 2017. Carlos Chagas. Available at: http://www.fiocruz.br/ioc/cgi/cgilua.exe/sys/start.htm?infoid=151&sid=76 • Revista Exame, 2010. Açaí pode transmitir doença de Chagas. Available at: http://exame.abril.com.br/ciencia/acai-pode-transmitir-doenca-chagas-558972/ • DNDi América Latina, 2017. Available at: www.dndial.org

INTERVIEW:

BERNARD PÉCOUL

EXECUTIVE-DIRECTOR OF THE DRUGS FOR NEGLECTED DISEASES INITIATIVE (DNDI) After 5 years working as Director of the Campaign for Access to Essential Medicines at the Médicins Sans Frontières (MSF), Dr. Bernard Pécoul helped create DNDi in 2003, a nonprofit research and development organization aimed at finding solutions for neglected diseases.

Last August, Dr. Pécoul visited our headquarters to follow up on the collaboration between ISAGS and DNDi. The two organizations held a High-Level meeting in Quito in 2016, during the UNASUR Health Week.

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ISAGS: How did the idea of devising an initiative on drugs for neglected diseases come up?

Bernard Pécoul: In the world, there is a lack of innovation, research and development for diseases affecting a large number of people, who, in turn, do not represent a profitable market. The result is that most companies abandon research on these fields. Back in the 1990s, the numbers we used as reference didn’t lie on this regard: only 10% in research was dedicated to 90% of the world’s population.

This is what is called the Fatal Imbalance. In other words, people affected by old tropical diseases, such as Chagas disease and leishmaniasis, as well as malaria, tuberculosis and others could not benefit from the advancements in science. Therefore, we created the initiative in order to focus on these diseases that affect mostly the most vulnerable populations, in an effort to fill this gap.

I: What are the main challenges in terms of neglected diseases in South America?

BP: South America is gravely afflicted by a double burden and to tackle that we need a two-axed approach.

The neglected tropical diseases generate a great social and economic burden for the countries and its population.

Between the most endemic are Chagas disease and Leishmaniasis, both affecting a huge number of people.

Chagas alone affects more than 6 million people in 21 countries in the region – up to 8 million worldwide, and there is very little research compared to the challenge. DNDi has a research and development (R&D) pipeline that goes all the way to basic research for those diseases as well as a strong strategy alongside governments such as Colombia and Brazil to scaling up access to health tools.

On the other hand, South America also has diseases for which there are brand new treatments and a level of innovation that has totally changed the way we treat diseases. Still, this technology is not adapted for the region, particularly in terms of price, which is not affordable neither to large parts of the population, nor to the health systems.

Part of our efforts, then, refer to reducing the cost of existing drugs. Our strategy is to reduce the cost drastically, whilst keeping the same efficacy for the treatment.

I: Can we say DNDi challenges the for-profit R&D model and the current intellectual property framework?

BP: DNDi has not been created against intellectual property, which we respect. But, Intellectual property rights can sometimes act as a barrier to innovation and access.

We use, then, existing flexibilities within the international agreements on the one hand, and, on the other hand, as much as possible, we develop new treatments for diseases that affect the poorest as a public good in a way that they are available and affordable for the majority of the population. It’s one of our guiding principles. So far, we have developed, improved or implemented seven treatments, all of which respect this principle, and we have quite a lot of projects in our pipeline of research.

I: How does DNDi work with multilateral and intergovernmental organizations, such as the WHO and PAHO? BP: Since its inception, DNDi has worked very closely to WHO. The fact that our headquarters is located in Geneva is not totally by chance. In fact, WHO has contributed a lot in priority-setting in the portfolio of DNDi. On the other hand, WHO is fundamental when we are making progress with one disease, because it incorporates this progress into the list of essential medicines, into the guidelines and support policy changes at country level. It is the same with PAHO in the Americas. Therefore, we have a lot of interaction with these organizations to discuss strategies and to make sure our progresses are used in national programs and increase the number of people that could benefit from the new treatments.

“South America also has diseases for which there are brand new treatments and a level of innovation that has totally changed the way we treat diseases. Still, this technology is not adapted for the region, particularly in terms of price, which is not affordable neither to large parts of the population, nor to the health systems” I: Last year, ISAGS and DNDi held a High-Level meeting on Hepatitis C during the UNASUR Health Week. Tell us about your organization’s initiatives to tackle this disease.

BP: Our last year meeting in Quito was indeed very important. We talked about innovation and access using Hepatitis C as a very good example, because there is innovation in this field, we have very effective new treatments, not at an affordable price, though. In Latin America, for instance, there are a lot of people that are affected by Hepatitis C, and very few can benefit from these new treatments. Since the meeting, we’ve been working alongside some of the South American countries to develop new and more affordable treatment, with the intention to extend these strategies throughout the continent. Our goal is to have a drug for the price of less than US$ 500, maybe less than US$ 300 for the full course of treatment. Nowadays, most of the countries in Latin America pay more or less US$ 10,000 to treat one patient. If we make it, we are likely to change the future of Hepatitis C management in the continent. However, to be successful, we need a lot of partnerships and support from governments, as well as public and private entities in the region.

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TO THE POINT

By Carina Vance

PRIMARY HEALTH CARE AND THE ROAD TO UNIVERSALITY The Declaration of Alma Ata in 1978 was a turning point in the history of public health worldwide, drawing a path in which health, understood as a state of physical, mental and social well-being, is a human right. The Declaration recognizes the close relationship between health and social development and social protection and emphasizes the responsibility of States to implement measures that address the social and health needs of the population by promoting Primary Health Care (PHC) under the principles of equity and social justice, with broad and deep social participation. It not only considers the need for everyone to enjoy health, but also takes into account the importance of sustainability of health systems. The implementation of PHC is required to the the achievement of Universal Health Systems, as stipulated by the UNASUR objectives.

Despite important advances in our region, it is necessary to closely monitor the impact of the health policies that are being implemented, especially in times of economic decline, to avoid setbacks. The community of academics, politicians and activists related to the health field are on alert and have dedicated events, research and publications to a concern based on history: the health sector has been cannon fodder when dealing with economic crises, and that path is unfortunately already traveled and known, it becomes a dead end street for the most vulnerable populations.

In 2015, ISAGS published the book “Primary Health Care in South America,� which is an important 12

contribution to understand the advances in the implementation of models based on PHC in the South American region. With the contribution of eminent authors like Ligia Giovanella and Oscar Feo, it analyzes the advances and challenges in the implementation of the PHC in the 12 South American countries in a comprehensive way. The contributions constitute a baseline taken between the years 2011 and 2014 that would allow to distinguish whether the steps taken in the current juncture go forward or backward.

Among its main findings is the fact that all the countries of the region incorporate the concept of PHC in their systems. This in itself is remarkable, not all regions of the world display this characteristic.

Although there are marked differences such as varying degrees of decentralization or deconcentration and the existence of contributory models in some countries and models based on subsidies in others, there are common characteristics such as the public financing from permanent state revenues, either through direct transfer or through insurance programs. In most countries, the first level of care is free at the point of service. In the last decade, there was a significant decrease in out-of-pocket spending, which, despite remaining high (up to 60% private expenditure), contributed to the reduction of poverty.

In relation to the system of delivery and organization strategy, countries have health care teams made up not only of health professionals but

SALUD SUR

Photo: AraquÊm Alcântara (Flickr)

also of community workers. They generally have processes of territorial ascription with populations of different sizes according to characteristics such as population density or the degree of social vulnerability, facilitating the monitoring and allowing the identification of risks beyond clinical care. Coordination of care and integration in the service network is characterized in all countries by having the first level of care as the gateway to the system, although referral and counter referral processes are not always clear and there are problems of lack of coordination between the first level and specialized services. Some of the greatest challenges at the regional level were identified as the low articulation with actions of prevention and health promotion and the low public offer of specialized services.

According to the authors’ analysis, there are important gaps in the number of professionals in the region, for example, in 7 countries the ratio of nurses per 1000 inhabitants is lower than that of doctors. Likewise, the internal distribution of HR is inequitable, with great challenges in rural areas.

The majority of the staff is public, but with great instability in many cases, Chile being the only country with a career path in the area of PHC. High turnover prevents linkages with families and communities, although there are educational strategies that seek to address this problem.

As recommended in Alma Ata, all countries have norms or strategies to promote intersectoral

work, in some, around specific strategies such as combating malnutrition. Countries such as Brazil have implemented conditional cash transfers linked to health services, but in general there are no sustained and clear mechanisms of articulation with other sectors. The book identifies that in most countries there are institutionalized mechanisms of social participation, but it is mainly limited to diagnosis with little involvement in the construction of public policies. The intercultural approach has grown, but with very different implementation processes between countries, with only 4 countries mentioning explicitly interculturality.

As Marcos Cueto reminded us at ISAGS a few days ago, we should focus not only on health, but on social protection systems. Faced with a time of economic contraction, the risk of regressing in the recognition of rights is latent in relation to financing, in terms of social participation, in the role of the State as guarantor of rights, and in the inclusion of more vulnerable populations. Having a stable budget is not the only element required by the systems, it is necessary to deepen Primary Health Care strategies, with efficiency and quality, decisions based on evidence according to the epidemiological profile of each country, taking into account the situation of the most vulnerable populations. There is still a way to go and although each country must draw its own path, cooperation in health and regional solidarity are elements that can boost these advances.

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WHEN WILL THE BARRIERS GO? Left-handed people make up about 10% of the world’s population, and no more than a few decades ago their status was considered an anomaly. While in medieval times they were burnt alive as sinners and practitioners of witchcraft, much of the twentieth century teachers in schools had to correct the ‘problem’ and even punish those who insisted on using the left hand. Even today, almost all utensils and tools are designed exclusively for right-handers, scissors being the most obvious example.

Since the late 1970s, however, with the emergence of organizations to defend the rights of left-handed people, this perception of disability has changed, and many studies have shown that they have specific abilities, such as a greater propensity for creativity. From the activism of these organizations, ergonomic adaptations arose and, in some countries, even laws were enacted. In Brazil, for instance, one obliges schools to offer suitable conditions to left-handed students.

The developments of this approach seem to confirm the preamble to the Convention on the Rights of Persons with Disabilities, which recognizes that it is an ‘evolving concept’; that is, its definition is not definitively established. Broadly speaking, however, the document recognizes that it ‘results from the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others’.

Starting from this premise, but without knowing exactly who people with disabilities were, where they lived and what they needed, ten years ago, 14

Ecuador began a process that would lead the country to the forefront of the struggle for a more inclusive society. At the time, with a paraplegic Vice-President, Lenin Moreno (the country’s current President), the government launched a comprehensive interdisciplinary research, which investigated housing conditions, gender, violence, working conditions, among others. “We found, for example, that in the case of women the prevalence of disabilities was associated to gender violence and in the case of men, to traffic accidents,” says Gustavo Giler, then Coordinator of Cooperation in the country’s Ministry of Health. “It confirmed other things that we already knew, such as the relationship between disability and poverty because of a very low labor insertion and the fact that they have access to Health and Education services less frequently”, he adds.

The study’s inputs gave rise to several response programs, such as the Solidarity Action Manuela Espejo, which provided more than 500 thousand people with assistance devices of the 22 included in the program, among wheelchairs, walking sticks and hearing aids. A neonatal screening program was started for congenital diseases that could be preventable, such as galactosemia and adrenal hyperplasia, as well as an income transfer bonus for people with severe disabilities. Between 2006 and 2014, for example, 50 thousand people with disabilities were lifted out of poverty and 20 thousand were lifted out of extreme poverty.

Another aspect of the country’s actions on the issue was in the international health agenda, a field where, according to Giler, “people with

“Ecuador made use of its regional space to take its vision and the region´s to the international arena with greater weight. During the Meeting of the UNASUR Health Council in Lima in 2012, we presented the proposal for a resolution pleading for the elaboration of a Global Action Plan to the World Assembly”, says Giler. This Plan, which was the first such document at the international level, would finally be approved in 2014 in the WHA and focuses on three objectives: remove barriers and improve access to health services and programs; strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation; strengthen the collection of relevant and internationally comparable data and promote research.

The increase in visibility did not stop there. Unlike the Millennium Development Goals, in which people with disabilities were not mentioned, 2030 Agenda brings seven references on the subject in terms of goals related to education, employment, inequality reduction and inclusive cities. If we also include the 9 mentions in the disaggregated indicators of the SDGs, it is easy to conclude that, indeed, overcoming barriers to people with disabilities has gained an emblematic role in an agenda that is intended to be inclusive and global.

Some initiatives in our region show that we are in tune with this trend. In Colombia, an advanced regulation was approved to guarantee the sexual and reproductive rights of people with disabilities.

In Argentina, at the beginning of September, VicePresident Gabriela Michetti - another top authority on the continent living with disability - announced a pension similar to Ecuador’s in the framework of the National Disability Plan 2017-2019, which based on three main guidelines: inclusion, heterogeneity and community engagement with the participation of governments, civil society and the private sector.

Both the movement on the global agenda to create conditions for people with disabilities to reach their full potential, and the increasingly frequent emergence of personalities in several areas of public life with outstanding performance suggest that, with due proportions, society begins to look at people with disabilities as we look at lefties today; that is, people with potentialities still hidden by barriers that have to be broken down.

Manoel Giffoni manoelgiffoni@isags-unasur.org

disabilities were completely invisible”. The WHO had developed a Global Disability Report in 2011, recommending initiatives, such as changes in legislation and adaptations in health systems. The World Health Assembly (WHA) only took note of the challenges, without taking effective measures.

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INSTITUTIONAL ISAGS HOSTED THE SUBCOMMITTEE MEETING OF THE SOUTH AMERICAN NETWORK ON HEALTH DISASTER RISK MANAGEMENT On August 2 and 3, ISAGS received the subcommittee of the South American Network on Health Disaster Risk Management (GRIDSUNASUR, in Spanish), in continuity with the process initiated in 2016 for the creation of the first Health Disaster Risk Management Plan for the region. The subcommittee was composed of the GRIDS-UNASUR coordinator, Julio Sarmiento, from the Ministry of Health of Chile; Eliane Lima, from the Department of Environmental Health of the Ministry of Health of Brazil; our specialist in Health Surveillance, Eduardo Hage; and the coordinator of the Network of Disaster Risk Management in the Andean Regional Health Agency-Convention Hipólito Unanue (ORASCONHU), Luis Beingolea More.

During the meeting, they prepared a draft version of the Plan which “was based on the strategic guidelines defined by GRIDS and approved by the South American Health Council (SHC). For each objective, we proposed activities that will be developed over the next five years”, explained our specialist, Eduardo Hage.

Activities include consolidating the analysis of the regional situation diagnosis (started in 2016); supporting the participation of professionals in training (using materials already available in the region); supporting the development of virtual training tools; creating new methodologies for risk assessment and monitoring events in the region; the composition of a panel of regional specialists (professionals and institutions) and mechanisms for mutual cooperation; as well as identifying and disseminating research results, studies and other publications on the effects of climatic change.

Now, the proposals will be debated in a virtual meeting with GRIDS´members to be presented later to the South American Health Council.

ISAGS SIGNED A COLLABORATION AGREEMENT WITH THE INSTITUTE OF HEALTH TECHNOLOGICAL ASSESSMENT OF COLOMBIA On August 25, ISAGS signed an interinstitutional collaboration agreement with the Institute of Health Technological Assessment (IETS, in Spanish), to promote and strengthen relations between both institutions, as well as enhancing joint activities, generating convergence and identifying approaches to jointly address Health in our region.

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PILLS

HEALTH WITHOUT BORDERS Beyond political divisions, approaching borders as spaces for convergence and cooperation from the perspective of Health, will be the main topic of the third edition of the cycles of debates “Dialogues of the South”, which will take place next September 21, 3:00 pm (Brasília time), at ISAGS headquarters. The guests of this edition are Carolina Moulin, professor and coordinator of the Postgraduate program at the Institute of International Relations of PUC-Rio; and Paulo Cesar Peiter, Ph.D. in Geography at the Federal University of Rio de Janeiro (UFRJ) and researcher at the Laboratory of Parasitic Diseases of the Oswaldo Cruz Institute (IOC/Fiocruz). The moderators will be ISAGS´specialists, Félix Rígoli (specialist in Health Systems and Services) and Francisco Armada (specialist in Social Determination of Health).

“Dialogues of the South” is open to the community and will have live streaming from our Facebook page.

To participate, write to comunicacao@isags-unasur. org with the subject: “Salud sin Fronteras”.

ARGENTINA ASSUMES THE COORDINATION OF RINC-UNASUR Since August 18, the Network of National Cancer Institutes and Institutions (RINC, in Spanish) of UNASUR has a new coordination: Argentina. The country´s National Cancer Institute will be in charge of the Network for the next year in the framework of the UNASUR Pro Tempore Presidency. According to the new coordinator of RINC, Dr. Roberto Pradier, the lines of action will be oriented to the prevention and early detection of colorectal and cervical cancer, as well as to the promotion of palliative care.

From the IETS headquarters in Bogota, our specialist in Medicines and Health Technologies, Angela Acosta, represented the Institute in a meeting with the director of the organization, Dr. Jaime Calderón.

“It is very important for ISAGS to strengthen and develop new alliances, studies and research on medicines and health technologies.

Establishing a supportive relationship with the IETS is a great step forward this regard”, he stated.

ISAGS’ CONSULTIVE COUNCIL

IETS has the mission of conducting the evaluation of health technologies based on scientific evidence, as well as producing guidelines and protocols on medicines, devices, procedures and treatments in order to recommend to the competent authorities the technologies that must be covered with public resources. Its members are the Ministry of Health and Social Protection of Colombia, the Colombian National Food and Drug Surveillance Institute (Invima, in Spanish), the National Institute of Health (INS, in Spanish), the Colciencias, the Colombian Association of Faculties of Medicine and the Colombian Association of Scientific Societies.

This month, ISAGS will organize an extraordinary virtual meeting with its Consultive Council to discuss proposals for the Annual Operating Plan 2018, document that unifies the main actions, goals and proposals for the period. The last face-to-face meeting of the Council was held in April of this year when its members proposed suggestions and evaluated ISAGS´ latest actions.