Suerie Moon

The political origins of health inequity: prospects for change

Ole Petter Ottersen, Jashodhara Dasgupta, Chantal Blouin, Paulo Buss, Virasakdi Chongsuvivatwong, Julio Frenk, Sakiko Fukuda-Parr, Bience P Gawanas, Rita Giacaman, John Gyapong, Jennifer Leaning, Michael Marmot, Desmond McNeill, Gertrude I Mongella, Nkosana Moyo, Sigrun Møgedal, Ayanda Ntsaluba, Gorik Ooms, Espen Bjertness, Ann Louise Lie, Suerie Moon, Sidsel Roalkvam, Kristin I Sandberg, Inger B Scheel

Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola

Harvard Global Health Institute (Prof A Jha MD, S Moon PhD, L R Woskie MSc, J A Leigh MPH), Harvard T.H. Chan School of Public Health (Prof A K Jha, S Moon, L R Woskie, J A Leigh), and Harvard Kennedy School (S Moon), Harvard University, Boston, MA, USA; University of Edinburgh Medical School, Edinburgh (Prof D Sridhar DPhil); Duke Global Health Institute, Durham, NC, USA (M A Pate MD); Bill, Hillary & Chelsea Clinton Foundation, New York, NY, USA (C Clinton DPhil); Medecins Sans Frontieres, New York , NY, USA (S Delaunay MA); Campaign for Good Governance, Freetown, Sierra Leone (V Edwin MA); Action Contre La Faim International , Monrovia, Liberia (M Fallah PhD); Indiana University Maurer School of Law, Bloomington, IN, USA (Prof D P Fidler JD); Council on Foreign Relations, New York, NY, USA (L Garrett PhD); University of California, San Francisco, CA, USA (Prof E Goosby MD); Georgetown University, Washington, DC, USA (Prof L Gostin JD); Chatham House, London, UK (Prof D L Heymann MD); Simon Fraser University, Burnaby, BC, Canada (Prof K Lee DPhil); Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China (Prof G M Leung MD); Center for Strategic and International Studies, Washington DC, USA (J S Morrison PhD); AIDS Executive summary The west African Ebola epidemic that began in 2013 exposed deep inadequacies in the national and international institutions responsible for protecting the public from the far-reaching human, social, economic, and political consequences of infectious disease outbreaks. The Ebola epidemic raised a crucial question: what reforms are needed to mend the fragile global system for outbreak prevention and response, rebuild confi dence, and prevent future disasters? To address this question, the Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine jointly launched the Independent Panel on the Global Response to Ebola. Panel members from academia, think tanks, and civil society have collectively reviewed the worldwide response to the Ebola outbreak. After diffi cult and lengthy deliberation, we concluded that major reforms are both warranted and feasible. The Panel’s conclusions off er a roadmap of ten interrelated recommendations across four thematic areas:

Governance Challenges in Global Health

In this article in the Global Health series, the authors argue for a coordinated (i.e., a governed) international response to a variety of health issues that affect people worldwide.

A lifeline to treatment: the role of Indian generic manufacturers in supplying antiretroviral medicines to developing countries

BackgroundIndian manufacturers of generic antiretroviral (ARV) medicines facilitated the rapid scale up of HIV/AIDS treatment in developing countries though provision of low-priced, quality-assured medicines. The legal framework in India that facilitated such production, however, is changing with implementation of the World Trade Organization Agreement on Trade-Related Aspects of Intellectual Property Rights, and intellectual property measures being discussed in regional and bilateral free trade agreement negotiations. Reliable quantitative estimates of the Indian role in generic global ARV supply are needed to understand potential impacts of such measures on HIV/AIDS treatment in developing countries.MethodsWe utilized transactional data containing 17,646 donor-funded purchases of ARV tablets made by 115 low- and middle-income countries from 2003 to 2008 to measure market share, purchase trends and prices of Indian-produced generic ARVs compared with those of non-Indian generic and brand ARVs.ResultsIndian generic manufacturers dominate the ARV market, accounting for more than 80% of annual purchase volumes. Among paediatric ARV and adult nucleoside and non-nucleoside reverse transcriptase inhibitor markets, Indian-produced generics accounted for 91% and 89% of 2008 global purchase volumes, respectively. From 2003 to 2008, the number of Indian generic manufactures supplying ARVs increased from four to 10 while the number of Indian-manufactured generic products increased from 14 to 53. Ninety-six of 100 countries purchased Indian generic ARVs in 2008, including high HIV-burden sub-Saharan African countries. Indian-produced generic ARVs used in first-line regimens were consistently and considerably less expensive than non-Indian generic and innovator ARVs. Key ARVs newly recommended by the World Health Organization are three to four times more expensive than older regimens.ConclusionsIndian generic producers supply the majority of ARVs in developing countries. Future scale up using newly recommended ARVs will likely be hampered until Indian generic producers can provide the dramatic price reductions and improved formulations observed in the past. Rather than agreeing to inappropriate intellectual property obligations through free trade agreements, India and its trade partners - plus international organizations, donors, civil society and pharmaceutical manufacturers - should ensure that there is sufficient policy space for Indian pharmaceutical manufacturers to continue their central role in supplying developing countries with low-priced, quality-assured generic medicines.

The Global Health System: Actors, Norms, and Expectations in Transition

In the first in a series of four articles highlighting the changing nature of global health institutions, Nicole Szlezák and colleagues outline the origin and aim of the series.

From sovereignty to solidarity: a renewed concept of global health for an era of complex interdependence

The moment is ripe to revisit the idea of global health. Despite tens of billions of dollars spent over the past decade under the auspices of global health, a consensus defi nition for this term remains elusive. Yet the way in which we understand global health critically shapes not only which and whose problems we tackle, but also the way in which we raise and allocate funds, communicate with the public and policy makers, educate students, and design the global institutions that govern our collective eff orts to protect and promote public health worldwide. The importance of advancing a coherent idea of global health has become clear in recent debates about the post-2015 development agenda. Health was central to four of the eight Millennium Development Goals (MDGs; on hunger, child mortality, maternal health, and HIV/ AIDS and malaria) and directly linked as an outcome or determinant to the four others (on primary education, gender equality and empowerment, environ mental sustain ability, and global partnership). However, health advocates are concerned that health will not feature centrally in the post-2015 Sustainable Develop ment Goals (SDGs), having had its moment in the spotlight and succumbing to competition from other issues demanding attention, such as climate change or food security. But a broader conceptualisation of global health makes clear that health and sustainable develop ment are inseparable. As recognised in the Rio+20 Declaration on the Future We Want, health “is a pre condition for and an outcome and indicator of” sustainable development. How should global health be understood in an era marked by the rising burden of non-communicable diseases (NCDs), climate change and other environmental crises, integrated chains of production and consumption, a power shift towards emerging economies, intensifi ed migration, and instant infor mation transmission? As we explain in this Viewpoint, global health should be reconceptualised as the health of the global population, with a focus on the dense relationships of inter depen dence across nations and sectors that have arisen with globalisation. Doing so will help to ensure that health is duly protected and promoted, not only in the post-2015 development agenda but also in the many other global governance processes—such as trade, investment, environ ment, and security—that can profoundly aff ect health. Since it was coined, around the creation of the International Health Commission in 1913 by the Rockefeller Foundation, the term international health was identifi ed with the control of epidemics across borders and with the health needs of poor countries. Various textbooks and training programmes also included the health of indigenous populations of developed countries. Supporters of this original view regarded international needs as alien and peripheral, and very frequently as threats. Consistent with these ideas, international activities were identifi ed as aid and defence, and delivered through unilateral perspectives. The international health agenda was also aff ected by the idea that most health needs could be fully addressed with technology. This notion is still prevalent nowadays among various global health initiatives. The temptation to pin all hope on the latest technology is every bit as powerful as it was in the near past. This reductionist perspective contrasts with the growing realisation that most global health problems have strong behavioural, cultural, social, political, and economic determinants that demand compre hensive—not only technical—approaches. International health also placed excessive emphasis on vertical programmes devoted to control specifi c diseases and paid little attention to health systems as a whole, with well documented consequences. This tendency has yet to be fully replaced by a more comprehensive diagonal perspective that would use explicit intervention priorities to drive improvements into the health system. International health cooperation has traditionally fallen under the rubric of foreign aid—support for polio eradication and treatment of HIV/AIDS are prominent examples. But the very concept of aid conveys an asymmetric image in which problems and risks fl ow from south to north, whereas resources and solutions move in the opposite direction. This view fails to capture the reality of health interdependence. It also fails to take into account the major shifts taking place in the global distribution of resources, infl uence, capabilities, and needs as emerging economies continue their expansion. A sort of linguistic modernisation has revitalised the traditional contents attributed to international health through the use and dissemination of the notion of global health. In the media, in lay and scientifi c literature, and in major initiatives, global health is still identifi ed with problems supposedly characteristic of developing countries, and global cooperation in health with a sort of paternalistic philanthropy that is armed with the technological developments of developed countries. It is again the idea of the poor, ignorant, passive, and traditional societies in need of the charity and technology of the rich that prevails in the use of this term. Paradoxically, this use of the notion of global health fails itself to capture the essence of globalisation. In a real sense, we need to globalise the concept of global health. To this end, it is necessary to move beyond reductionist defi nitions and to reconceptualise global health to refl ect Lancet 2014; 383: 94–97

Innovation and Access to Medicines for Neglected Populations: Could a Treaty Address a Broken Pharmaceutical R&D System?

As part of a cluster of articles leading up to the 2012 World Health Report and critically reflecting on the theme of “no health without research,” Suerie Moon and colleagues argue for a global health R&D treaty to improve innovation in new medicines and strengthening affordability, sustainable financing, efficiency in innovation, and equitable health-centered governance.

Intervening in global markets to improve access to HIV/AIDS treatment: an analysis of international policies and the dynamics of global antiretroviral medicines markets

BackgroundUniversal access to antiretroviral therapy (ART) in low- and middle-income countries faces numerous challenges: increasing numbers of people needing ART, new guidelines recommending more expensive antiretroviral (ARV) medicines, limited financing, and few fixed-dose combination (FDC) products. Global initiatives aim to promote efficient global ARV markets, yet little is known about market dynamics and the impact of global policy interventions.MethodsWe utilize several data sources, including 12,958 donor-funded, adult first-line ARV purchase transactions, to describe the market from 2002-2008. We examine relationships between market trends and: World Health Organization (WHO) HIV/AIDS treatment guidelines; WHO Prequalification Programme (WHO Prequal) and United States (US) Food and Drug Administration (FDA) approvals; and procurement policies of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), US Presidents Emergency Plan for AIDS Relief (PEPFAR) and UNITAID.ResultsWHO recommended 7, 4, 24, and 6 first-line regimens in 2002, 2003, 2006 and 2009 guidelines, respectively. 2009 guidelines replaced a stavudine-based regimen (

Focusing on quality patient care in the new global subsidy for malaria medicines.

88/person/year) with more expensive zidovudine- (

The global pediatric antiretroviral market: analyses of product availability and utilization reveal challenges for development of pediatric formulations and HIV/AIDS treatment in children

154-260/person/year) or tenofovir-based (