South Korea
South Korea becomes an ML4-designated country for medicines and vaccines regulations.

South Korea became the first country in the world to achieve the highest level, “maturity level 4” (ML4), in regulating medicines and vaccines. 

The Ministry of Food and Drug Safety (MFDS) in the Republic of Korea is the only national regulatory authority to be recognised by the World Health Organization (WHO) to have advanced oversight on locally produced and imported medicines and vaccines. The WHO had assessed 33 countries in total, of which only South Korea earned the highest accolade. 

WHO’s benchmarking on regulatory authorities offer a reference point on drug and vaccine regulation to countries that do not have the internal capacity to do so. Currently, only around 30% of the regulatory authorities across the world have the capacity to ensure that the medical products (drugs and vaccines) they produce meet the required standards, work as intended and do not cause harm in patients, the WHO said. 

“We highly appreciate the support already provided by the Republic of Korea to several other countries in strengthening their oversight of vaccines and medicines. Its role during the COVID-19 pandemic in supplying countries with quality assured vaccines and in vitro diagnostics has been well recognized,” Dr Zsuzsanna Jakab, WHO’s Deputy Director-General and Officer-in-Charge of the Western Pacific Regional Office said. 

The Republic of Korea’s regulatory authority was assessed by the WHO in 2022 and the MFDS worked closely with the agency in implementing the recommendations made by an international body of experts. 

The WHO’s assessment is based on the “global benchmarking tool”, a unified evaluation tool launched in 2019, which examines regulatory systems on their framework and functions. It designates the level of regulatory oversight in countries on a scale of one to four. Level 1 indicates the presence of some regulatory elements whereas level 4 indicates that the regulatory system is operating at an advanced level, with continuous improvements. 

Regulations
Global Benchmarking Tool – WHO

Apart from South Korea, Singapore is also designated at ML4 level for regulation of medicines. Ten other countries are at the ML3 level on WHO’s list. Countries at ML3 and ML4 levels are eligible to become a WHO listed authority, by which they can be considered a reference point by other countries’ regulators to decide on approving medical products. 

Image Credits: Photo by Muhammad Syafi Al – adam on Unsplash, World Health Organization.

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Samuel Kumwanje
Samuel Kumwanje

When Samuel Kumwanje was diagnosed with a kidney disorder in 2004, his home country Malawi had only one dialysis unit located in the capital Lilongwe, about 330 km from the city of Balaka where he lived.

“This is the time I learned that affordability of dialysis services is limited for Malawians,” Samuel writes in the NCD Diaries project, an initiative launched by the NCD Alliance.

NCDs (short for noncommunicable diseases) are diseases that are not transmissible from person to person. They are the first cause of death and disability worldwide, accounting for 74% of all deaths and more than three out of four years lived with a disability.

NCDs are also a sustainable development issue. They have a disproportionate impact on people living in low- and middle-income countries and are both a cause and a consequence of poverty.

NCD Alliance leads and coordinates global advocacy efforts to maintain political momentum and action, and sustain focus on NCDs.

Born in 1976 in rural Malawi, Samuel started to suffer from problematic symptoms when he was 12. The symptoms included body pain, loss of appetite and vomiting, yet no one could understand the cause.

“A district hospital referred me for a checkup at a public hospital (at which services are provided free of charge), and my results were sent to the UK for further investigation,” he recalls. “However, no diagnosis was made because tests related to kidney performance were not conducted – an indication of lack of focus on kidney disorder in our health system.”

As a result, Samuel’s symptoms worsened.

“Without a diagnosis, I turned to herbals from the local communities that my father sourced,” he says. “I believe that these herbs may have worsened rather than solved my kidney condition.”

For years, the man continued to be misdiagnosed and prescribed the wrong treatments.

“Finally at NGO-run Likuni Mission Hospital, they diagnosed me with kidney failure because one of my sisters-in-law, who is a nurse, advised me to request a check of my kidney performance,” he remarks. “This was a private service covered by my Medical Aid Society of Malawi medical insurance, made available through my employer.”

Afterward, Samuel started to commute for dialysis. At that point, the Kamuzu Central Hospital, a government-run hospital in Lilongwe, only had four machines. As the number of patients in need of dialysis in Malawi increased, accessibility to treatment became an issue.

At that point Samuel and other patients decided to take action.

“We formed the Kidney Foundation – Malawi, an association to amplify the needs of people in the dialysis unit,” he says. “Among several objectives guiding the association, advocating with the Malawi Ministry of Health to prioritize renal conditions was one.”

While things for patients with chronic kidney conditions in Malawi have improved, there is still much work to be done. Currently, there are only two public hospitals in the country that offer free dialysis services, with few machines for many patients. Malawi has a population of about twenty million people.

“It’s not easy to live with kidney disorder when you are the breadwinner of the family, and it’s challenging when you are employed because you need to satisfy your boss while at the same time adhering to dialysis sessions,” Samuel says. “My goal is to shed light on the challenges that myself and people living with NCDs in Malawi face when it comes to affording care, in the hope for positive change around Universal Health Coverage.”

Read Samuel Kumwanje full NCD Diary.
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Image Credits: Courtesy of NCD Alliance.

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Dr. Hedwig Borges as he goes through his journey with cutaneous T-cell lymphoma.
Dr. Hedwig Borges as he goes through his journey with cutaneous T-cell lymphoma.

For many years, Betsy Rodriguez was terrified that she could lose her daughter Carmen to hypoglycemia at any moment. As a girl, Carmen was diagnosed as having type 1 diabetes.

“I cannot count the hours I’ve spent dealing with insurance companies and third-party vendor pharmacies for my daughter to receive a life-saving continuous glucose monitor and an insulin pump,” Betsy writes in the NCD Diaries project, an initiative launched by the NCD Alliance. “Now that she has these, my fear of losing her to hypoglycemia has settled!”

Diabetes is one of the most common forms of NCDs – short for noncommunicable diseases, which are diseases that are not transmissible from person to person.

Continuous glucose monitor (cgm) and continuous subcutaneous insulin infusion (csii).
Continuous glucose monitor (CGM) and continuous subcutaneous insulin infusion (CSII).

NCDs are the first cause of death and disability worldwide, accounting for 74% of all deaths and more than three out of four years lived with a disability. They also include cancers, cardiovascular disease, stroke, chronic respiratory diseases, mental health and neurological conditions, amongst many others.

The NCD Diaries are a participatory, community-based and multimedia storytelling project that illustrates and highlights individual lived experiences and calls for action on NCDs.

Because of Carmen’s condition, Betsy had always been aware of the challenges of taking care of a person with a chronic disease. However, this did not prepare her for the moment her husband Hedwig, also known as Papa Bear, was diagnosed with cancer five years ago.

“Hearing the word ‘cancer’ in a diagnosis is terrifying enough, but here’s another scary thought: the treatment method is likely to be dictated by your insurance coverage,” she wrote. “It was devastating to see the love of my life and husband of 46 years go through his journey with Cutaneous T-cell lymphoma – a rare cancer.”

Hedwig and his whole family were heavily affected by the disease and the treatments he had to undergo.

“His appearance, vitality and productivity altered, so I became the caregiver and only source of income,” Brenda says. “Catastrophic conditions like these demand high out-of-pocket payments. Sometimes, I feel like a deflated balloon!”

For her, taking part in the NCD Diaries was very important.

“I want to give a voice to those that live with chronic conditions that do not have a voice, especially those from marginalized communities living and experiencing health disparities and inequities,” Brenda emphasizes. “I want to help put a face to diabetes and other chronic conditions.”

Read Betsy Rodriguez’s full NCD Diary.
Read previous post.

Image Credits: Courtesy of NCD Alliance.

A special project celebrating the fifth anniversary of “Our Views, Our Voices” | Learn more

Brenda Chitindi
Brenda Chitindi

When Brenda Chitindi was growing up, one of many children in a family in a rural village of Zambia, she had no idea that her father’s habit of smoking would have a negative effect on her health.

“We lived in a three room, grass thatched house with our parents,” she recalls. “Our house had no ventilation, so smoke circulated all around the room. Each time he smoked, we, the children, would enjoy the smell and didn’t feel any signs of health complications.”

However, when she was 45, Brenda, who is now 70 years old and a mother of five, was diagnosed with hypertension, rheumatoid arthritis and chest congestion.

The woman shared her experience in the NCD Diaries project, an initiative launched by the NCD Alliance.

“As I waited for my appointment, my condition worsened,” she explains in her testimony, as she describes how she had to wait for three months before the only specialist at the local hospital could see her. “I continued taking painkillers but experienced stiffness of my hands and fingers, weight loss, knee and feet pains, numbness on my left side, shortness of breath at night, weakness and dizziness.”

NCDs (noncommunicable diseases) are the first cause of death and disability worldwide, accounting for 74% of all deaths. Among many others, they include cancers, cardiovascular disease, stroke, chronic respiratory and kidney diseases, diabetes, mental health and neurological conditions – all conditions that are not transmissible from person to person.

An estimated 80% of NCDs are preventable. They are driven by modifiable risk factors including tobacco use, unhealthy diet, physical inactivity, harmful use of alcohol, and air pollution.

Brenda says that her hypertension medication – whose cost she had to cover out of pocket with the help of her children – left her with significant side effects, including fatigue.

“This led me to develop obesity as I slept more and exercised less,” she writes. “Since developing obesity, my health provider advised me to adopt a special diet which I still follow, and to walk 2-3 km every morning.”

Zambia has now introduced its National Health Insurance Management Authority, which covers the costs of Brenda’s treatments.

Brenda has also benefited from the establishment of Zambia NCD Alliance.

“I’ve acquired knowledge on risk factors of hypertension, obesity, arthritis and other NCDs, which has helped me to spread awareness to women on prevention measures relating to tobacco and alcohol use, and on the importance of physical exercise,” the woman remarks.

Yet, there is still significant work to do to support NCD prevention and treatment in the African country.

“My NCD care journey highlighted key challenges with health providers in Zambia, including long wait times, limited pain management expertise, and scarcity of resources and services,” Brenda points out in her diary. “There’s a need to improve NCD prevention, care and pain management, and equip people with the skills to self-manage their own treatment.”

Read Brenda Chitindi’s full NCD Diary.
Read previous post.

Image Credits: Courtesy of NCD Alliance.

A special project celebrating the fifth anniversary of “Our Views, Our Voices” | Learn more

Seema Bali
Seema Bali

In March 2011, Seema Bali, a mother of two from India, was recovering from a hysterectomy. However, just as she went back to work, her husband Anand’s health suddenly deteriorated. In the following months, this crisis forced her to assume the role of caregiver, in addition to the ones of the family’s sole breadwinner and parent looking after her children.

Bali shares her experience in the NCD Diaries project, an initiative launched by the NCD Alliance and people living with NCDs.

NCDs (noncommunicable diseases) are the first cause of death and disability worldwide, accounting for 74% of all deaths. Among many others, they include cancers, cardiovascular diseases, stroke, chronic respiratory and kidney diseases, diabetes, and mental health and neurological conditions – all conditions that are not transmissible from person to person.

In the case of Seema’s husband Anand, it was not immediately clear what was causing his problems.

“He had lost some 17 kgs of weight in two months, he had come down from 87 to 70,” she writes. “He was experiencing loss of appetite and was generally very sleepy, sleeping for 22 hours a day.”

When they met with a doctor, the physician thought that Anand was suffering from depression and put him on antidepressants. After two cycles of antidepressants led to no improvement, Seema insisted on a full checkup.

The tests revealed that Anand’s kidneys had shrunken and were not functioning correctly.

“My legs just turned into jelly, and I just sank into the sofa,” Seema recalls. “For that moment of time there was total blackout.”

Because her husband had just relocated to India from Dubai, he did not have any health insurance which meant that they would need to cover the cost of treatment out of pocket.

Seema knew there was nothing to do but face the situation. Anand got his fistula fixed and started dialysis as they were exploring options for a transplant.

“When Anand had dialysis, I used to accompany him and take a day off from work,” Seema says. “On the days when he did not have dialysis, he used to be at home, and I used to go to work.”

NCDs have a disproportionate impact on people living in low-and middle-income countries, and are both a cause and a consequence of poverty.

The Bali family was no exception.

Every session of dialysis for Anand would cost over 3,000 rupees, which amounted to 48,000 rupees in a month.

“My salary was 50,000,” Seema remarks. “There was no help available. I did not know which door to knock on and I had to take all of our savings.”

Life, she says, became “a rollercoaster ride for me because it was hospital, home, school, kids, shopping essentials, looking after the education of my kids, visit to the bank, take out money, go to the hospital. So it was like a vicious circle I was into.”

As a result of the situation, Seema developed psoriasis and mental health issues herself.

“It was devastating and heartbreaking, but I had full faith and trust in God,” she recalls. “And I was waiting to come out of this, thinking that maybe the transplant thing could happen.”

Indeed, one day the hospital called the family to inform them that there was an available kidney for Anand.

“I called my family and my husband’s family and quickly we got the act together, we deposited the money and he was admitted to the hospital because the doctor said that the procedure had to be done on the same day,” Seema recalls.

The operation was successful. After ten days, Anand was discharged from the hospital.

“I had converted our room into an intensive care unit,” she explains. “I had to be on my toes 24/7 and there were some hiccups. We tried to deal with it. Postoperative care is really crucial and critical.”

However, while Anand was physically recuperating, he was also becoming mentally unstable, worried about his job, his future and the children.

Seema struggled but continued to manage.

“I feel like a machine that wakes up at a specific time and works by the clock,” she says. I cannot travel, I cannot attend functions. Social life is highly compromised and it affects my mental well-being really hard. Overall efficiency at home and performance at work also get badly affected.”

“Nobody signs up for something like this,” she notes. “But when we actually face these kinds of situations, why is there no help?”

Read Seema Bali’s full NCD Diary.
Read previous post.

Image Credits: NCD Alliance, Courtesy of NCD Alliance.

European Commissioner Stella Kyriakides

Stronger international rules and cooperation mechanisms on health are at the heart of the European Union’s new global health strategy, which was launched on Wednesday. 

The strategy is based on three priorities: ensuring that people stay well throughout their lives, strengthening health systems particularly by advancing universal health coverage, and applying a ‘One Health’ approach to preventing health threats.

“This is a strategy which is rooted in equity. It’s rooted in solidarity, in human rights and in partnership. But what really fuels it is our determination to strengthen good global governance,” said European Commissioner Stella Kyriakides.

Stressing that global health threats “know no borders”, Kyriakides called for “stronger international rules and cooperation mechanisms on health, including a legally binding pandemic agreement”.

The strategy – the first in 12 years – also means that the EU is “stepping up its leadership on global health”, said Commissioner Jutta Urpilainen.

Urpilainen said that the EU would “ramp up investments in health systems with innovative financial instruments”, including supporting the African Union to achieve its goal of producing 60% of the continent’s vaccines by 2040.

“COVID-19 really highlighted the deep challenge in medical manufacturing capacities and other supply chains, bottlenecks. Africa, for example, still imports 99% of its vaccines and 94% of its medicines,” said Urpilainen.

The EU wanted to fill any gaps in global health governance and financing through a “strong and responsive multilateral system” with the WHO at the core.

More power for EU?

However, the EU also indicates that it wants a more prominent seat at the decision-making table, based on its large investment in global health, and some sources have indicated that the EU might seek membership of the WHO itself.

“The main message of this strategy is that the EU intends to reassert its responsibility and deepen its leadership in the interest of the highest attainable standards of health,” the strategy states.

Pointing out that the EU and its member states contributed €53.7 billion to assist 140 countries during the COVID-19 pandemic, the strategy states that “the EU’s influence in shaping the agenda must match its financing support as a champion of global health”. 

Sandra Gallina, European Commission Director-General for Health and Food Safety.

Sandra Gallina, European Commission Director-General for Health and Food Safety, also stressed the need for “an international rulebook” because, without it, there had been a “cacophony” and “very, very rapid degradation of relations” during COVID-19.

“We want to have a pandemic treaty with antimicrobial resistance at the heart of it,” she stressed.

UHC contribution

A smiling World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus, while commending the EU’s strategy for being aligned with that of the WHO, revealed that the EU had just contributed €125 million to the WHO to promote universal health coverage. 

“This new strategy comes at a critical time as our world faces so many threats to health from the continuing COVID 19 pandemic, to the silent pandemics of non-communicable diseases and antimicrobial resistance, conflicts around the world, rising inequality and the existential crisis of climate change,” said Tedros.

“Each of these challenges transcends borders, sectors, language, ethnicities, and political divides. No single country or organisation can deal with them in isolation, which is why multilateralism is more important than ever. “

Dr Ayoade Alakija, chair of the Africa Vaccine Delivery Alliance and WHO Special Envoy for the ACT Accelerator.

Dr Ayoade Alakija, chair of the African Union (AU) Africa Vaccine Delivery Alliance and the WHO’s Special Envoy for the ACT Accelerator, said that the EU’s strategy was important to address the “geopolitical schism” and reassert a “global” response.

Pointing to the fact that “global procurement didn’t work during the pandemic”, Alakija said that the influence of the global vaccine alliance, Gavi, was declining, and being replaced by other organisations like CEPI and FIND with ‘transformative leaders” that are cooperating with regions.

EU leaders travelled to Nigeria to consult with the African Union before finalising the strategy, which will now be fine-tuned by member states.

Lack of detail on climate change

But Alan Dangour, the Wellcome Trust’s director of climate and health, was critical of the lack of “clearly defined deliverables” about how to address climate change.

“So there are really, I’m afraid, substantial things that are potentially missing from this strategy, which is a much greater ability to plan for the future for something that we know is coming. This is physics. This is basic physics. And I would love there to be a substantially stronger agenda on climate change and the impact that climate change is having and will continue to have around the world.”

The WHO’s head of health emergencies, Dr Mike Ryan, welcomed that the document stated what needed to be done “because we need to move our communities from doom to do”.

However, Ryan stressed that “global solutions will not deliver what we need” in a health emergency.

“Epidemics, pandemics, begin and end in communities. Global health security emerges when you have strong national and local systems responsive to the needs of their communities, well prepared, agile, mobile, scalable, and able to serve.

“There are only two things we do in a public health crisis. We protect communities, and we provide safe, scalable, clinical treatment.”

Ryan warned that, in terms of climate change, the world needs to prepare for “multiple intertwined amplifying events” rather than a single event.

Meanwhile, Prof Peter Piot, the special advisor to the President of the European Commission, warned that Europe, in seeking to address its health workforce problems “should make sure that we are not making things worse for low and middle-income countries by recruiting staff from there. So we need to make sure that we honour international commitments at that level.”

What are the promises?

To address people’s well-being, the strategy undertakes to “prioritise addressing the economic, social and environmental root causes of health and disease – including poverty and discrimination, age, nutrition and healthy diets, social protection, education, care, water, sanitation and hygiene, occupational health – and other areas such as healthy ecosystems pollution or contact with chemicals and waste and threats to security of energy supply.”

It also aims to put the needs of women, girls and young people at the forefront of responses, and te EU will  “engage with partner countries to expand access to a basic package of health services covering prevention and care with particular focus on poor and marginalised populations through bilateral and regional programmes”.

The EU also plans to make digital health a pillar of its approach, undertaking to “leverage the potential of health data worldwide in line with the principles of the planned European Health Data Space and foster the use of new technologies including artificial intelligence to boost their potential to improve diagnosis and treatments worldwide”. 

Way forward

At this stage, the strategy is a draft that is not binding on member states. Radic Policar, the Czech deputy health minister, said that it will be presented to member states’ development ministers for further discussion.

However, Sweden assumes the presidency of the EU from the Czech Republic in 2023 and it will need to champion the strategy with members, a challenge that Anders Nordstrom, Sweden’s Ambassador for Global Health seems ready to do.

“During the Swedish EU Council presidency , starting on 1 January, member states will have the opportunity to address the strategy through council conclusions and we will do our utmost to support that process. And what will be important that is of course to see how we as, member states, together with EU institutions actually can support the implementation of this and also ensure that there is an effective monitoring and accountability,” said Nordstrom.

Dr Tedros Adhanom Ghebreyesus at an earlier event.

WHO’s Director General Dr Tedros Adhanom Ghebreyesus has announced the “interim” appointment of five new senior leaders to replace outgoing members of his senior team, whose departure was announced internally just last week, Health Policy Watch has learned. 

The new appointments were also revealed in a second internal email sent by Tedros to WHO staff on Wednesday, and seen by Health Policy Watch. 

Strikingly all of the new appointees have been drawn from within WHO’s internal ranks – a significant departure from Tedros’ previous pattern of making high-profile appointments of professionals drawn largely from outside WHO’s direct ranks, when he first took office in 2017, and during the last major shakeup in 2019. 

In contrast, the five new appointees are longstanding WHO directors and known quantities.  

Notably, however, all of the appointees have been named as “interim” heads of WHO’s major divisions – leaving questions over whether Tedros still intends to eventually replace them with other, outside, candidates, or to merely test the performance of the acting leaders, more thoroughly, prior to deciding whether to make the appointments permanent. 

Additionally, no replacements were announced at all for three outgoing staff members. That may be a signal that Tedros was finally bending to pressures from donor states, including the United States, to cut unnecessary frills at WHO’s top echelons where the salary and pension benefits of one senior staff can effectively pay for two mid-level professionals. Critics had accused the DG of making excessive appointments of senior advisors and aids with vague and poorly defined jobs – outside of the organization’s key disease theme and activity areas. 

No public announcements by Tedros 

So far, however, Tedros has not made any public announcements about the staff changes – only communicated through internal staff emails.  Outside speculation was that he might wait until January’s WHO’s Executive Board meeting to communicate his long term intentions more fully.   

“At the end of November, several senior leadership team members will depart the Organization, and once again, I reiterate my thanks for their contribution to WHO.”

“I have asked several colleagues to serve, in ad interim, as heads of divisions while keeping their portfolios.  I have also requested Dr Zsuzsanna Jakab to delay her retirement date and continue as DDG [deputy director general] and OIC WPRO for some more time,” Tedros said in the mail. Jakab, born in 1951, is now 71 years old. 

The key new appointments include: 

The key new appointments confirm reports earlier this week of pending staff changes. They include: 

Dr John Reeder, Director of TDR, the Special Programme for Research and Training in Tropical Diseases, will be the acting head of the WHO Science Division, replacing the outgoing Soumya Swaminathan.

Dr John Reeder
Dr John Reeder

Dr Hanan H. Balkhy, currently Assistant Director-General, Antimicrobial Resistance, will also lead the Division of Access to Medicines and Health Products, replacing Mariangela Simão, a Brazilian national.

Dr Hanan Balkhy
Dr Hanan H. Balkhy

Dr Tereza Kasaeva, Director, Global Tuberculosis Programme, will lead the Division of Universal Health Coverage/Communicable and Noncommunicable Diseases, replacing the outgoing Ren Mingui, a Chinese national.

In addition, Dr Maria Neira, Director of WHO’s Department of Environment, Climate Change and Health, was appointed as acting head of the Division of Universal Health Coverage/Healthier Populations, replacing the outgoing Naoko Yamamoto, a Japanese national.

Dr Maria Neira
Dr Maria Neira

And Dr Anshu Banerjee, Director, Department of Maternal, Newborn, Child and Adolescent and Aging, was appointed as acting head of the  Division of Universal Health Coverage/Life Course – a role which until now had been held by Jakab as DDG.

Dr Anshu Banerjee
Dr Anshu Banerjee

Doubling up on other appointments  

In several other cases, meanwhile, the DG has asked other senior staff to take on tasks held by outgoing leaders – effectively saving their salaries for the moment at least.  Among those appointments:  

Dr Bruce Aylward, Senior Adviser for Organizational Change and coordinator of the Access to COVID-19 Tools (ACT) Accelerator, was appointed, as acting leader of the Division of External Relations and Governance, a position held by the outgoing Jane Ellison, a former UK health minister.

Dr Bruce Aylward
Dr Bruce Aylward

In the Health Emergencies, Preparedness and Response (WHE) team, no new appointment was made to replace the outgoing Dr Jaouard Mahjour, Assistant Director General for Emergency Preparedness.  Instead, “the directors in the Division of Emergency Preparedness will report to Dr Mike Ryan, Executive Director, WHE, upon the incumbent’s retirement.  The directors in the Division of Emergency Response will also report to Dr Mike Ryan,”  Tedros’ message to staff stated. 

Dr Mike Ryan

Similarly, Tedros said that work on cervical cancer, “will become part of the Department of Noncommunicable Diseases reporting to Dr Bente Mikkelsen.”  

Dr Bente Mikkelsen
Dr Bente Mikkelsen

Cervical cancer was one of  the key tasks in the portfolio of South Africa’s outgoing DGO Special Advisor, Dr Princess Nothemba Simelela, along with gender, equity, health rights and youth (GER/DEI).  The gender equity and health rights work, Tedros stated, “will remain in DGO,” without specifying a replacement.  

Image Credits: Science of Eradication, UNFCCC, Photo © Dominic Chavez/World Bank Group, By Salesforce.org, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=114278728, World Economic Forum.

World AIDS day Report UNAIDS
Winnie Byanyima (UNAIDS), George Simbachawene (Prime Minister’s Office for policy coordination and parliamentary affairs, Tanzania) and Dr Godwin O Mollel (Deputy minister of health, Tanzania).

The world is not on track to end AIDS by 2030 due to patriarchy, stigma against vulnerable communities and inequality, according to UNAIDS in its 2022 World AIDS Report. 

The report, titled “Dangerous Inequalities”, points out that unequal power dynamics between men and women and norms that prevent girls and women from exercising their bodily autonomy are major reasons behind the slowdown in HIV response.

The criminalisation of gay relationships and discrimination against key populations like gay men, men who have sex with men and transgender persons are also major stumbling blocks in the global HIV response. 

“The world will not be able to defeat AIDS while reinforcing patriarchy. The only effective route map to ending AIDS and achieving the sustainable development goals is a feminist route map. We can take action now to tackle gender inequalities and promote healthy masculinities—to take the place of the harmful behaviours which exacerbate risks for everyone,” Winnie Byanyima, the executive director of UNAIDS wrote in the foreword. 

Launching the report in Tanzania on Tuesday, Byanyima added that AIDS can end only if there is equality in the world. “The reason why we call it “dangerous” is because, currently, we are not on track, globally, to end AIDS by 2030 as was agreed by all the governments of the world. We are not on track. And the reason is inequality…But we can end AIDS by equalising.”

The gender lens

While 49% of new HIV infections across the world were among women and girls in 2021, in high-incidence regions like sub-Saharan Africa, women and girls accounted for nearly 63% of the new HIV infections. 

Women experiencing intimate partner violence in the past year are also three times more likely to have contracted HIV recently. This finding, coupled with the recent report by UN Women and UN Office on Drugs and Crimes (UNODC), which stated that more than five women are killed every hour by intimate partners or their own families, highlights women’s vulnerability. 

Distribution of new HIV infection by age and sex in sub-Saharan Africa, 2021.

Patriarchal norms also prevent men and adolescent boys from seeking the healthcare services they need, according to the report.

“Transforming harmful gender and masculinity norms among men and boys will help reduce their HIV risks, but it will also reduce risks and vulnerabilities to HIV among women and adolescent girls, including by respecting their sexual and reproductive health and rights and upholding zero tolerance for any violence against them,” the report added.  

Calling for an inclusive and comprehensive curriculum at schools that includes sexuality education, Byanyima said that pushing girls to complete secondary education would reduce their vulnerability to HIV infection by up to 50%. 

“We must combine services for sexual and reproductive health together with services for preventing and responding to gender-based violence and services for preventing and responding to HIV. These three must come together.. We must design it in such a way that they are tailored to meet the needs of girls and women in all their diversity.” 

Decriminalisation of queer relationships

While there is a significant decline in the incidence of HIV in western, southern, eastern and central Africa since 2010, the decrease is not significant among gay men and other men who have sex with men in these regions. 

“Key populations” – groups particularly vulnerable to HIV including men who have sex with men, people injecting drugs and sex workers – accounted for about 5% of the global population in 2021 but they and their sexual partners accounted for about 70% of new HIV infections. 

While several countries have decriminalised queer relationships, many countries still consider it a criminal act. Byanyima called for the decriminalisation of queer relationships to improve access to healthcare.  

“When you decriminalise, people will come forward and get services. Decriminalising saves lives…I suggest let’s confine these colonial and harmful laws to history. We don’t need them. God can judge them if they’re wrong. We don’t need the laws. They take people away from services. But we don’t only need to decriminalise, we need to fight stigma. Stigma is a sentence passed by society on people for who they are. Stigma kills. We need to end the stigma for people living with HIV.” 

Similarly, people who engage in sex work and those who inject drugs are at a higher risk of contracting HIV, which can only be addressed by involving community-led organisations in an effective manner to reach these key populations with prevention and treatment services.

“While efforts to expand services for key populations are critical to reducing the epidemic’s burden in these groups, the mere availability of services will not have the needed impact without concerted efforts to address societal enablers.”

Children left out of the equation

The UNAIDS report stated that children are disproportionately affected by HIV. While they make up 4% of the total HIV burden in 2021, they account for 15% of all AIDS-related deaths. The report also flagged that the gap between HIV treatment coverage for adults and children has widened since 2010. 

Antiretroviral treatment coverage comparison between children and adults at the global level, 2010-21.

It is estimated that globally, 800,000 children living with HIV are not receiving treatment. The report also stated that in Africa, the decrease in the number of new HIV infections among children has stagnated in the past five years. 

“Late diagnosis is an important contributor to the treatment inequalities that children experience. Globally, only 62% of HIV-exposed infants are tested within the first two months of life, but in western and central Africa, only one in four HIV-exposed infants receive early infant diagnostic services,” the report highlighted.

“The treatment gap for children can be closed if more pregnant and breastfeeding women and their infants are supported to confirm the child’s HIV status at birth and at the end of breastfeeding.” 

Allocation to key populations must increase

In 2021, low and middle-income countries channelled only 3% of their total HIV spending towards prevention and societal enabler programmes for key populations. UNAIDS said that this share has to increase to 21% by 2025 for the HIV response to be on the right track. 

Pointing out that increases in bilateral investment in HIV response in low and middle-income countries are usually met with similar increases in domestic investments in HIV response, UNAIDS said that donor and development partner investments into this cause must expand. 

Comparison of expenditure of external and domestic funding towards HIV response, 2018-20.

Similarly, the agency also called for focussed investments towards programmes that benefit young women and girls. 

Image Credits: UNAIDS.

A WHO press conference earlier this year.

Professor Hanan Balkhy will step into the shoes of Dr Mariângela Simão, the World Health Organization’s (WHO) Assistant Director-General for access to medicines and health products, when she leaves on Thursday, according to WHO sources.

Professor Hanan Balkhy

Currently WHO Assistant Director-General of antimicrobial resistance, Balkhy served as executive director of infection prevention and control in Saudia Arabia for 10 years.

Meanwhile, Australian national Professor John Reeder, WHO’s Director of the Special Programme for Research and Training in Tropical Diseases (TDR), steps into the Chief Scientist role about to be vacated by Dr Soumya Swaminathan.

Dr Teresa Kasaeva, who directs the WHO’s global TB programme, will replace Dr Ren Minghui as Assistant Director-General for universal health coverage (UHC), and communicable and non-communicable diseases.

It is understood that the three will be acting in the various positions, but the WHO did not respond to Health Policy Watch queries about the appointments or their status.

As Health Policy Watch reported previously, eight members of the WHO’s 16-member senior leadership team at the Geneva headquarters will leave the global body at the end of November.

This is the biggest single leadership change that Tedros has made since 2019, two years after he took office, when he made a set of sweeping changes as part of his “Transformation” agenda for the organization. 

It has been anticipated for months by Geneva insiders who say the Director-General has been itching to shake up his team since being re-elected for a second term. Additionally, there have been pressures from large donors for Tedros to streamline his senior team, which is the largest it has ever been.

All three current appointments are internal, which could indicate that Tedros is responding both to criticism that he has not promoted enough people within WHO’s ranks and to pressure from member states led by the US to trim personnel costs.

Tedros is unlikely to replace Dr Nono Simelela, an Assistant Director-General and special adviser and may also rationalise other posts to save costs.

Other staff departing this week are Jane Ellison, executive director for external relations and governance, Dr Jaouard Mahjour, Assistant Director-General for emergency preparedness and international health regulations and Dr Naoko Yamamoto, Assistant Director-General for UHC and healthier populations.

Abortion affects women.
There are still many barriers to women getting abortions in India.

Although India’s Supreme Court issued a landmark decision granting all women the right to an abortion up to 24 weeks of pregnancy in late September, many obstacles stand in the way of women getting abortions – including the conservative attitudes of health workers towards unmarried women.

The Supreme Court decision erased the difference between married women and unmarried women, which had been enshrined in a 2021 amendment of India’s Medical Termination of Pregnancy (MTP) Act, passed in 1971.

Under the 1971 law, abortion was technically allowed for all women up until 20 weeks – although in fact multiple cultural and practical obstacles existed for unmarried women.

The 2021 amendment expanded abortion rights for certain categories of women, such as survivors of rape and incest, allowing them to obtain abortions until 24 weeks.  It also allowed married women to terminate their pregnancies up to 24 weeks under certain circumstances, such as failure of contraception – but did not allow unmarried pregnant women the same right.

Expansion of abortion rights aims to reduce deaths from botched procedures

Abortion rights India
Inside a healthcare facility in India.

The expansion of abortion access is aimed at protecting women’s health, as eight women a day are estimated to die in India as a result of botched abortions, according to the United Nations Population Fund, UNFPA. 

Over a quarter (27%) of all the abortions in India are performed by women themselves in their homes, according to National Family Health Survey (NFHS) – 5.  Around 16% of women who had abortions reported complications, and 90% of these needed medical treatment.  

But while the ruling has been praised as a milestone for India and South East Asia, with respect to reproductive health rights, activists in India say that the situation on the ground remains unchanged in many respects.  Women seeking access to abortion continue to face social stigmas and prejudices that are far from the liberal attitudes reflected in the court decision.   

Judgemental health workers

Ground-breaking research conducted by the progressive Indian YP Foundation, has identified a range of barriers – from high costs of the procedure to judgemental health care workers. 

Service providers’ impose value judgements on premarital sex, as well as abortion, the research found, with some providers insisting that unmarried women obtain their parents’ consent for the procedure. 

The research fellows, who posed as patients at health facilities and conducted surveys amongst young people and in seven Indian states, also found confidentiality breaches in government facilities, caste prejudice and gender disparity in treatment, with those women who were accompanied by male partners getting a much better reception.  Finally there are the arbitrary costs of abortion in public clinics, as well as providers’ reference to  expensive private facilities even when lower-cost alternatives exist.

Anecdotally, as well, the stories mount up, as well.

One tweet by an Indian doctor stating that it was important for her to ask patients if they were married as this determined how she would treat them, opened a floodgate of responses from angry social media users, many of whom had bad experiences with doctors, especially gynaecologists. 

There have been a number of reports of gynaecologists, even in India’s urban centres, refusing to perform a vaginal examination on an adult patient without the consent of their parent or partner.  

Years ago, Akshita* remembers visiting her gynaecologist in Hyderabad after she missed a period. “I was suspecting polycystic ovarian disorder (PCOD) and requested a diagnosis. I made it clear to the doctor that I was not sexually active,” she told Health Policy Watch. However, her doctor refused to believe her and then went on to suggest a diet plan without diagnosing her condition. The experience traumatised the 22-year-old Hyderabad-based young professional, who avoided going to a doctor for a long time after. 

“When I have gone for smaller, simpler things, they have traumatised me so thoroughly. I cannot imagine what it would be like to approach one for something like a birth control or abortion, which they would definitely be much more judgemental about and would straight up deny access to these services.” 

Informal networks pushing back on stigmas and prejudice

Abortion rights
Women queuing up in front of a pharmacy in India. Though ECPs are not illegal/banned in India, many pharmacies don’t stock them.

The petition that pushed the Indian top court to issue its milestone pro-choice verdict in September was filed filed by a 25-year-old unmarried woman who was 22 weeks’ pregnant.  

In her petition, she said that her partner refused to marry her and she didn’t want to have the baby out of wedlock due to societal stigma. She also asserted that she could not afford to raise a child as she was unemployed and did not come from a wealthy family. 

In the southern Indian state of Tamil Nadu, Chennai activist Archanaa Sekar works with an informal network of women in the city who have been instrumental in helping such women to get abortions from non-judgemental gynaecologists.   Her group also has organised with local government actors and pharmacies to ensure that emergency contraceptive pills (ECPs), which are not normally stocked, may be made available. 

While acknowledging that the September Supreme Court decision was groundbreaking, she added that it will still take a long time for new legal thinking to filter into health workers’ responses, and broader societal values. Meanwhile, advocacy and women’s support networks will play a critical role in expanding women’s access, little by little, on the ground. 

“As a doctor, one is in a position of power of allowing a person access to abortion. Unfortunately, we are still not in a place where a professional comes into the table just as a professional. They bring their baggage and prejudices with them,” said Sekar, in an interview with Health Policy Watch.

“With respect to abortion, there is a cultural, moral understanding that killing anything seems wrong and therefore you think abortion is illegal,” she said.  “So, for you to come around to the fact that abortion is legal, it takes a while. In all of this, in case of something like pregnancies you are losing precious time.”

“Unlike environmental laws where it is easy to expose people flouting the law, in cases of abortion it is difficult to speak out against someone who goes against the law and denies abortion,” Seker explained. 

“To a layperson it doesn’t matter whether the law exists or not. Because the law is not going to protect them,” she added. “People need to know their rights. If we are doing any kind of rights education, are we including a module also on laws such as the MTP Act and the Mental Healthcare Act?” 

Deeper issue remains attitudes towards sexuality

But even deeper attitudes towards sex and sexuality, which remain taboo topics in much of Indian society, also come into play in the abortion access landscape, she says.

Sex education continues to be banned in states like Gujarat, Karnataka and Maharashtra, for example.  And even when sex education is included in the curriculum, students are taught to abstain. Most adolescents in India are not aware of contraception or how to use it, which leads to unsafe sex and unwanted pregnancies, she noted. 

“Until we take the shame out of sex, we are not going to take the stigma out of contraception or abortion access.” 

The Rosa Luxemburg Foundation provided support for this article.

Image Credits: Srimathi Jayaprakash/ Unsplash, The White Ribbon Alliance/Flickr, Trinity Care Foundation/Flickr.