HAI Asia's response to Tore Godal's comments on Anita Hardon's article

The first paragraph is factually wrong. Health development has occupied the central stage in the national and international agenda. Between the mid-1950s and 1980, developing countries introduced health development strategies and made considerable gains in health standards with increasing life expectancy and reduction in infant mortality rates. Annual reports of the WHO had recorded these gains. Unfortunately beginning in the early eighties with the imposition of structural adjustment programmes [SAPs] by the World Bank and International Monetary Fund several countries, particularly those in Sub-Saharan Africa lost all their gains. The poor health standards in these developing countries is not due to the neglect of health development but external factors including SAPs, globalisation and World Trade Organization (WTO) multilateral trade agreements. The recent issues of UNDP's Human Development Reports have described these negative impacts in detail.

Health and economic development have been highlighted on the global stage for over thirty years. It is not new. But what is new is public and private partnership in health development. In the early 1970s the United Nations agencies proposed a New International Economic Order as the way forward for economic, technological and commercial development of the Third World. There was no public private partnership to promote the New International Economic Order, which unfortunately disappeared from the UN agenda in the 1980s. It is now replaced by globalisation, liberalisation and WTO multilateral trade agreements. There is public private partnership to promote this new economic order.

In 1977 the WHO proposed a model list of essential drugs and advised countries to formulate and implement national drug policies based on the concept of essential drugs. WHO argued that this was the only way to ensure access of drugs to developing countries. There was no public private partnership to ensure access to drugs. The private drug industry strongly opposed and campaigned against the concept of essential drugs.

In 1978, the WHO and UNICEF and the World Community adopted the Alma Ata Declaration -"Health for All [HFA] in the Year 2000". This is undoubtedly the greatest health development strategy proposed and accepted by the United Nations agencies. There was no public private partnership to make HFA a reality.

When the WHO proposed equity pricing in 2000 to ensure access to essential drugs, a public private partnership was forged but the word "equity" was dropped to be replaced by "differential". A WHO/WTO seminar on differential pricing was convened in Oslo in April, 2001. HAI and other NGOs which participated in the seminar issued a statement explaining their position on differential pricing.

This lengthy response to the first paragraph is to reiterate HAI Asia's position that the private sector had ignored health development strategies proposed by the UN agencies particularly WHO up to now. The partnerships proposed now protect commercial interests through guarantees and conditionalities attached to these partnerships. These include the following:

• reasonable prices;
• support for a credible and sustainable market;
• respect for intellectual property rights; and
• prohibition on compulsory licensing and parallel imports

The responses from the World Bank, GAVI secretariat and the Dutch Ministry of Health, Welfare and Sport, have not made any reference to these guarantees mentioned in Anita's paper.

In this context, the HAI briefing paper to the 54th World Health Assembly provides evidence that the WHO, European Parliament and the Human Rights Commission support developing countries' demand for revision of the TRIPs Agreement and for allowing compulsory licensing and parallel imports, the two safeguards in the TRIPs agreement. The guarantee now given to the private industry in the GAVI initiative is, therefore, contradictory to the position taken by the WHO, European Parliament and the Human Rights Commission.

Let us go to the rest of the comment. HAI Asia thanks Tore Godal for giving relevant background information on GAVI.

HAI Asia wants a revitalising of the EPI and UCI campaign to cover all the children of the world against the six main target diseases. The infrastructure in all developing countries are available. It makes sense to continue to strengthen and expand these health care structures.

The GAVI initiative on the other hand is selective, focussing the introduction of new vaccines, specifically hepatitis B in lower-income countries.

Selection of countries

1. It is stated that the ultimate aim is that all children in all countries have access to immunisation that are epidemicologically justified.
2. It is proposed to address inequities by providing the poorest countries with support. Eligibility has been defined as a per capita GNP below US$1,000. According to UN reports 58 countries have a per capita GNP of less than US$1,000. But per capita GNP is not at all a realistic measure of the purchasing power of the people since the income distribution is highly skewed in all developing countries. For example, Brazil has a per capita income of US$4,720. But 16 million Brazilians live on less than one dollar a day. The World Bank poverty line for Brazil is two dollars per person per day.
3. One of the milestones of the Alliance is to ensure that 80% of countries should reach 80% coverage in all districts. How these 80% or about 100 countries are to be supported to reach 80% coverage and with what vaccines are not stated. As stated earlier eligibility for support is a per capita GNP of below US$1,000 or 58 countries.

Support to health services and new vaccines

There are two budget lines or sub-accounts; one for strengthening health services and the other for purchase of new and under-used vaccines. Anita Hardon, referring to details of the first disbursement (2000-2001), reported that approximately 10% of the funds are earmarked to strengthen immunisation services while 90% will go towards introducing new vaccines.

Let us see how these allocations will help poorest countries to benefit from the GAVI initiative. HAI Asia's concern that the GAVI's initiative is a means of securing markets for the new vaccines is confirmed. Most eligible countries have chosen to introduce hepatitis B vaccine. A few countries have chosen to introduce the more expensive Haemophilies influenzae type b - the Hib vaccine.

As a result many countries have requested support for rapid assessment of Hib disease burden in order to get a scientific basis for making any decision on the introduction of Hib vaccine!!

The GAVI comment is certainly a paradox. In describing the background we are told that the history of the Alliance goes back to a meeting initiated by the head of the World Bank in 1998. The reason for these meetings among concerned partners was the issues Hardon mentioned: immunisation rates in the poorest countries, stagnating or going down after the earlier success of EPI which raised the global immunisation rates from below 5% in 1970 to around 80% in 1980.

What happens to this Alliance? It collected over a billion dollars to revitalise the immunisation programme in the poorest countries where the immunisation rates were stagnating or falling.

And what did the Alliance do? According to GAVI, they are exploring the optimum way to support countries with strong programmes in their efforts to expand their programmes by including new vaccines,rather than by increasing coverage.

Where is the equity?

Using the funds collected to provide immunisation coverage for children in the poorest countries with weak health systems, the Alliance seems to be creating a market for expensive vaccines including Hib vaccine in countries with strong health systems.

Anita Hardon's concerns are very real. HAI Asia requests the World Bank, GAVI and the Dutch Minister of Health, Welfare & Sport to answer these concerns.