In this regard, it is crucial to consider territorial disparities in terms of both the characteristics of the populations and their health status, in addition to the geographical distribution of health services. For this purpose, a reliable and up-to-date data system providing precise geospatial information is required. This information will help produce the necessary indicators for analyzing disparities in access to care and identifying deficiencies.

Thus, public health authorities would have the ability to determine which areas require the most healthcare services and where resources should be allocated as a priority. This approach would effectively improve healthcare services management, with a focus on territorial planning and combating health inequalities.

Accessibility and utilization of healthcare services

Accessibility to healthcare is the ability of patients to obtain necessary care and medications from healthcare professionals when needed. In reality, access to healthcare remains constrained by various factors such as an insufficient healthcare supply and a shortage of healthcare personnel. Further, medical care costs are high and social coverage is limited. It is also important to note that disadvantaged populations frequently face mobility challenges that impede their access to healthcare.

The World Health Organization (WHO) has raised a major concern about limited healthcare access, affecting nearly half of the global population. This situation represents a crucial challenge for public health due to its complexity related to several critical aspects. On the one hand, it is essential to identify optimal locations for healthcare services. It is also essential to understand the correlation between current service locations and actual health needs. This analysis helps comprehend geographical disparities that may limit healthcare access, especially for rural and disadvantaged populations. On the other hand, it is crucial to identify the health needs of the population to efficiently allocate healthcare resources and meet population demands. This evaluation helps us recognize the most pressing health issues, and the most vulnerable population groups. In fact, targeted health policies ensure that resources are utilized efficiently while addressing the specific needs of a particular population.

Information management for healthcare access assessment 

Assessing healthcare access is essential to understand inequalities in healthcare provision and identify areas where healthcare is most needed. Any study of healthcare services accessibility and utilization must take into account several key factors, such as socio-economic variables, needs, supply, and demand.

A range of tools and methods are used to address healthcare planning issues. They provide management proposals that improve limited accessibility to healthcare service locations.

Health dashboards and health maps are highly useful tools for presenting health data in a simple and understandable manner. They provide general statistics on population health and well-being from different perspectives. They allow tracking the temporal evolution of various health indicators and highlighting disparities based on socio-economic levels, rural and urban environments, and local/regional health networks.

Combining these tools will provide a precise and comprehensive picture of healthcare accessibility in a particular country or region.

Often, a study of the available resources is conducted in order to characterize the service potential, both in terms of human and institutional resources, as well as material resources. An accurate count of healthcare facilities, healthcare equipment, and healthcare providers (general practitioners, specialists, nurses, etc.) can provide insight into healthcare distribution and disparities within it. This can be used to identify areas where healthcare is available and areas where it is scarce or insufficient.

In Tunisia, the national health service map “Carte sanitaire” provides statistics and a graphical representation of healthcare services distribution. This allows a clear visualization of their geographical spread at the level of each governorate.

In order to fully understand healthcare accessibility, we must look beyond healthcare provision evaluations and take into account inequities in access to care. It is therefore necessary to analyze the alignment between healthcare services and the served population, within the context of a healthcare system’s territorial planning policy. This approach facilitates the efficient planning and organization of material and human resources to improve healthcare access for all. This is regardless of geography or socioeconomic status.

However, to implement such analyses, having access to a robust and well-defined data system is crucial, allowing the collection of geolocated data related to socio-economic, environmental, epidemiological, and individual health factors. Statistical analysis must be conducted to identify all factors influencing the population’s healthcare needs. This will highlight the key factors contributing to healthcare access inequalities. It will enable the planning of effective interventions to address population health needs and ensure efficient resource distribution.

Recognizing the importance of data in assessing healthcare access is crucial. Organizations and public health authorities must integrate analytical approaches and rigorous statistical methods when considering strategies for healthcare service distribution. However, these approaches heavily rely on the availability of accurate data on the population, its health status, and environmental risks.

Data dependence poses a major challenge for specialists involved in in-depth surveys and spatial analyses. Therefore, it is essential to develop more comprehensive health information systems that efficiently collect, analyze, and share the necessary data. This will improve evaluation quality and develop more equitable and effective health policies.

The post Data challenges in healthcare access evaluation first appeared on Research Media.]]> https://www.researchmedia.org/data-challenges-in-healthcare-access-evaluation/feed/ 0 https://www.researchmedia.org/valueofhealthdata/ https://www.researchmedia.org/valueofhealthdata/#respond Fri, 28 Jul 2023 06:43:14 +0000 https://www.researchmedia.org/?p=5973   Manel Ben Fdilen, Meriem Ben Tarjem Several commonly observed pathologies in healthcare services, such as acute or…

 

Manel Ben Fdilen, Meriem Ben Tarjem

Several commonly observed pathologies in healthcare services, such as acute or chronic neurological and cardiovascular diseases, systemic diseases, and hereditary diseases, continue to present challenges in terms of diagnosis and patient orientation. These diseases have been extensively studied to constantly evolve management recommendations.

Despite advancements in prevention, diagnosis, treatment, and monitoring, these diseases still represent a public health problem due to their high frequency, multifactorial and clinical polymorphism, as well as their significant impact on morbi-mortality, and economic costs.

In Tunisia, the lack of national registries that establish the epidemiological profile of various diseases hinders our understanding and care protocol improvement. To address this, it is crucial to continuously update the data. This will enable the development of guidelines for diagnosis, treatment, and follow-up, while reducing healthcare burdens. By doing so, we can improve disease management and optimize healthcare resource allocation.

In this context, it is essential to emphasize the importance of health data in establishing national registries and their pivotal role in advancing scientific research and enhancing care quality. By doing so, we gain valuable insights that directly inform the development of effective health policies firmly rooted in current epidemiological information.

National Registries: An Essential Resource for Public Health Surveillance and Research in Tunisia

National registries are defined as “the continuous and comprehensive collection of individual-level data pertaining to one or more health events in a geographically defined population, for the purposes of surveillance, research, and evaluation in public health, by a team with appropriate expertise.”

The geographical definition of national registries encompasses several key aspects, such as the scope of diseases, medical specialty, population defined by age and sex, coding nomenclature, and data accessibility.

When determining the scope of diseases covered by the registry, consideration is given to the relevant medical specialties and domains pertinent to data collection. This ensures that the registry captures comprehensive information specific to the designated medical areas.

By defining the population in terms of age and sex, the registry provides precise demographic data. This allows for a better understanding of the characteristics of the population affected by recorded health events.

The registry’s coding nomenclature plays a vital role in organizing and analyzing recorded health events. It entails the use of a standardized classification system to assign specific codes. This facilitates data management, comparability, and interoperability across different registries and healthcare settings.

Lastly, data accessibility entails determining the appropriate access to recorded data, including the conditions and purposes for which it can be accessed. Striking the right balance is essential to sensitive data confidentiality and protection. It also enables authorized individuals and organizations to utilize the data for research, policy development, and initiatives aimed at improving healthcare.

In Tunisia, scientific societies play an essential role in managing registries by establishing the necessary policies and strategies for their implementation. These registries are specifically designed to address healthcare priorities, needs, and essential decision-making criteria. Furthermore, certain registries are part of national public health strategies, such as regional cancer registries. This demonstrates their importance in tackling major health challenges.

A concrete example is the Northern Tunisia Cancer Registry (NTCR), which was established by ministerial decree. The Epidemiology, Medical Informatics, and Biostatistics Department of the Salah Azaiz Institute was designated NTCR headquarters. These registries play a crucial role in providing a clear picture of cancer epidemiology in Tunisia. They allow for an accurate assessment, identifying existing disparities between genders and different regions of the country regarding cancer prevalence and access to care.

Furthermore, these registries play a crucial role in detecting epidemiological changes. They guide awareness strategies, individual or mass screenings, and cancer combat efforts. They also contribute to making well-informed decisions regarding patient management while fostering innovation in treatments, monitoring, and research.

However, despite progress, the epidemiological profile of many diseases is insufficiently covered by national health registries and remains unknown. It is in this context that the Tunisian Society of Cardiology and Cardiovascular Surgery initiated, for the first time in Tunisia, an international registry called “The Big 4 CVD Registry” (Africa and MENA). This registry aims to establish the epidemiological profile, improve management, and monitor therapeutic adherence for four major cardiovascular diseases: atrial fibrillation, heart failure, coronary insufficiency, and valvular heart diseases.

This ambitious initiative requires significant financial resources and expertise, but it promises to contribute significantly to scientific research by providing relevant data. It also highlights the fundamental role of coordination, both at the national and international levels, in developing health data for scientific research.

Data roles in health registry development

In order to ensure a comprehensive collection of information for registries, it is essential to draw upon different data sources. These sources include archives and hospital statistics, clinics, private practices, public or private analysis laboratories, autopsy reports and death certificates. The use of these diverse sources allows for a comprehensive and detailed view of health events in the population of interest. This increases the accuracy and relevance of established registries.

However, it is important that personnel responsible for data collection and registry creation receive adequate training and follow clear operational procedures. This is to ensure data quality. Meeting this requirement, however, necessitates the mobilization of significant human and financial resources.

To establish robust governance of this data, a national strategy for digital health development (e-health) is being developed. This strategy encompasses various initiatives, including medical records digitization. This modernization of the data management system will facilitate the collection of essential information for establishing registries. In addition, it reduces data loss risk.

Additionally, data protection is essential during registry development. A precise legal framework must govern the registry, ensuring information confidentiality, securing access to data, and regulating their use in other scientific research endeavors. It is also critical to control the distribution, dissemination, and sharing of this data. Certain registries are subject to legal obligations outlined in ministerial orders, with the primary objective of ensuring confidentiality, as is the case with the RCNT (Northern Tunisia Cancer Registry).

To ensure registry reliability, evaluation and certification committees are in place to guide researchers who wish to use the data. The National Health Evaluation and Accreditation Agency accredits several registries, ensuring compliance and reliability of collected information. This process aims to establish trust among users and promote ethical and responsible health data use.

The development of national and regional networks, as well as collaboration between scientific societies, healthcare institutions, the Ministry of Health, and the public and private sectors, plays a key role. On the one hand, this allows for quality and comparability standards for registries. On the other hand, it promotes collaboration among registries and facilitates data flow.

Therefore, institutes, healthcare organizations, and the Ministry of Health must commit to supporting and accrediting these registries. Their engagement is crucial to ensuring the success and sustainability of these initiatives, thus guaranteeing the reliability and value of the collected data.

 

In conclusion, it is highly advantageous to regularly update the national coverage of health registries in Tunisia. This would be done by assessing the range of pathologies they cover, and creating a national directory listing all accredited registries. This would guide researchers toward reliable data sources, facilitating research and analysis.

Moreover, it is essential to define and specify the data to be collected based on the specific missions of each registry. This approach rationalizes the budgetary, human, time, and effort resources invested in data collection. Interoperability between different databases and registries, as well as collaboration between the public and private sectors and national and international stakeholders, would be key factors in promoting registry data dissemination and utilization. This synergy would allow for optimal use of available resources and strengthen Tunisia’s role as a major actor in international research and scientific dissemination.

By implementing these measures, Tunisia could enhance its position as a key player in health data governance. This is while adhering to legislative and scientific quality standards. It would also become an indispensable reference in public health research, improving care quality and making informed decisions regarding national and international health strategies.

 

 

 

 

 

 

The post The value of health data in national registers: a scientific research and healthcare quality improvement tool first appeared on Research Media.]]>

The Fakhfakh government announced a fundraising hotline to collect donations for the national health system and revealed the reorganizing of budget spending priorities in order to reallocate an overall amount of 2,500 billion TND ($860 million) to support small and medium enterprises (SME) and companies suffering from the economic shutdown. The government also agreed to transfer 200 TND ($68) as a social safety net to the 600,000 poorest families for the month of April. So far, an additional 1.4 million Tunisians requested this aid, and the number of applications for emergency cash assistance is expected to rise. The government extended this monthly allocation to May as the targeted lockdown was extended. Other emergency policies include mortgage and loan freeze for middle-income households, a freeze of social contributions from the private sector from three to six months, and a reduction by the central bank of the interest rate by 100 basis points in order to preserve the demand side. However, these measures were generally perceived as insufficient especially with attempts of banks and companies to violate the imposed measures and the agreement with the government to maintain salary payments for workers forced into confinement. Therefore, a great discontent emerged between different classes (workers and business owners), between the private and public sector, and between different unions due to the general belief that some will pay more for the others^[2].

This feeling of injustice is not unfounded as social and fiscal injustice have persisted during decades of economic and fiscal policies guided by austerity measures imposed by international financial institutions (IFIs) and donor countries, and even more so after the 2011 revolution. As a result, workers’ rights have been undermined and their struggles criminalized^[3].

This situation is exacerbated by the government officials’ belief that guaranteeing salary payments in Tunisian Dinar, social transfers to the poorest, and doing “Whatever it takes” to preserve jobs and income for workers and households, can only be done through taxation, or new debts or by collecting donations, or through threatening the rentiers capitalist class by a hypothetical wealth tax measure.

While Tunisia is a currency issuer state and is not fiscally constrained, the Central Bank of Tunisia (CBT) could have accommodated the government’s plan to stabilize the income of the most vulnerable people without fearing inflation, especially in this context of international trade contraction, instead of allowing banks and the financial sector to take advantage of this crisis by seeking more profits, from high-interest rate lending to the state, and by investing public money in non-productive sectors.

This is a political decision that could have been made by the Chief of Government when legislative power was delegated to him at the end of March, but unfortunately such a proposal –of allowing the CBT to accommodate government deficit limited to 5% of GDP- was strangely deleted from the last version of the delegation law.

A new loan with new conditions

Regrettably, the government made another political decision to prioritize external debt servicing and to acquire even more external debt.  Indeed, on the 14th of April, Tunisia and the IMF announced an agreement for the disbursement of a new loan: The Rapid Financing Instrument (RFI) worth $745 million – the second-biggest disbursement by an African country after Côte d’Ivoire – to support “the government’s efforts to contain the pandemic.”

Taking a closer look at the letter of intent^[4] jointly signed and sent by the finance minister and the central bank governor, we find that the loan is conditional, despite the government claiming otherwise. In fact, there are immediate and future commitments that predicate the continuation of the same dependency policies that may jeopardize any attempt by Tunisia to create a more resilient and sovereign economic model.

Indeed, the immediate commitment consists of a reduction of investment in non-priority projects without any clear definition of such projects. The announced budget cuts included the canceling the procurement of cars for government officials, flours and roses for the presidential palace, but most impactful, the reduction of fuel subsidies^[5], the increase in the price of tobacco, the increase in water distribution cost, and the freezing of subsidized fuel and food vouchers for public servants. Already one day of work was cut from workers’ payroll in the private and public sector as a compulsory contribution to the government’s efforts to “collect” funds, this one-day salary cut included healthcare workers and workers in essential and strategic sectors who continued to serve during the pandemic. Farmers also contributed with 1% of their turnover on the wholesale markets, while banks, financial institutions, and large profitable corporations were left free to contribute to the donations fund voluntarily based on their goodwill.

All of these measures will have a negative impact on the income of the vast majority of the marginalized people, unemployed, low wage workers, but also the middle class, which is mostly composed of public employees, while the capitalist class continues to enjoy the special fiscal status that provides them with tax cuts, especially for companies whose activity is 100% export-oriented.

The government also committed to increasing natural gas prices after the Covid-19 crisis eases. Authorities will put a strain on its workforce by freezing promotions and limiting overtime hours in the public sector to prevent any new wage bill surge for 2020. The government is also negotiating with the Tunisian General Labor Union (UGTT) so that any planned salary increases for 2021 will not exceed the inflation rate. In addition, an audit of the public sector will be performed to reduce absenteeism and ‘ghost’ workers. This may announce hard bargaining times between the government and the national union as the weight of the crisis will mainly be borne by labor, not capital. The UGTT played a major role during the last round of IMF negotiations to push back against reforms that were mainly targeting public sector privatization, wage cuts and a reduction in the number of public sector employees working in local administrations, and strategic sectors like water, energy, transport, education, and health.

As for the limited participation of private banks and financial institutions in the national effort to support SMEs and households, and the non-compliance of some banks to the CBT’s decisions to freezing loan payments, the Ministry of Finance, Nizar Yaïche, reiterated the holy principle of CBT independence. This principle, included in the new statute of the CBT, was also imposed by the 2016 loan agreement with the IMF whose main objective was to prohibit the CBT from directly financing government deficits via treasury bond purchases and to maintain legal independence in policymaking from the central government, even though most of CBT policies are guided by the IMF staff priorities and in agreement with their recommendations.

Although central banks of advanced economies have undertaken massive if not unlimited liquidity injections, to support their economies and support workers whose livelihoods have been adversely affected, this option has been denied for Tunisia. The IMF had the Central Bank of Tunisia commit to not interfering in the foreign exchange market, or limiting foreign transfers (dividends, debt repayments), trade transactions, or entering into bilateral payment arrangements with other countries. Moreover, the IMF imposed that any loan guarantees or subsidies to companies should be borne by the government rather than the Central Bank. With these prescriptions, the IMF clearly plays the role of a self-appointed watchdog of global capitalism. What worries the IMF is the leeway that countries like Tunisia could leverage with their sovereign currency, should their central bank unleash more robust counter-inflationist policies and national rights-based economic stimulus targeting full employment and rebuilding local productive capacity. That is why policing central banks have always been central to the IMF conditionalities.

As for future commitments, the government is planning to permanently reduce subsidies for electricity and natural gas, and to make social safety nets are offered on a temporary rather than permanent basis. This is part of the general neoliberal orientation maintained by the IMF to cancel governmental subsidies as they are considered distortions to market equilibrium. These reforms may certainly apply later to the few products that are still subsidized in Tunisia, namely wheat and semolina flour, sugar, vegetal oils, milk, and tomato paste (the latter are price-settled), all of which are really important food staples for Tunisian consumers, as shown during the COVID-19 crisis. Price-subsidized basic products are a sensitive issue for most Tunisians since the monthly minimum wage for a Tunisian worker is only 403 TND ($140 per month) for 48 hours/week. For a long time, subsidizing basic commodities was a necessary strategic decision for governments to maintain social peace in an economic environment of a race to the bottom wage policies.

Last but not least, to obtain this RFI disbursement, the Tunisian government committed to starting a new IMF program (Extended Fund Facility) in the third quarter of 2020, which will also include a number of painful reforms, as Nizar Yaïche, the Finance Minister stated in his recent interview with Bloomberg News.

While this Covid-19 pandemic allowed debt servicing relief for 25 African countries, Tunisia was excluded from this debt relief program announced by the G20. On the contrary, the new IMF loan is expected to be a lever to other loans from the G7 and international financial markets. The European Commission also announced a new Macro-Financial Assistance (MFA) of €600 million that will help fill the gap of debt servicing tranches which will be due in 2020 and 2021. These MFAs, like former ones that “benefited” Tunisia, were also a European Commission tool to secure its trade-related interests.

It must be noted that the amount allocated to debt servicing in the government’s budget exceeds 11 billion TND ($3,78 billion) for 2020, which is one-quarter of the government’s budget, more than six times the budget allocated for the ministry of higher education and scientific research, 35 times the investment allocation for education, and five times the budget of the ministry of health^[6]. In 2019, more than 4,000 health workers left public health services and were not replaced.

Can Modern Monetary Theory solve Africa’s debt crisis ?

This deal with the IMF is, in reality, imposing an unwarranted burden on government spending, and as a consequence, will tighten the government’s fiscal policy space which would hinder the prioritizing of health, education, universal public services for its population. However, more deceivingly, this deal is making it less likely for Tunisia to launch any new green infrastructure and a job guarantee program^[7] that may act as a stimulus and a stabilizer of economic activity; which could, in turn, protect people’s lives and dignity, especially if the central bank continues its high-interest rate policy focus, and ignores its role in financing the budget deficit or supporting any national rights-based recovery program.

The recent decision of the G20 to relieve some financial constraints on the poorest countries that are liable to find themselves in default is only aiming to avoid an imminent ‘sovereign debt default domino effect’ without addressing the structural deficiencies of developing countries or addressing the root causes of their balance of payment (BoP) deficits^[8].  At the same time, they would approve new concessional loans to countries with fewer financial difficulties, well-controlled markets (like Tunisia), and continue making these loans conditional based upon limiting government spending and deficits, excluding the central bank as an important policy tool, and making sure there are no capital controls or constraints on trade.  This strategy maintains the dependency relationship with creditor countries who need market access in developing countries where they can sell high value-added products, and where they can buy cheap factors of production and resources at stable and affordable prices.

Is this strategy sustainable?

One might, however, wonder to what extent and under which circumstances can this strategy be sustainable. The answer may be found in the blog post[9] of the IMF managing director Kristalina Georgieva who stated “But more lending may not always be the best solution for every country. The crisis is adding to high debt burdens and many could find themselves on an unsustainable path. We, therefore, need to contemplate new approaches, working closely with other international institutions, as well as the private sector, to help countries steer through this crisis and emerge more resilient.”

In reality, “supporting the government’s efforts to contain the pandemic”, could be understood in IMF’s terms as directing the government’s efforts to secure private and multilateral debt servicing, international trade, capital transfers for international investors and opening the door to more lucrative, speculative, rentier profit-making private investments, through private-public partnerships in strategic sectors, further commodification of public goods, and greenwashing that will ultimately lead to more capital accumulation.

To make it clear, the imperialist countries controlling these multilateral institutions (like the IMF, the World Bank, the WTO, ..) are desperately trying to maintain their dominance and the privileged status of their currencies in an increasingly multi polarized world for the benefit of the financialized transnational capitalist classes.[10]

Nevertheless, one hope still persists for most Tunisians: that the revolution of dignity achieves two out of three objectives for which people died, jobs and dignity.

If there is something to learn from this pandemic, it is that today more than ever, a job guarantee program is needed: namely, a green economic program supported by the government, the central bank, and public banks, and in cooperation with the private sector (subject to workers’ rights and environmental protection), managed locally, relying on the real resources and productive capacity of the country, and addressing the real needs of its population, respectful of its climate specificities and water scarcity. Guaranteeing jobs in sustainable agriculture – aiming at ensuring food sovereignty, safe and affordable food – jobs in green infrastructure, using solar, wind and hydroelectric energy to end the fossil fuel economy, and investing in the high value-added industry, in healthcare, childcare, eldercare, education, culture, community building, R&D, and in the local pharmaceutical industry to delink the dependence on big pharma’s speculation on people’s health.

Jobs, decent wages, and bold social rights to restore economic sovereignty and a healthy environment are now necessary for Tunisia’s post-covid-19 recovery. This is the only way for the government to address the root causes of the balance of payment structural deficiencies and the only political ground for the progressive movements’ struggle to end decades of economic dependency. Recent initiatives from Tunisian women and men, engineers, unemployed, students, researchers, practitioners, textile workers, farmers, and civil society during the Covid-19 pandemic to develop solidary local, innovative and autonomous solutions to save our lives are proof that a sovereign, prosperous, and sustainable Tunisia is not an impossible reality, but is rather within reach.

^[1] By End of May the number of total cases counted to 1,084 cases, and 48 deaths, which makes Tunisia one of the few successful countries in managing the pandemic.

^[2] https://orientxxi.info/magazine/tunisie-qui-paie-le-prix-du-coronavirus,3784?fbclid=IwAR0bx85c0zHiY0Hf1NnTsw_ALPXmFnR4N1dKxHNaljiQNyN5mRyQ3Rj8Uq0

^[3] See https://rosaluxna.org/wp-content/uploads/2020/02/What-Democracy-for-Tunisian-Workers.pdf

^[4] https://www.imf.org/~/media/Files/Publications/CR/2020/English/1TUNEA2020001.ashx

^[5] While international fuel prices were collapsing, the internal market prices were very slightly declining, in reality, the consumer is paying an internal price per liter higher than the international price, which makes the consumer subsidizing the government’s loss from falling quantities and not the way around.

^[6] http://www.finances.gov.tn/sites/default/files/2020-02/Loi_finances_2020_fr.pdf

^[7] To learn more about Job Guarantee program for developing countries, African economic and monetary sovereignty, colonialism and independence see the work of Fadhel Kaboub and Ndongo Samba Sylla

http://macroncheese.com/the-spectrum-of-monetary-sovereignty-in-developing-nations-with-ndongo-samba-sylla-and-fadhel-kaboub

https://www.youtube.com/watch?v=HctT4HjgChY

https://urpe.wordpress.com/2019/02/07/fadhel-kaboub-on-monetary-sovereignty-colonialism-and-independence/

https://www.youtube.com/watch?v=xD6mUDRwZ7k

https://www.rosalux.de/en/news/id/41681/modern-monetary-theory-in-the-periphery?cHash=1400f4d40c2caba146cfcd7cd8d19bcc

^[8] Ndongo Samba Sylla explains here how Senegal and other non-monetarily sovereign African countries are trapped in a permanent external debt cycle https://www.rosalux.de/en/news/id/42302/how-foreign-debt-undermines-sovereignty?cHash=71f2e5caaec2a503268898ea98b7db2a

[9] https://blogs.imf.org/2020/04/20/a-global-crisis-like-no-other-needs-a-global-response-like-no-other/

[10] For more information on the Bretton Woods institutions’ response to covid-19 crisis, see the biannual analysis of the World Bank and IMF Spring and Annual Meetings of the Bretton Woods project : https://www.brettonwoodsproject.org/2020/04/spring-meetings-amid-covid-19/

See also the works of Radhika Desai on Geopolitical Economy, and multipolarity and her more recent commentaries on WHAT IS TO BE DONE? A MANIFESTO FOR POLITICS AMID THE PANDEMIC AND BEYOND https://canadiandimension.com/articles/view/political-hope-rises

The 258 civil society organizations (CSOs) that sent an open letter to the World Trade Organization (WTO) and its members could not be more concerned. On April 17, 2020, when they asked the WTO to stop all trade and investment treaty negotiations during the COVID-19 outbreak and refocus on access to medical supplies and saving lives, the virus death toll surged past the 150,000 mark.

Trade and health: a prisoner’s dilemma

On the same day, the WTO organized a virtual meeting, in which its director general stressed the importance of “maintaining open markets for trade in laying the groundwork for a strong recovery.” The virtual meeting also discussed if the WTO members “would be open to formal decision-making through virtual meetings or written procedures until traditional in-person gatherings can resume.”

The letter’s endorsers that represent social movements in 150 countries, such as the United States, Brazil, India, Australia, many European countries and Tunisia, said they were shocked by “the business as usual” attitude of the WTO. For them, not only does the institution’s agenda ignore technological deficiencies of some developing countries, but it also diverts the efforts and resources from the most important purpose of combating the virus.

Many of these CSOs, such as the Third World Network, Oxfam, Greenpeace, Arab NGO Network for Development and the Tunisian Observatory of Economy, have been advocating for a fair distribution of world resources and fighting against the adverse impact of free trade on social welfare, especially in the Global South.

The Covid-19 pandemic just seems to revive these concerns. Indeed, access to affordable medicine often stumbles on the binding rules of the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPs). Adopted in 1994, the latter expanded the scope of intellectual property rights, especially in terms of patent protection and conferred more powers to patent holders.

Despite its binding effect, TRIPs offers flexibilities such as compulsory licensing for public health purposes. Barr al Aman has recently stressed the importance of this flexibility and urged the Tunisian government to use compulsory licenses if the prices of health products are excessively expensive and / or if the quantities made available to Tunisia are not sufficient to cover the urgent national need.

Soigner le COVID-19, l’urgence d’une licence obligatoire

However, for many countries the use of the flexibilities is not that easy. According to a study conducted by the WHO and the South Center in 2005, “a number of provisions in recently concluded FTAs between developed countries (essentially the US) and developing countries, pose a real risk of undermining an effective use of TRIPs flexibilities in developing countries for public health purposes.”

Therefore, besides the discrepancy in the priorities scale of both its issuers and its receivers, the open letter brings back governments, drug companies and the public opinion back to an essential question: will intellectual property hinder the access to the potential COVID-19 medicines and other vital medical supplies?

“From the point of view of intellectual property, of course, a tension exists – and it is a tension that exists around access,” Francis Curry, the director general of the World Intellectual Property Organization (WIPO) said back in 2015, at a symposium on innovation and access to medicine held jointly with the WTO and the World Health Organization (WHO) in Geneva.

Curry then added: “on the one hand, what intellectual property does economically is making access a salable commodity, and that is the basis of markets in technology and creative works. But on the other hand, access as a salable commodity… raises questions about the cost and possibility of access.”

A deep-rooted paradox

The roots of this paradox are deep and old. Since the enactment of the first modern patent law in Venice in 1447, there has been a heated debate over the moral and philosophical foundation of patents and other forms of intellectual property such as copyright, trademarks and trade secrets.

As explained by the Stanford Encyclopedia of Philosophy “patent protection is the strongest form of intellectual property protection, in that a twenty-year exclusive monopoly is granted to the owner over any expression or implementation of the protected work.”

The idea of monopoly over ideas was endorsed by philosophers like John Locke (1632 – 1704) and G.W.F. Hegel (1770 – 1831).

The English theorist claims that individuals are entitled to control the fruits of their labor (including their intellectual labor).

The German thinker has rather a personality-based justification as he argues “that individuals have moral claims to their own talents, feelings, character traits, and experiences.”

Another philosophical justification for intellectual property is to be sought in utilitarianism. The utilitarian point of view was explained in the Virginia law review, by Jeanne C. Fromer Associate Professor at Fordham Law School. “Copyright and patent laws are premised on providing creators with just enough incentive to create artistic, scientific, and technological works of value to society at large by preventing certain would-be copiers‘ free-riding behavior,” she wrote.

Do these arguments hold up when the patented intangible work is the formula of a saving-life drug?

Dr. Yusuf Hamied’s answer would be no. When Harvard Business School (HBS) interviewed the founder of the Indian pharmaceutical company Cipla in 2013, he said:

There should be no monopoly… [we are] willing to pay the originator [of drugs] a suitable compensation and India should not be deprived of newer drugs and be at the mercy of the innovators.”

If the HBS featured Dr. Hamied for its Creating Emerging Markets Project, it is because of the man’s exceptional battle against the human immunodeficiency viruses (HIV) that causes acquired immunodeficiency syndrome (AIDS).

Back in 2001, Cipla mixed three molecules– Nevirapine, Didanosine and Zidovudine and came up with a new anti-HIV drug. Dr. Hamied then gave his antiretroviral therapy (ART) to humanitarian organizations and poor Asian and African governments for $350 a year.

That price was thirty times lower than market prices. Suddenly, big multinational pharmaceutical groups were left with their useless patents and with financial shortfalls of billions of dollars. Full of wrath at seeing their monopolies collapse, western multinationals had to lower their AIDS treatment prices by 80%.

While western business groups and media accused Dr. Hamied of piracy, the United Nations organizations described him as India’s Robin Hood of drugs.

When Dr. Hamied gave that interview, the world was still dazed by the 2009 swine flu pandemic and its estimated death toll of 284,000 victims. So, he intuitively evoked the example of the Oseltamivir; the antiviral drug used to prevent and treat swine flu, other subtypes of influenza A and influenza B.

The patent on the Oseltamivir in the US was then held by the Swiss multinational Roche. An epidemic before the patent’s expiry date (2016) would have meant, according to Dr. Hamied, that the destiny of the world would have been in the hands of one company.

In a concluding remark that encapsulated his business philosophy, the Indian scientist said:  “I am a firm believer that if you are in the health care business like supplies, it is not a business per se; it is a business plus you are saving lives. So it has to have a humanitarian angle to it.”

Santé: la bataille autour de la transparence sur le prix des médicaments

“Can we sell more olive oil in Europe? Can we mention that it is a product coming from Tunisia? Would it be possible to postpone the next negotiation meeting? What guarantees do we have that our business owners and investors will be allowed on the European territory?” 

These few questions may seem simplistic, and obviously caricatural… but they eventually sum up, in a nutshell, the Tunisian negotiators discourse. 

Swapping dates, oranges and olive oil for Euros, but what is the counterpart? Where will the thousand tons of wheat consumed by Tunisian households in the form of subsidized baguettes and flour come from? What should the agricultural sector serve for? feed the local population or increase the foreign currency reserves? Should the right to healthcare take precedence over the intellectual property rights and the profits they generate for pharmaceutical companies?
These fundamental questions do not seem to be part of the Tunisian negotiators’ preoccupations. Is this an exaggerated statement? Perhaps. 

At the risk of recalling the obvious, the European Union is Tunisia’s first trade partner. But the EU is by no means a charity organization. It is an economic and political entity, one of the most powerful in the world, which position is being threatened by the USA and China. 

It is both predictable and legitimate that the EU defends its economic interests and its sphere of political influence in the region. And it should be the same for Tunisia. Interests of these actors can converge… but they can diverge as well.

It is not a question of discussing the modalities and extent of deeper free trade with the EU, but of assessing the balance of power and the impact of each article, each paragraph of this agreement on the lives of citizens, but also of the Tunisian State. As Ignacio Garcio Bercero, chief negotiator of the EU, states, Tunisia represents only 0.5% of the European market, while the European market represents more than 70% of Tunisian exports.

Why taking as much interest in Tunisia, then? Why didn’t the negotiation take place at a the Maghreb scale in order to reduce the lack of proportion between the negotiating parties? Indeed, Tunisia is in a relationship of economic and political dependence on the EU. Would Tunisia be able to re-balance or even… better negotiate its dependence? 

The EU and Tunisia are bound by an association agreement since 1995. What conclusion can we draw from it? The evaluation on Tunisia’s part is dragging. The terms of reference used to choose a consulting cabinet were published in January 2017. Selected at the end of 2018, it is barely starting its work just as this article is being written. Our requests to access information about the final interim reports remain unanswered. 

In this series of article about DCFTA, we will first address the ongoing negotiations, happening in the dark. They are the fruit of an investigation led by Fadil Aliriza after a conference by the Tunisian Forum on Economic and Social Rights (FTDES) held in October 2018.

Thereafter, we will concentrate on the topics of food security and sovereignty. The third article will focus on the fragile balance between the right to life and health and the right to intellectual property, a balance which might be challenged by the DCFTA. 

Our demands since October 2018 to meet the Tunisian chief negotiator, Hichem Ben Ahmed, currently Minister of Transport remained fruitless. His European counterpart, Ignacio Garcio Bercero, chose to answer our questions by email. 

Finally, the critical perspective is raised to us by Maha Ben Gadha, head of the economic programs at the Rosa Luxemburg Foundation – North Africa. Beyond these articles, our media, Barr al Aman, will produce meetings and Facebook lives to assess these embryonic public policies.  

Let us imagine a private, parallel and transnational justice to defend the interests of investors considered “not enough protected” by Tunisian laws. Let us imagine medicines whose production and marketing were prohibited because of extensions in protection periods, additional to those originally planned by the patent. 

Let us imagine calibrated, certified, imported and European-norm-compliant potatoes in our supermarkets. Let us imagine an adaptation of our job market to European expectations…

The Deep Comprehensive Free Trade Agreement (DCFTA) proposed to Tunisia by the EU certainly has an advantage: it questions us about who we are, and what we want to be.

Translated by An Hoang-Xuan