AN UNJUST ADJUSTMENT AN ANALYSIS OF THE WORLD BANK S REPORT by Ligia Giovanella & Felix Rígoli

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1 Rio de Janeiro, December No 13 AN UNJUST ADJUSTMENT AN ANALYSIS OF THE WORLD BANK S REPORT by Ligia Giovanella & Felix Rígoli The Shaddow of Monopolies in the Pharmaceutical Industry Carina Vance: Looking back at 2017 South America in the Global South-South Cooperation Expo

2 INSTITUCIONAL INSTITUTIONAL ISAGS-UNASUR Executive Director: Carina Vance Head of Administration and Human Resources: Gabriela Jaramillo Coordinator of International Relations: Luana Bermudez INFORMATION AND COMMUNICATION MANAGEMENT Coordinator: Flávia Bueno Editor-in-Chief: Manoel Giffoni Report: Carina Vance, Caroline Ignácio, Félix Rígoli, Flávia Bueno, Ligia Giovanella, Manoel Giffoni, Mario Camelo Colaboration: Ángela Acosta y Gabriela Jaramillo Team: Carlos de Lima Contact: comunica@isags-unasur.org Phone: This is the report from the South American Institute of Government in Health (ISAGS), the think tank on health of the Union of South American Nations (UNASUR) that aims to contribute to improving South America government quality in health by means of leadership training, knowledge management and technical support to health systems.

3 WORLD BANK: FISCAL ADJUSTMENTS AND EXPERIENCIAS Y DESAFÍOS DE BRASIL Y COLOMBIA HEALTH BUDGET CUTS The World Bank has released a summary of a report on the analysis of efficiency and equity of public expenditure in Brazil 1. This country has recently passed an amendment that constitutes a policy option aimed at economic adjustment in relation to health spending. However, it is relevant for health stakeholders in UNASUR countries to analyze the present report in a broader context, because global institutions such as the World Bank can have a decisive influence on supporting austerity policies in other countries in the region. Although the document is presented in technicalscientific veil, the nature of the report is mainly political, as it attempts to turn the World Bank s ideological assertions into scientific truths, in fact making its case for the reforms of austerity2. It proposes a conception of inverted citizenship, in which individuals only engage with the State at the moment when their rights fail and are effectively recognized as non-citizens3. At the same time, although the title proposes an analysis of efficiency and equity, the recommendations are explicitly devoted to studying public spending in the social sectors, with little attention to other items in the economy. The purpose of the report is to recommend cuts in public spending, especially social expenditures, the so-called primary expenditures. On the other hand, it makes rather tepid recommendations for reducing other expenditures such as debt servicing. It is noteworthy that high interest expenditures are by far the highest public expenditure, and the item in which Brazil has rates far above all comparable countries (see chart). Debt service expenditure in 2014 as a percentage of GDP in several countries Brazil Counterparts Average Brazil Sudáfrica Turquía Colombia Indonesia Brasil Colombia Perú Chile Brasil Portugal Italia Islandia Hungría Irlanda Grecia Israel Estados Unidos España Bélgica Canadá Reino Unido Áustria Japón Australia Francia Eslovaquia Alemania Dinamarca Corea Nueva Zelanda Finlandia Checa Suecia Suiza Noruega Chile Brasil Sudáfrica Rusia Structural counterparts Regional counterparts OECD BRICS Source: Report, p.36 3

4 The report states that the Brazilian government spends too much and spends badly, but is it true? Public health expenditures in Brazil are low, as a share of GDP, corresponding to less than 4%. On average, in OECD countries (a group of countries Brazil has requested to join), public spending on health is on average about 7% of GDP. Per capita public expenditures in Brazil are estimated at US $ 549, with comparable purchasing power (OECD, data for 2013), rather low compared to OECD countries, Cover of the report A Fair Adjustment, released by the World Bank in 2017 equivalent to 32% of public expenditures per capita in Portugal (USD $ 1717) or 26% of Spain s expenditure (USD $ 2090) or 13% of Germany s public health expenditure (USD $ 4157). From an international comparison point of view regarding public expenditures on health, it cannot be concluded that there is room to cut costs. On the contrary, public expenditures on health in Brazil should be increased and even doubled. This would allow the country to reach the average levels of the other OECD countries and meet the 6% of GDP proposed by the Americas Sustainable Health Agenda (ASSA) , as approved by the countries of the Americas including Brazil, at the most recent Pan-American Sanitary Conference in September The same World Bank report provides indications of where such resources could be obtained: 30 billion Brazilian reais (approximately US $ 10 billion) in subsidies to the private health sector. A footnote comments that the results are influenced by private health providers who spend large amounts of resources on a small part of the population (p.11). The report admits that public health expenditures are progressive (they improve equity) - although tax expenditures are highly regressive. The report uses the euphemism tax expenditures for the set of tax breaks for the pharmaceutical industry, private hospitals and insurance companies. A positive point to consider is the recommendation to abolish tax subsidies for private insurance and private health expenditure, provided that these resources are transferred to the Brazilian Unified Health System (SUS) to improve its offer. In relation to health expenditure, the report points to several aspects that show the SUS as a policy that has been evaluated as efficient and of a significant redistributive effect. For example, primary care in Brazil is very well evaluated in dozens of international articles. The report itself shows that there is significant efficiency in the family health program and that it should be extended to 100% of the population. However strong those arguments may be, the recommendation is to cut spending in the public sector by 34% using inefficiency estimates transformed into categorical assertions. The core of the report focuses on the productive efficiency of the health system, making countless calculations (which have been technically questioned by officials from the Brazilian Ministry of Health, in the Technical Note 266/2017, released in June by the Department of Health Economics, Investments and Development). It doesn t consider, for instance, the socalled distributive efficiency, that is, how these resources are distributed in terms of access and equity. The pretension of improving productive efficiency (fewer resources for more products) by keeping current subsidies to the private system would only lead to a less accessible and more unfair system. The main aim in a public health system such as the SUS, is not primarily to guarantee maximum efficiency, but to ensure the right to health and access to services as needed. The study s concern should focus on identifying access gaps and unattended demands. Efficiency is an important, albeit secondary objective, subordinated to the guarantee of access. In this sense, considering that the vast majority of Brazilian municipalities are small (68% of Brazilian municipalities have less than twenty thousand inhabitants and 1200 municipalities have less than five thousand), it is necessary to have accessible services that guarantee timely access, even with loss of economy of scale. Ensuring access to dispersed populations may always carry some loss of efficiency. Certainly, the best use of public resources, an optimal allocation of public resources to achieve more and better products, is one of the objectives of all public health policies. However, by transforming efficiency into the main objective, all perspectives of the guarantee of the right to health are lost. Although the report states that it aimed at increasing efficiency and equity, when it comes to making proposals, the detail and emphasis are on cutting costs, focusing solely on social programs. The corporate subsidies and the financial costs of the government (600 billion Brazilian reais, or approximately 200 billion US dollars) could also be reduced, but this path of action, in the opinion of the authors is not realistic, since the interest groups that currently benefit from the support of these programs are powerful (p.147). In other words, it is not advisable to reduce the benefits of the powerful, therefore it seems more convenient to slash the benefits of the weakest and most disenfranchised. References 1 - Banco Mundial. Um Ajuste Justo: Análise da eficiência e da equidade do gasto público no Brasil. Grupo Banco Mundial; Disponible en: en/ /pdf/ revised-portuguese-brazil-public-expenditure- Review-Overview-Portuguese-Final-revised.pdf Acceso en 7/12/ Cardoso Jr JC. Nem ajuste, nem justo: réplica rápida às estórias que os economistas contam. Plataforma da Política Social. dezembro 3, disponível em: com.br/nem-ajuste-nem-justo-replica-rapida-as-estorias-que-os-economistas-contam/ 3 - Fleury SM. Política social e democracia: reflexões sobre o legado da seguridade social. Cadernos de Saúde Pública, 1985; 1(4), Braga Neto FC, Barbosa PR, Santos IS, Oliveira CMF. Atenção hospitalar: evolução histórica e tendências. In: Políticas e Sistemas de Saúde no Brasil, editado por L. Giovanella, S. Escorel, L. V. C. Lobato, J. C. de Noronha e A. I. de Carvalho, Rio de Janeiro: Editora Fiocruz; Félix Rigoli felixrigoli@isags-unasur.org Ligia Giovanella giovanel@ensp.fiocruz.br 4

5 EXPERTS CORNER Community participation in health in South America by Caroline Ferraz Ignacio, ISAGS Intern on Social Determination of Health The importance of community participation, or related concepts such as social participation, popular participation and community involvement, is often stated in health and development policies. Specifically, UNASUR member countries have recognized the need for community participation in health and have committed to enabling participation through institutionalized mechanisms supported by national legal frameworks. The Alma Ata Declaration catalyzed this trend by declaring that the people have the right and duty to participate individually and collectively in the planning and implementation of their health care 1. Since health is intimately involved with mode of life and social determination processes, the people who utilize health services can direct those services to better attend local needs. However, there is no clear consensus on what constitutes community participation and how it should be implemented. The multitude of interpretations has led to a wide variety of approaches which reflect the concept of community participation held by stakeholders, especially governments, health industry representatives, nongovernmental organizations (NGOs) and/or other donors. Institutionalized mechanisms of community participation can result from community pressure; yet, institutionalization requires approval from stakeholders in formal positions of power. As such, participatory processes inherently generate conflict and participatory spaces must permit the multitude of actors to identify and mediate the conflicts between community and institutional interests. Although each country and community has its own specificities, formalized spaces of community participation in health should target improved health and equity. By enabling collaborations between health care providers, government officials (not only from the health sector but other sectors as well), civil society organizations, and NGOs acting in the territory, these multiple actors can develop locally appropriate strategies to reach this goal. When residents are encouraged to identify problems in their communities and develop solutions, participation is seen as an empowerment tool. Yet, what constitutes empowerment is relative, as is the level of the communities involvement in solving their priorities necessary to be considered community-led. When community members are persuaded to collaborate with a pre-defined activity in order to supplement available human or financial resources, the opportunities for managing conflicts or redistributing power between stakeholders are limited. Additionally, the mere presence of community representatives at the table when decisions are made does not equate to empowering participation. For example, if community members are present at the discussions, but excessively technical language is used to limit dialogue and impose a hierarchy of power, participation is effectively thwarted. In South America, examples of community participation are multiple and varied. They include improved transparency for information sharing, recruitment of local residents to perform surveillance of disease and risk factors, vector control through community cleaning taskforces, and the inclusion of volunteers at health centers. Other examples in the region encourage groups to identify problems in their own communities and develop solutions with the support of primary health care teams. Despite the variety, the most commonly used mechanism of community participation are health councils at the local or national level, composed of representatives of the State, civil society and NGOs. Councils generally identify priorities, guide the development of policy and monitor its implementation. However, some councils function as informal or formal advisory boards without decisionmaking power; whereas, others are formal bodies whose decisions are binding. Mechanisms of participation can be designed to support the ability of civil society to control planning and management processes. Permanent education for all council members can be utilized where both popular knowledge and technical knowledge are shared between civil society and other stakeholders. Also, commitments to create institutionalized processes that go beyond information-sharing and collaboration are needed where binding participatory processes are still limited. Furthermore, institutions must commit to upholding the decisions made in these spaces with transparency to validate participatory processes within the parameter of public policy and health regulations. Finally, it is necessary to reflect on the underlying purpose of community participation in health: promoting health and equity. As the last issue of Health to the South demonstrated, South America exhibits persistent inequality, despite reductions in poverty, because these inequalities stem from inequitable distributions of power. Mechanisms of community participation aim to redistribute the power involved in decision-making. Therefore, although there is no one-size-fits-all approach to implementing mechanisms of community participation in health, efforts should focus on enabling civil society to exert more power over the processes affecting them. To support community participation in health in South America, ISAGS will be performing an in-depth study regarding mechanisms of community participation in UNASUR member countries in WHO. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma- Ata, USSR, 6-12 September Alma-Ata: World Health Organization, Available from: 5

6 THE SHADOW OF MONOPOLIES IN THE PHARMACEUTICAL INDUSTRY How anti-competitive practices ensure exorbitant profits while limiting the ability of Health Systems to save lives In the annals of liberal economic theories, competition stands out as a fundamental aspect to the functioning of capitalism. In its perfect version, the market would be made up of multiple consumers and multiple producers (aggregate demand and aggregate supply, respectively), whose interaction would even be responsible for setting prices, as well as permanently stimulating innovation. However, there are sectors in the industry, in particular the pharmaceutical industry, that seem to have no trouble with contradiction: while they repeat ad nauseam the mantra in favor of a firm respect for intellectual property rights in order to encourage innovation, they conveniently do not give the same importance to free competition. On the contrary, they make use of a legal paraphernalia to maintain monopolies in the production of medicines at the expense of the welfare of millions of people and the sustainability of health systems. Surprisingly, however, antitrust policies in the pharmaceutical sector are not as used as one would expect in order to expand access to medicines. In fact, most countries have entire legislations on the subject and often have specialized State bodies. There are also provisions related to the subject in the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) within the scope of the World Trade Organization (WTO). This strategy appeared in a recommendation made by the High-Level Panel on Access to Medicines, convened by the former Secretary General of the United Nations. In order to deepen the knowledge on the subject, share the initiatives that are being carried out in UNASUR countries, and foster intersectoral work, ISAGS along with the United Nations Development Program (UNDP) and the Oswaldo Cruz Foundation (Fiocruz), invited representatives of the Ministries of Health and departments of government procurement, intellectual property and competition defense to a 3-day meeting in Rio de Janeiro, Brazil. WHY IS IT SO IMPORTANT? Besides country representatives, the meeting also featured the participation of international experts, UNDP consultants and members of civil society, who presented relevant information on the subject of competition. Ruth Lopert, an independent consultant for UNDP, for instance, explained how the real world of the pharmaceutical market stands completely apart from what liberal theorists state. First, the demand side is extremely inelastic; that is, consumers who require some medication are often willing to buy them at any price (or pressure their governments to acquire it, even by judicial measures). On the other hand, it is a market not necessarily recognized for its transparency, especially in relation to price setting. Lopert showed that Australia pays up to 30 times more for the same medicine compared to New Zealand, a much smaller country, which completely rules out possible explanations related to scale. In the realm of intellectual property, having a patent, as well as the power to determine prices in a nontransparent manner, basically means the industry has a de facto monopoly. Not to mention that there are various attempts to prolong them over time ensuring substantial profits. This strategy is also known as evergreening. The methods range from excessive patenting (patent applications for the same product with small variations in the formulation and/or the dosage, for example) and sham litigation (the act of using the Judicial Power to file lawsuits without the perspective of success, but rather to halt competition), to abusive price setting, among others. The impact, in turn, is very similar both in the countries of the South and in developed countries: health systems either become unable to offer the best treatments or are fragilized if they so. Worse yet, citizens eventually face catastrophic expenses. 6

7 World Health Organization estimates (2010) show that 100 million people around the world fell below poverty line due to out-of-pocket expenditure in health. SITUATION IN OUR REGION During the meeting, basically every country had a story to tell concerning the anticompetitive behavior of the pharmaceutical industry. They also shared important achievements in terms of price regulation, procurement mechanisms, patent evaluation, and defense of competition. Even smaller countries are not spared. The representative of Suriname, the Alternate Coordinator of the Universal Access to Medicines Group of UNASUR (GAUMU) Miriam Naarendorp, reported on the case of a company that publicly declared applying fair pricing strategies and that it had updated its commitment to offer human insulin products at a lower price to less developed countries. In the specific case of Suriname, however, the company introduced a new dosage form (penfill) and, right after, almost doubled its price compared to the old version (from US $ 0.89 / ml to US $ 1, 57). To top it all off, research conducted in the Caribbean Community (CARICOM) revealed that the country pays more for the same insulin dose than countries with higher GDPs. On the other hand, several countries expressed concern with so-called evergreening, which retains the limited legal and financial resources of governments for several years. Additionally, in cases of sham litigation, it is not clear how the health systems are supposed to be compensated for the periods during which they had to pay abusive prices due to a monopoly situation. When presenting a study regarding a patent application filed by Gilead for Tenofovir (TDF 300 mg), the Fiocruz specialist Gabriela Chaves revealed that had the country purchased the generic version for the 5 years it took for it to be finally rejected, the System of Health of Brazil would have saved USD $ 200 million. One of the strategies mentioned in the High- Level Panel s report to overcome problems of anticompetitive behavior is to increase transparency. Governments should require manufacturers and distributors to disclose to drug regulatory and procurement authorities, information pertaining to the of R&D, production, marketing and distribution says the document, which also recommends the establishment of price banks for patented, generic and biosimilar drugs in the countries where they are registered. PRICE BANK OF UNASUR The South American bloc has a regional database on the price of essential drugs since 2016, with a total of 34 drugs and vaccines identified as responsible for high pharmaceutical expenses. In this regard, Gabriela Chaves, believes that these sources should include more data, for example, regarding the status of the patent situation (pending, confirmed, rejected) and with the expiration dates of the patents. This tool would provide a baseline to countries that, individually, hardly have access to this type of information. Another recommendation refers to raising thresholds for patent applications. Carlos Correa reviewed several cases of excessive patenting. He was member of the Panel s Expert Advisory Group and also took part in the preparation of Argentina s Patentability Guidelines, one of the most advanced in the world. On the other hand, the importance of intersectoral work among different levels of government was emphasized, as emulated in practical activities carried out during the meeting among the Ministries of Health, the entities responsible for public procurement, the instances in charge of intellectual property and competition defense agencies. In this sense, the meeting left a positive impression on the participants. Having spent these three days, with the quality of the people representing their countries here, with the commitment and passion they have, with the potential they have to articulate and find a way to work together and establish effective mechanisms, I am very optimistic, concluded the executive director of ISAGS, Carina Vance. GENERIC COMPETITION: MAKING AVRS AFFORDABLE Prices of first line antiretrovirals $ 10, lowest brand-name (originator) price generic competitor price Brazil $ June 2000 $ 727 $ 621 Hetero $ 295 Hetero $ 281 Sept 01 Aurobindo $ 159 June Dec June Dec April Jan June Source: Medicins Sans Frontieres [MSF]. Untangling the Web of Antiretroviral Price Reductions [UTW], 14 th edition, July $ 555 $ 549 Cipla $132 June 06 July 07 $ 331 $ 331 $ 331 Hetero $ 87 Cipla $80 Aurobindo, Matrix Cipla $ 67 July August June Manoel Giffoni manoelgiffoni@isags-unasur.org 7

8 END THE EPIDEMICS In 2016, WHO launched the Global Health Sector Strategy on HIV, , which establishes who the health sector will contribute towards this accomplishment, in accordance with Target 3.3 of the 2030 Agenda. The world targets are, among others: to reduce the number of HIV-related deaths worldwide by 50% to reduce new infections among infants to zero. to repeal all discriminatory laws, regulations and policies related to HIV and eliminate discrimination related to this infection in all environments; ensure that 90% of people infected with HIV are aware of their HIV status; that 90% of people diagnosed receive antiretroviral treatment and that 90% of infected people undergoing treatment reduce viral concentrations to very low levels (also known as the Strategy). AIDS SALUD SUR The World AIDS Day is celebrated every December 1 st. The 2017 slogan is Everybody counts, calling attention to the need for universal access to health services as well as safe, effective, quality and accessible medicines and other health products. AIDS IN THE WORLD 1 In 2016, there were 36.7 million people living with HIV, 2.1 million were children less than 15 years old and 1 million died from AIDS-related diseases. However, in comparison to 2005, this number dropped by 48%. 1/3 of all deaths are still caused by tuberculosis. Since 2010, there was a reduction of 11% in new infections among adults and, among children, the reduction was 47%.

9 TO COUNTRIES Based on the global targets, each country should establish national objectives and goals for 2020, taking into consideration the national contexts, the nature and dynamics of the HIV epidemics and their health systems. AIDS IN SOUTH AMERICA 3 In 2016, almost 3000 cases of mother-to-child transmission were avoided. 98% of this kind of infection can be avoided with timely and appropriate treatment. The first country in the world to guarantee universal public access to HIV treatment is in our region: BRAZIL 4 Nowadays, there are approximately 1 million 420 thousand people living with HIV in South America, with an average of 48% receiving treatment. In 1996, law n /1996 was passed, establishing universal access to HIV treatment in the country. This was reinforced in 1999, with decision to start the local production of generic antiretrovirals. Furthermore, in 2007, the country issued the first compulsory license in the region, for the medicine efavirenz, one of the main first line drugs for HIV treatment. Until the end of 2017, it is estimated that 541 thousand people will be in treatment with antiretrovirals in the Unified Health System (SUS), with an investment of around 300 million dollars. In the last 10 years, the country achieved a decrease of 34.5% in the infection of children under Between 2006 and 2016, there was a 175%-increase in the number of new infections among the age group between 15 and 19 years old and of 111% in the age group between 20 and 24 years old. This population will be targeted by campaigns and future strategies of the Ministry of Health of the country. PREVALENCE OF HIV IN ADULTS (2016) Bolivia, Ecuador, Peru - 0,3 Argentina, Colombia - 0,4 Chile, Paraguay - 0,5 Brazil, Uruguay, Venezuela - 0,6 Suriname - 1,4 Guyana - 1,6 In addition, from this month on, the vulnerable population to the HIV infection will have access to PrEP - Pre-Exposure Prophylaxis to HIV. References 1 UNAIDS, Fact sheet - Latest statistics on the status of the AIDS epidemic. Disponible en < Acceso en OMS, Estrategia Mundial del Sector de la Salud contra el VIH, Disponible en < apps.who.int/iris/bitstream/10665/250574/1/who-hiv spa.pdf?ua=1 > Acceso en UNAIDS, AIDS INFO. Disponible en < Acceso en MINISTERIO DE SALUD DE BRASIL. PANORAMA 2016: Ampliação de diagnóstico e tratamento reduz casos e mortes por aids no país. Disponible en < dezembro/01/dia-mundial-de-combate-a-aids.pdf> Acceso en

10 SOUTH-SOUTH COOPERATION IN HEALTH: an important tool towards the SDGs It does not matter whether the country is developed or not, nor its size, all nations can cooperate. This was the statement of Ambassador Galo Yépez, representing the Ministry of Foreign Affairs of Ecuador and the G-77 at the last Global South- South Development Expo (GSSD Expo 2017). The affirmation somehow translates the feeling or the idea of solidarity that the South-South modality in global cooperation tends to arouse. Despite the fact most of the countries of the South have less income than the countries of the North, and therefore cannot fund so many initiatives, there are many tools other than financial ones that have produced expressive results in various fields of development, through concerted efforts. In South America, this is already a reality in many realms, be it political, economic, and obviously, in Health. At the GSSD Expo 2017, the most important event of South- South cooperation in the world, held between November 27 and 30, in Antalya, Turkey, by UNOSSC (United Nations Office for South-South Cooperation), ISAGS shared with the participants some of these projects and successful experiences jointly achieved in the field of Health among UNASUR countries. The Institute also moderated the panel Cooperation between countries for Health Development, which featured the participation of Ambassador Yépez and representatives of various organizations such as the Pan American Health Organization (PAHO / WHO) and the United Nations Program for Development (UNDP). They debated about the main challenges and issues concerning integration and cooperation in Health. The Health sector represents one of the greatest challenges we have in South-South Cooperation, so we must be creative and focus on generating new

11 SOME PROJECTS AND COOPERATION AGREEMENTS BETWEEN SOUTH AMERICAN COUNTRIES IN 2017 Network of storage banks and provision of breast milk: In May, Ecuador and Brazil held a meeting to define guidelines for an unprecedented project in the region: an information system for breast milk donors and recipients in the countries banks. Health at the borders: In July, Paraguay and Argentina begun the elaboration of plans against vector diseases on their borders. Collaboration agreement: In July, the Ministries of Peru and Chile signed a Memorandum of Understanding that establishes a Commission to monitor and assess bilateral and border health commitments. Blood donation: In September, in an unprecedented effort of the Ministries of Health of Brazil and Colombia, a rare type of blood was transported in just one day to save the life of a 1-year-old girl. Sharing experiences: In October, the Ministries of Peru and Bolivia agreed to jointly elaborate various binational plans to broaden the exchange of experiences on issues such as the reduction of maternal mortality and the donation of organs, blood, tissues and cells. financing, evaluating processes and sharing the best experiences, said Silvia López Cabana, of the Ibero- American General Secretariat. She also presented the panel the Ibero-American Integrated Data System on South-South and Triangular Cooperation (SIDICSS), an online data platform designed and built on the joint effort of the 20 countries that make up the Secretariat. Among the main topics brought to the table were the growing difficulties in obtaining funds for traditional cooperation projects and whether the South-South modality could be a viable solution. In this scenario, sub-regional organizations acquire a very important role. It is known that countries usually have cooperation initiatives among them, but regional authorities have the potential to systematize, organize and share knowledge. In other words, they have a strategic function. In the task of unifying the geographical affinity and the affinity of issues, they can be very agile and very quickly generate the South- South Cooperation responses that are necessary, said Jorge Chediek, Argentine Director of UNOSSC. SOUTH-SOUTH COOPERATION AND THE SDGS At the opening of the expo, whose motto was South-South Cooperation in the Era of Economic, Social and Environmental Transformation: The Road to the 40th Anniversary of the Adoption of the Buenos Aires Plan of Action (BAPA + 40), Chediek also recalled that global cooperation is going to be one of the main mechanisms for achieving the goals of the 2030 Agenda, including SDG 17 - Revitalizing the Global Partnership for Sustainable Development. Its targets refer to ways in which countries can enhance their cooperation mechanisms at all levels. Achieving the 2030 Agenda for Sustainable Development and also the Paris Agreement will require the involvement of different sectors, at all levels and in all countries, the UNOSSC Director added. A pending issue in terms of this type of cooperation is the lack of robust data regarding its scale and impact. The collection and analysis of information is paramount for monitoring the 2030 Agenda as well as its accountability. It is also fundamental for sharing knowledge among countries. Without precise definitions or comparable data, UNCTAD estimates that the total value of South-South Cooperation varies between US $ 16 and US $ 19 billion (2016). The creation of capacities in data management is one of the priorities for the BAPA+40, the summit that will be held in the capital of Argentina in 2019 to commemorate the 40 years of the Buenos Aires Plan of Action. There is no doubt that South-South Cooperation and triangular cooperation, as a complement to North- South cooperation, will be vital for achieving the SDGs. In this scenario, the countries of South America have a great potential for participation concludes Chediek. Mario Camelo mariocamelo@isags-unasur.org

12 INTERVIEW: Between November 27 th and 30 th, ISAGS attended the Global South-South Development Expo (GSSD Expo 2017), the largest South-South Cooperation event in the world, for the third time. It brought together around 120 countries and organizations, 800 participants in total, in Antalya, Turkey. During the conference, we interviewed different specialists who gave their impressions on South-South Cooperation and Health issues. JORGE CHEDIEK ENVOY OF THE SECRETARY GENERAL OF THE UNITED NATIONS FOR SOUTH-SOUTH COOPERATION AND DIRECTOR OF UNOSSC What is the importance of South-South Cooperation and Cooperation in Health in the world? JC: As we are seeing in this event, South-South Cooperation has an increasing importance in the construction of the International Agenda. It is an essential movement to achieve the Sustainable Development Goals and there is really a great enthusiasm to deepen and create new channels and new mechanisms. This is not only reflected in the impressive numbers of the GSSD 2017 Expo, but also in the relationships, partnerships and common projects that have been strengthened here and will surely bear fruit. In March 2019, as decided in the last United Nations General Assembly, the BAPA+ 40 Summit will be held to celebrate the 40th anniversary of the signing of the Buenos Aires Plan of Action, a landmark document for South-South cooperation. It will be an opportunity to think through everything that has been going on since then and also to look ahead for the next steps, within the framework of the 2030 Agenda. What is the importance of the performance of regional organizations in South-South Cooperation? JC: The role of the sub-regional organizations is extremely strategic. In the task of unifying the geographical affinity and the affinity of the issues and problems, they can be very agile and very quickly generate the necessary South- South Cooperation responses. In that sense, I would like to congratulate the work of ISAGS-UNASUR, which is really doing a great job, trying to unite and promote the cooperation of our health systems in the South American continent. CARLOS ANDRÉS EMANUELE REPRESENTATIVE OF THE AREA OF COOPERATION BETWEEN COUNTRIES OF THE PAN AMERICAN HEALTH ORGANIZATION (PAHO / WHO) What are the main challenges and opportunities of Cooperation in terms of Health for the coming years? CE: One of the main challenges we have seen in the Member States is the availability of financing. There is political will, there is technical capacity in the countries, but we lack this catalyst. It makes it hard to honor commitments. There is also a great challenge in terms of the sustainability of cooperation, both traditional cooperation and South-South cooperation. It is also one of the areas of work of PAHO. In terms of opportunities, these will be based on the capacity that already exists in the countries. PAHO is working precisely to be able to capitalize on that political will to cooperate, so that this abundance of knowledge among nations is properly shared. How can different organizations articulate to achieve greater synergy in terms of South-South cooperation? CE: In terms of South-South Cooperation, there is space and work for all. Particularly with regional integration organizations, such as UNASUR, ISAGS, ORAS-CONHU, OTCA, etc. PAHO is working particularly hard this year to consolidate this regional universe, in order to gather all these actors to work jointly. We recognize the great added value of integration efforts to achieve the SDGs as well as the national, regional and universal health goals. So, in the coming months we will be concluding in South America, for example, the Sub-Regional Cooperation Strategy. We held a consultation, a couple of weeks ago, in Lima, Peru. Many regional organisms of South America were present and we will continue working on this issue. 12

13 IAN MACFARLANE REGIONAL DIRECTOR OF UNFPA Could you comment about what you have seen in the GSSD Expo so far and about the trends of South-South Cooperation? IM: First, this is obviously a very significant event. I think the South-South Cooperation itself is a very significant mechanism and movement, and it s going to get more and more important. That s because of the volumes of the resources it entails, but also because in the world we live in, issues in the South are really issues we must all pay attention to. So, there are a lot of experiences related to the adaptation to new realities that must be shared among countries with similar goals and challenges. One example: population dynamics are changing rapidly in this part of the world, as people are getting older. This is good news because it means that they are healthier and living longer, but it also has a lot of implications, for instance, in the economy. How do countries adapt to this new reality? This is one of the areas UNFPA has been working on and there is a lot that could be done in terms of cooperation. What is most challenging aspect of this type of cooperation? IM: Certainly, there is the unfinished business, much of which has been framed in the context of the Sustainable Development Agenda. However, there were some very important goals we failed to meet in the Millennium Development Goals and we should take a closer look at them. Still today, thousands of women die giving birth. I think the spirit of solidarity, which is perhaps the most distinguished characteristic of South-South Cooperation, can be an important driver in addressing this kind of issue. As a global community, we have the moral obligation to do so. I also understand this spirit is very present in the SDGs, as it focuses in those furthest behind. We will have to garner all the resources available, either in the traditional North- South cooperation, through South-South cooperation and national resources themselves. The way we are going to articulate them is an open question, but I see a lot of potential in the South-South modality. MAURICIO CYSNE DIRECTOR OF EXTERNAL RELATIONS OF UNITAID What is the importance of the GSSD Expo 2017 for South- South Cooperation? MC: The GSSD Expo 2017 is an event that brings together not only the organizations, but also all those who practice South-South cooperation, a very used instrument, yet not very discussed. It is a way in which the countries of the South, or in a triangular way, help each other in a complement to traditional cooperation. Undoubtedly, all the discussions of the event, mainly in the context of the Sustainable Development Agenda, are very relevant because we already know that there are limitations in terms of what traditional cooperation can achieve. I think that, in that sense, South-South Cooperation has great potential. Are there data or numbers that explain this importance? MC: Let me give you an example. Global cooperation in 2016 accumulated around US $ 140 billion. It is estimated that the SDGs need between US $ 400 and US $ 600 billion to be achieved. That gap will never be filled only with traditional cooperation, but with the actions of everyone, either with the contribution of resources or with the exchange of knowledge and experiences, which has a real impact for carrying out successful policies. 13

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15 SALUD SUR TO THE POINT By Carina Vance ACHIEVEMENTS AND PERSPECTIVES FROM ISAGS The vision that the South American countries had when creating the South American Institute of Government in Health was to create a space for the generation and dissemination of knowledge in health policies and support for the training of health leaders in the region. Since 2011, the contributions of ISAGS have included various publications, including 3 books that are currently of reference in the field of South American health, in addition to having developed dozens of workshops and conferences on the subject with hundreds of representatives of the Ministries of Health of the region. In ISAGS history, the year 2017 has been a landmark as the countries of UNASUR opted to strengthen its structure and incorporate four regionally recognized health specialists, who have taken the institution to a new moment. The developments of this decision have expanded our capacity to produce and address regional and global health issues with the integrality that results from shared visions from the areas of health surveillance, universal health systems and services, access to medicines and other health technologies and social determination, according to the South American Health Council s priorities. In 2017, ISAGS held workshops and specialized conferences on asymmetries in health systems in the region, disaster risk management, health surveillance of emerging and re-emerging diseases, introduction of new health technologies and the risks that these processes present, health communication and anticompetitive practices in the pharmaceutical sector as an element that limits universal access to medicines. These opportunities for exchanges between country representatives, and for getting to know the vision of international experts in the various subjects addressed, counted with the participation of more than a hundred regional health actors. This year, we have managed to publish five original technical studies on drug purchase processes in the region, medicines at risk of stock-outs and country responses to this problematic, the regional situation related to unplanned adolescent pregnancy, the mapping of intercultural health policies in the UNASUR countries and the development of regional policies and approaches related to population aging in the region. These contributions feed the efforts to better understand the advances, potentialities and challenges of the region in health matters, as well as constituting a catalog of good practices in health governance as an input for the South American integration processes. Another innovative and successful project was the development of the First Virtual Health Diplomacy Course, carried out jointly with the Oswaldo Cruz Foundation of Brazil (Fiocruz) and FLACSO Argentina. It counted with 60 participants from the Ministries of Health and Foreign Ministries of the region, and the contribution of 29 experts from various universities worldwide. As a final product, the students had hands-on experience developing proposals for regional integration projects in health that will be made available to member countries. A milestone in 2017 was the launch of the monthly magazine Health to the South. It is the first of its kind to focus on prioritized health issues of the South American region, reaching the Ministries of Health, academic bodies and social organizations related to this area. We seek to examine and share relevant issues on health, reaching the general population as a tool for empowerment on the right to health and promotion of social participation. After a brief highlight of what 2017 was for ISAGS, we can share our perspectives for next year. By unanimous decision of the 12 ministries of health of UNASUR, in 2018 we will develop a new edition of the virtual course of Government in Health, with a view to update it on a yearly basis with different approaches. Likewise, after a first year of successful regional positioning, we will continue to analyze and disseminate the most important topics in regional health through our magazine Health to the South, seeking to further expand its dissemination. Finally, we will launch our on-line monitoring platform for asymmetries in regional health systems, turning our new website into a dynamic instrument of information and analysis on how we are progressing towards the full realization of the right to health in South America. From ISAGS we will continue accompanying the processes of regional integration in health with conviction.

16 INSTITUTIONAL ISAGS DIRECTING COUNCIL APPROVES THE AOP 2018 The 2 nd Ordinary Meeting ISAGS the Directing Council was held on November 29 th and 30 th, at the Institute s headquarters. The meeting was attended by representatives of Argentina - country that presided over the meeting as the Pro Tempore Presidency of UNASUR - Brazil, Chile, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname and Venezuela. One of the Council s functions is to define and guide ISAGS actions, approving its plans and projects. It is also an opportunity for the institute to socialize its work and the results achieved during the year. Thus, each area of the Organization presented the activities developed and its main accomplishments. This year, some of the projects addressed were the research carried out by the new team of health specialists. Furthermore, ISAGS presented important networking initiatives that resulted, for example, in the South American Health Council s approval of the project to create a regional observatory on climate change and its impact on health, through the bloc s Fund of Common Initiatives (FIC). The Council emphasized the work that ISAGS has been developing, since 2011, to support the participation of countries in international forums such as the World Health Assembly as an important generator of inputs for member countries decision-making. The importance of the coverage that ISAGS has been giving to the countries participation in these forums was also highlighted. Finally, the Institute s projects and activities proposed to be included in its Annual Operating Plan (AOP) for 2018 were discussed. ISAGS proposed activities in the area of communications, a study on the epidemiological impact of environmental changes, on judicialization of health, the organization of a workshop on the advances in the strengthening of Models of Integrated Networks of Health Services, among others. They were all approved by the Directing Council and will be developed during the next year. HEALTH DIPLOMACY COURSE CONCLUDES WITH PRESENTATIONS OF FINAL PROJECTS For the first time, the representatives of the South American countries had the opportunity to participate in a course on Health Diplomacy from our region s perspective. The day before the meeting of the Directing Council, participants, tutors and other guests met at ISAGS to attend the presentation of the groups final project proposals. The day began with the keynote speech of the former Brazilian chancellor and current general director of UNITAID, Ambassador Celso Amorim. Amorim participated as chancellor in the creation of UNASUR. During his presentation, he spoke about the importance of health for cooperation and added: We live in a world of blocs. In this world, we have to think about South America. After the presentation, the groups presented their projects in person and virtually. There were more than 10 proposals, which will be developed in the FIC project format. They will be gathered in a bank of ideas for future projects of the Health Council. There were 60 participants from all 12 UNASUR member countries, who had classes with 29 high-level professors divided into 6 modules. The course was organized by ISAGS in collaboration with the UNASUR Network of International Relations Offices (REDSSUR-ORIS), Fiocruz and the International Relations area of FLACSO Argentina. PILLS ISAGS NEW STUDIES ISAGS presented the publication Situation of Essential Medicines at Risk of Supply Shortage with Emphasis on South American countries, developed by the Institute s specialist in Medicines and Health Technologies, Ángela Acosta, in collaboration with the Andean Health Organism (ORAS-CONHU). The research identifies the causes of shortages in the region and presents a list of stock-outs according to data from South American Ministries of Health; in addition to possible strategies to approach the problem. The investigation can be downloaded at: ly/desabastecimientoisags (the English version will be available soon) ISAGS will launch this study and three others, in the beginning of One on the Interculturality policies in South America, coordinated by Francisco Armada (Social Determination of Health), who also coordinated a study on Healthy Aging with Félix Rígoli (Systems and Health Services). From her area, Ángela Acosta coordinated another investigation, on the mechanisms of medicines procurement (developed jointly with the SERCOP- Ecuador). Join our platforms and social networks to follow the launch of the studies. CALL FOR PAPERS FOR THE PAN AMERICAN JOURNAL OF PUBLIC HEALTH The Pan American Journal of Public Health, a scientific publication of the Pan American Health Organization (PAHO/WHO), announces a call for a next special issue on Primary Health Care in the Americas: Forty years after Alma-Ata, which will be published in The idea of the publication is to make a revision of projects that were carried out during these 40 years, as well as perspectives for the future on the agreement signed by the member countries to protect and promote the health of all people by articulating Primary Health Care as the guiding principle of a comprehensive Health System. UN LAUNCHES AWARD TO RECOGNIZE INNOVATIVE INITIATIVES WITHIN THE FRAMEWORK OF THE SDGs The United Nations Action Campaign for the Sustainable Development Goals opened a call for an inaugural program of awards. The objective of the program is to find individuals, civil society organizations, local governments and other stakeholders from all over the world who are working on innovative initiatives in the international sustainable development movement and, consequently, towards the achievement of the SDGs. The inscriptions and suggestions go until January 15. More details at