An earlier version of this piece first appeared at Latin America Goes Global.
By bringing together the 12 South American countries, the Union of South American Nations (UNASUR) is advancing an effective rights agenda in access to medicines and attention to developing country demands.
In an open letter to the heads of government of all Trans-Pacific Partnership Agreement (TPP) negotiating countries, Médecins Sans Frontières / Doctors Without Borders, expressed serious concerns over provisions under TTP and bilateral trade negotiation that threaten to restrict access to affordable medicines for millions of people in low- and middle-income countries, and hence their right to health as expressed by the UN Committee on Economic, Social and Cultural Rights in numerous international declarations. This is the case for instance of the EU-Andean Trade Agreement on Access to Medicines in countries such as Peru and Colombia. It is estimated that the introduction of the measures on patent protection would lead to an increase of 459 million USD in Peru’s total pharmaceutical expenditure by 2025; and of 756 million USD in Colombia’s total pharmaceutical expenditure, leading to a significant decrease in consumption of life saving medicines.
Facing this scenario it is not surprising that attention to access to medicines as an issue of rights is increasing. In 2014, a joint commission from the medical journal The Lancet and the University of Oslo published policy report in which it cited the imbalance of political power between nations as a major cause of health care inequality across the world. According to the report, disparities in health are not just linked to poverty but also to the unequal distribution of material and knowledge resources across nations and the capacity to influence global governance.
While there have been tremendous global advances in expanding civil liberties—through international laws and practice—much of the normative infrastructure and policy to support rights was crafted and is still shaped by the interests of the developed north. Even in the morality of rights—civil, political, social, and economic—power rules.
International frameworks pushing for universal human rights in relation to social and economic development are still filtered through institutions such as the UN, the Bretton Woods institutions (the International Monetary Fund and the World Bank) and northern donor organizations. These are conservative institutions that have been slow to embrace broader economic and social rights, including health.
Today, though, in the new rash of regional organizations, can the Global South reset the norms and rework global (health) governance in support of rights and social justice goals?
While the Global South has struggled to advance broader economic and social rights in the development agenda, the Union of South American Nations (UNASUR) has focused on a significant concern for its regional members: the right to health.
Access to medicines and the right to health
In the area of health, developing countries have historically been disadvantaged in the access to medicines and influence in setting the global health agenda—a result of they weaker status relative to business and the developed north. Developing countries’ access to medicines has been hampered by trade negotiations that reinforce existing intellectual property standing and international institutions and laws governing intellectual property rights that favor business over patients in the developing world.
In South America, the high cost of medicine and the lack of alternatives to existing drugs is particularly acute. Medicines not only define who lives and who dies but also why (and how) countries in the south. According to the Secretary General of UNASUR, Ernesto Samper, almost 30 percent of the total public and private health care in South America is spent on medicine. UNASUR picked up this challenge, creating the UNASUR Health Council—one of the first councils created by the new regional group—and forming an alliance with the regional health think tank, the South American Institute of Health Governance (Instituto Sudamericano de Gobierno en Salud, ISAGS), in Rio de Janeiro, Brazil.
The new alliance is in a far strong position to pursue South America’s agenda in medicine than the traditional Washington, DC-based Pan-American Health Organization (PAHO) UNASUR/ISAGS is in a better position to deliver effective health governance than PAHO, which is focused on “health coverage” instead of UNASUR/ISAGS’ more ambitious agenda of “universal access to health.” These two approaches represent different ways of addressing how health care reaches societies, and ultimately speak of different conceptions of entitlement and equality. ISAGS focus has been on the broader idea of strengthening health governance capacity, advocating the right to health and supporting policymaking and policy reforms towards the universalization of health care. In this capacity it has trained policy-makers and practitioners by setting up UNASUR-sponsored public health schools in Bolivia, Guyana, Peru and Uruguay, and assisted in the creation of a UNASUR network of public health schools.
ISAGS has also provided support directly to ministries of health in Guyana and Paraguay on primary care and the preparation of clinical protocols, and has supported reforms aimed to move towards universalization of health sector provision in Bolivia, Colombia and Peru. ISAGS is involved in the diffusion of information on combating HIV/AIDS, influenza and dengue fever across the region, and has developed mapping techniques to coordinate shared policies for the production of some key medicines.
Policy advances of this sort—concrete, modest, focused and cheap to deliver taken in a relatively short timeframe and below the radar of political commentary—are unusual in previous efforts in at regionalism in South America. And they stand as evidence of UNASUR’s focused, grounded approach.
ISAGS has begun to scale up its level of activity on behalf of UNASUR, once again with relatively little attendant publicity. ISAGS has been quietly targeting global health governance forums and is trying to establish a joint bargaining position for South American negotiators vis-à-vis pharmaceutical companies and in the World Health Organization (WHO). ISAGS now holds meetings prior to each annual gathering of the WHO, so that UNASUR member states coordinate their actions at the WHO. It’s an approach that both UNASUR and ISAGS are now using to speak out more widely on behalf of other developing countries.
Reclaiming sovereignty, rebuilding diplomacy
As part of this campaign, UNASUR has also begun to take action on access to medicines. The strategy centers on coordinating active resistance to the dominance of pharmaceutical companies under a motto that links regional health diplomacy with sovereignty.
For instance, UNASUR is setting up a “Medicine Price Bank”, a computerized database revealing the prices paid by UNASUR countries for drug purchases. By making the information public and comparative, UNASUR is seeking to provide policymakers and health authorities information to strengthen the position of member states in purchases of medicines vis-à-vis pharmaceutical companies. Likewise, UNASUR’s Health Council has approved a project for the mapping regional pharmaceutical capacities in 2012, to coordinate common policies among member states for production of medicines.
Within the WHO, UNASUR has pressed to change international norms regarding the combat of counterfeit medical products. Until recently that effort was spearheaded by the International Medical Products Anti-Counterfeiting Taskforce (IMPACT), an agency led by big pharma and the International Criminal Police Organization (Interpol) and funded by developed countries engaged in intellectual property rights enforcement.
At the 63rd World Health Assembly in 2010, UNASUR successfully proposed that an intergovernmental group replaced IMPACT to act on, and prevent, counterfeiting of medical products. This resolution was approved at the 65th World Health Assembly in May 2012. In the course of the meeting, UNASUR also lobbied for opening negotiations for a binding agreement on financial support and research to meet the pharmaceutical needs of developing countries, and issue that was resumed at the 67th WHO meeting last May.
More recently, a key policy has been agreed in support of the establishment of a fund to negotiate centralized purchases of the Hepatitis C virus treatments. This proposal, agreed by UNASUR Health Council in July 2015, will represent a milestone in the region in savings through price negotiation on an innovative and expensive medicine. It could also create incentives for the industry as centralized purchases could be a more conciliatory route towards medicine price reduction rather than the practice of compulsory licenses and direct government price cuts in the region.
The presence of UNASUR in this type of health diplomacy, and its coordinated efforts to redefine rules of participation and representation in the governing of global health, demonstrate that there is a new logic and momentum in regional integration and regional policy-making in Latin America. These actions create new spaces for policy coordination and collective action. In the all-important case of health rights, UNASUR—and other regional institutions too—can become an opportunity for practitioners, academics and policy makers to collaborate and network in support of better access to healthcare, medicines and policy-making.
Author’s note: This article draws on a combination of documentary analysis and interview data. Some of the research was carried out in the context of the research project ‘Poverty Reduction and Regional Integration: SADC and UNASUR Health Policies (PRARI)’, supported by the Economic and Social Research Council (ESRC), grant ref. ES/L005336/1. The article does not necessarily reflect the opinions of the ESRC. For information on the project: http://www.open.ac.uk/socialsciences/prari/