Towards Equitable Healthcare: Insights from the Great Coherence Debate

The Great Coherence Debate, held in The Hague, was a gathering of global health experts. The speakers, including Victorine de Milliano, Dr. Joyce Brown, and Dr. Eve Nakato, discussed the importance of fair access to healthcare, advocating for systematic improvements and local drug manufacturing. They called for a paradigm shift in research and dev elopment, along with a rights-based and outward-looking approach to address health inequalities.

Equity, inclusivity, justice, accountability, and not profit-seeking will ensure fair access to health for all. This is according to Victorine de Milliano, Policy Advisor at Médicins Sans Frontières (MSF).

‘The current status quo of biopharmaceutical companies means that people in lower- and middle-income countries are automatically placed at the back of the queue when it comes to access. We must change this to a system based on equity, justice, inclusivity, and accountability—not profit-seeking,’ she said.

Milliano was speaking during the recently held Great Coherence Debate, Fair Access to Health as the Best Medicine. She was one of the three main speakers, together with Dr. Joyce Browne and Dr. Eve Nakato.

Hosted by Kido Koenig, Director of Foundation Max Van Der Stoel (FMS), the debate took place in The Hague, Netherlands with virtual global audience participation. The Vice Versa-organized event—held in partnership with KIT Royal Tropical Institute, the Netherlands Ministry of Foreign Affairs, Knowledge Centre for Global Health (KCGH), and WEMOS—was the second of its kind this year.

In her presentation, Dr. Joyce Browne, a medical practitioner and epidemiologist, emphasized the need for a systematic approach to better understand the healthcare system and ensure fair access to health for everyone. ‘We need to ask; are we doing the right thing? How can we do it better? How can we make sure it is more equitable? What can we do to make fair opportunities for everyone a reality? How can we remove the systemic barriers in place to make sure it is just, and be able to check that what we are doing works?’

Dr. Eve Nakato presented a scenario of access to medicine and pricing with a focus on Uganda. She said priority should be given to setting up manufacturing plants of drugs in lower- and middle-income countries.

‘Governments have a role to play in ensuring access to affordable health care and medication to the people. The question is not about availability per se, but the regulations concerning affordability. It is crucial to prioritize local production of medicines in Africa, especially those required to treat diseases that solely affect the continent, such as malaria. This will ensure accessibility and affordability,’ she said.

She added that incentives from governments for drug manufacturing companies and funding should be put in place first.

One of the highlights of the debate was a video segment featuring Eva Nakato, a journalist and coordinator of Vice Versa Global in Uganda. It is worth noting that she is not related to the aforementioned doctor. Nakato, with her twin sister Robinah, is living positively with HIV/AIDS. She gave an account of the challenges they and other people living with the condition faced during the COVID-19 pandemic in Uganda, particularly concerning access to antiretroviral drugs (ARVs).

Her column highlighted the heightened challenges of the supply chain in getting medicine to the communities. This is especially during challenging times as was the case during the pandemic. ‘The lockdown opened our eyes to the immense suffering people living with HIV/AIDS go through to get to health facilities to access medication. It was even worse for those living in remote areas,’ she said.

The speaker urged the Dutch government to do more to ensure access to health and medicine as outlined in its Global Health Policy Coherence Action plan, following the video column.

Calling in from Malawi, Global Health advocate at WEMOS, Amanda Banda, said the Dutch government needs to build on its already active presence in the global health space. It should lead to creating a new narrative because those are contested issues at the global level. ‘There is a need for one of the Global North governments to be bold and be the one to tip the narrative. On the one hand, we are talking about global health equity, but when it comes to talking about issues that put this into practice, everybody becomes silent,’ she said.

Adding: ‘So, will it be the Dutch Government that will take the bold step and say: We stand for equity and would like to see issues that support equitable access addressed differently? Or will they simply support what other Global North countries are saying and pushing for?’

The speakers called for the Dutch Government to support the prioritisation of coordinated research and development based on global health needs. They emphasised the significance of breaking away from relying on the voluntary goodwill of pharmaceutical companies.

Other significant issues raised included the need to put the importance of health insurance systems and coverage on the agenda. This would ensure people’s access to health care systems, drugs and diagnostics while avoiding out-of-pocket payments.

Civil society organisations and NGOs were also called upon to hold governments and pharmaceutical companies accountable. This is to ensure that public funds being used to develop lifesaving tools are not monopolised by private institutions.

‘It is important for governments to require transparency and affordability in research and development costs, technology sharing, and non-exclusive licensing as a condition for public funding. It’s unbelieve that we invest millions of euros into developing life-saving medical tools, yet many people do not have access to them. It’s unacceptable that private companies profit while millions suffer due to lack of access,’ Milliano said.

She also urged the Dutch Government to take measures to improve transparency, starting with implementing the 2019 Transparency Resolution. The WHO resolution urges member states to enhance public sharing of information on actual prices paid by governments and other buyers for health products. It also calls for greater transparency on pharmaceutical patents, clinical trial results, and other determinants of pricing along the value chain—from laboratory to patient.

In their final remarks, the speakers called for solid post-trial access plans to be considered as a fundamental right to access for those taking part. ‘We have created a system where the outcome is not based on health needs but on profit. The medicine should be made accessible and affordable to meet the needs of the people. Many of the communities that will benefit more are in places where healthcare systems are interrupted. They should be put at the front of the queue,’ Miliano said.

Supporting this, Dr. Browne said; ‘The fascinating thing about putting those who are hardest to reach first is that it will benefit everyone. This is because reaching those people requires you to understand the problem, build networks, and put the right people in place to deliver it.’

In her final statement, Browne urged the different stakeholders to acknowledge that access to medicine is part of a larger health system.

‘Covid had an impact on access to essential medicines for HIV patients. It also had an impact on maternal, newborn, and child health services, among other health services. We need to ensure that whatever we do is equitable, just, inclusive and accountable. If we start asking these four questions, we will get on the right path to creating better health systems that work for everyone,’ she said.

To wrap up the debate, Global Health Advocate at WEMOS, Brechje Oonk, said while the recently concluded Dutch elections may have left many sceptical, it is important to note that there are other ways to create a new narrative as proposed by participants.

‘This is not only done through development aid solutions. There are a lot of possibilities to work on achieving the solutions that were presented today. There is room for civil society to push for change by coming together and making the case for a more outward-looking rights-based approach,’ she said.