GKE is both a concept and its implementation. As a concept, GKE is the application to kidney transplantation of Alvin Roth’s economic model based on Lloyd Shapley’ algorithm, and for which they received the 2012 Nobel Prize in Economic Sciences. Their model addresses the difficulties inherent to “matching markets”, or markets where one has to choose and also be chosen, like loan allocation to entrepreneurs and school placement of students in the U.S. GKE’s implementation is being promoted by groups in the United States and Europe, with the aim of facilitating trans-national kidney donation. The GKE program currently being implemented between the U.S., Mexico and the Philippines aims at reducing the unmet demand of kidneys in the U.S. through the trans-nationalization of kidney exchange programs. Such kidney exchange programs facilitate donation when a donor is incompatible with a loved recipient, through a chain of donations that ultimately help each recipient get a transplant. In the U.S., this organ exchange is ultimately funded by the individuals’ health insurance, be it private, public or mixed. GKE would also be funded through US-based individuals’ health insurance, which would cover the immediate costs for the foreign, uninsured donor and recipient, and the financial incentive for insurance companies is that over the years, the costs of such transplants are cheaper than replacement therapy through dialysis.

Critics of GKE programs argue that it would offer financial and symbolic incentives that have the potential of promoting organ trafficking, that it wrongly assumes that low- or middle-income countries (LMICs) do not offer organ transplantation to those who need it, and would add barriers to the efforts that LMICs countries are already doing to improve their responses to end-stage renal failure and organ trafficking. For GKE to be implemented, it would need to be allowed to operate in at least some LMICs.  So, the capacity of GKE “to ensure that targeted donors in “underdeveloped” countries will be emotionally related, free of coercion, and fully informed of risk is not feasible when the culture is so experienced with organ sales”.

What should Global South countries do about GKE programs?

First of all, countries need to acknowledge that GKE programs have the potential of both increasing health inequities and promoting human trafficking with the purpose of organ donation. In consequence, countries should decide between prohibiting such programs to operate and allowing their operation under strict regulation. In other words, just letting GKE programs operate freely should not be an option.

Secondly, countries should understand that some issues of concern are beyond the level of influence of local authorities. For instance, there is an unmet demand of kidneys in high-income countries that incentivizes organ trade and transplant tourism, an important problem that needs solutions. Similarly, transnational organ trafficking as well as human trafficking with the purpose of organ donation are problems that need more visibility if solutions are ever going to be found. Global health governance currently lacks effective mechanisms for supranational institutions to harmonize national legislation and regulating the imbalances in counties’ wealth and regulatory power.

Finally, countries should asses the local realities affecting chronic kidney disease and human trafficking. It is necessary to analyze the countries’ needs and response to kidney transplant, organ trafficking, transplant tourism and black markets for organs, as well as the local legal, ethical and sociocultural dimensions of organ donation. In other words, the response needs to be rooted in the local situation, even if a transnational response is clearly also required.

In sum, countries in the Global South should not let GKE programs operate freely, but an effective response should be both local and transnational. The GKE programs and the global epidemic of chronic kidney disease highlight the need for global solutions that should be based on a system of global health governance that promotes health equity. The latter can only be achieved through participatory and democratic processes that involve civil society organizations, health professionals and authorities.

The theme this year was ‘Ethics and transparency in access to medicines’, a hot topic across the globe now, including in Latin America.  The agenda featured 2 main panels on the first  day: the first panel focused on transparency in the negotiation process and access to medicine information and medical supplies, the second one zoomed in on ethics and conflicts of interest in the management of medicines and medical supplies.

This was an opportunity to discuss the many barriers that hamper equitable access to medicines in these Latin American countries. One of the main barriers is related to the rising cost of high-cost medicines (such as antiretrovirals, orphan drugs and biologics, … ), a global trend as you know, which in turn jeopardizes the sustainability of health care systems. A well-documented case is that of cancer drugs. For instance, it has been reported that the median annual price of cancer drugs has increased from US$ 12,000 before 2000 to more than US$ 120,000 by 2015, much higher than the per capita gross domestic product (GDP/capita) of any Latin American country. Even more disturbing is the fact that many new cancer medications do not always offer meaningful clinical benefits or therapeutic value to patients despite their elevated cost. Additionally, in some cases (cancer) treatment drugs are costlier in LMICs than in high-income countries. Drug prices are usually set at whatever “the market” will put up with.

We think it is important for governments to do their own (internal) analysis on the transparency of the pharmaceutical sector. Regulating entities play a vital role, trying to strike a balance between the practical guidelines, supplies and technologies and the ethical practices. Therefore, disciplinary strategies should be implemented to prevent corruption in the negotiation process of purchasing medicines. An example of this is the Ricarte Soto Law in Chile, which states that technical commissions in charge of making recommendations on which treatments should be financed, cannot comprise professionals who have had financial links with the pharmaceutical industry in the previous 24 months; these professionals are also forbidden to have any link till up to 24 months after playing a role in such commission.

The strengthening of national regulatory agencies, with a view on increasing their regulatory competencies and control over health technologies is urgent and necessary. These efforts should reach beyond local action by governments and also involve regional action, allowing the implementation of strategies to improve access to medicines, supplies and technologies. An important regional initiative is DIME (Informed Decisions over Medicines), a platform that has been built through Communities of Practice, coordinated by consultants and health authorities from the 8 participating countries. The platform will soon be open to the public.

Another example of how to mitigate the burden of public spending on high-cost medicines was the joint bargaining effort & purchase of high-cost medicine by countries from the intergovernmental regional organizations UNASUR and MERCOSUR, in 2015. This smart move resulted in collective cost savings of approximately US $ 20 million for the involved countries in the joint purchase of darunavir—an antiretroviral treatment for HIV and AIDS. Hopefully we can see more of this in the years to come, despite the political changes (and challenges) in the region.

Scarce knowledge and expertise, weak institutional structures vulnerable to pressure from suppliers, lobbyists and other unwanted influences are among the other obstacles to be overcome by most of the fragmented health care systems of the Latin American region. The development of entities that can detect, analyze and penalize anticompetitive and corrupt activities should be another aim. For instance, the former Minister of Health in Guatemala, Lucrecia Hernández Mack, had signed an anti-corruption and transparency agreement. She recently resigned, however, in protest of the presidential decision to expel the International Commissioner Against Impunity in Guatemala – a major setback to the efforts made to curb corruption in the country, obviously.  Even when there are legal mechanisms to improve the access to generic medicines, these have not always been used due to the lobbying of private stakeholders of the pharmaceutical industry and the lack of knowledge of the technical, political and judiciary authorities on the topic. Making use of the existing legal mechanisms requires capacity and technical expertise of national authorities along with a strong political commitment to take on market forces. PAHO and other expert agencies (including non-governmental ones) should support the member states in this respect—as is the case with the Salud Derecho Initiative.

Anyhow, the issue of access to medicines is here to stay. It will definitely also be a hot topic at the upcoming G20, hosted by Argentina in 2018.