Coercive interventions under the new Dutch mental health law: Towards a CRPD-compliant law?

The Netherlands became State Party to the United Nation Convention on the Rights of Persons with Disabilities (CRPD) in 2016, a treaty that holds great promise for promoting and protecting human rights of persons with mental disorders. Yet, the Dutch government also made explicit reservations to the Convention. On 1 January 2020, the Netherlands introduced a new mental health law, the Compulsory Mental Health Care Act (CMHCA), which aims to strengthen the legal status of persons with psychiatric illnesses. To which extent does the new Dutch mental health law comply with the regulations as outlined in the CRPD? In this article, we examine how coercive interventions, specifically the elements of competence, involuntary treatment and involuntary admission are regulated in the domestic legislation and compare them to the CRPD approach. A normative analysis combined with literature review helps to understand the law, reveal the gaps and uncover the barriers that remain. Is there a need to reassess the domestic legal provisions allowing for coercive treatment, and if so, what advancements are required? After all, should the CRPD be strictly adhered to at all times?

Essential Medicines in Universal Health Coverage: A Scoping Review of Public Health Law Interventions and How They Are Measured in Five Middle-Income Countries

Very few studies exist of legal interventions (national laws) for essential medicines as part of universal health coverage in middle-income countries, or how the effect of these laws is measured. This study aims to critically assess whether laws related to universal health coverage use five objectives of public health law to promote medicines affordability and financing, and to understand how access to medicines achieved through these laws is measured. This comparative case study of five middle-income countries (Ecuador, Ghana, Philippines, South Africa, Ukraine) uses a public health law framework to guide the content analysis of national laws and the scoping review of empirical evidence for measuring access to medicines. Sixty laws were included. All countries write into national law: (a) health equity objectives, (b) remedies for users/patients and sanctions for some stakeholders, (c) economic policies and regulatory objectives for financing (except South Africa), pricing, and benefits selection (except South Africa), (d) information dissemination objectives (ex. for medicines prices (except Ghana)), and (e) public health infrastructure. The 17 studies included in the scoping review evaluate laws with economic policy and regulatory objectives (n = 14 articles), health equity (n = 10), information dissemination (n = 3), infrastructure (n = 2), and sanctions (n = 1) (not mutually exclusive). Cross-sectional descriptive designs (n = 8 articles) and time series analyses (n = 5) were the most frequent designs. Change in patients' spending on medicines was the most frequent outcome measure (n = 5). Although legal interventions for pharmaceuticals in middle-income countries commonly use all objectives of public health law, the intended and unintended effects of economic policies and regulation are most frequently investigated.

Legislating for universal access to medicines: a rights-based cross-national comparison of UHC laws in 16 countries

Universal health coverage (UHC) aims to ensure that all people have access to health services including essential medicines without risking financial hardship. Yet, in many low- and middle-income countries (LMICs) inadequate UHC fails to ensure universal access to medicines and protect the poor and vulnerable against catastrophic spending in the event of illness. A human rights approach to essential medicines in national UHC legislation could remedy these inequities. This study identifies and compares legal texts from national UHC legislation that promote universal access to medicines in the legislation of 16 mostly LMICs: Algeria, Chile, Colombia, Ghana, Indonesia, Jordan, Mexico, Morocco, Nigeria, Philippines, Rwanda, South Africa, Tanzania, Turkey, Tunisia and Uruguay. The assessment tool was developed based on WHO's policy guidelines for essential medicines and international human rights law; it consists of 12 principles in three domains: legal rights and obligations, good governance, and technical implementation. Relevant legislation was identified, mapped, collected and independently assessed by multi-disciplinary, multi-lingual teams. Legal rights and State obligations toward medicines are frequently codified in UHC law, while most good governance principles are less common. Some technical implementation principles are frequently embedded in national UHC law (i.e. pooled user contributions and financial coverage for the vulnerable), while others are infrequent (i.e. sufficient government financing) to almost absent (i.e. seeking international assistance and cooperation). Generally, upper-middle and high-income countries tended to embed explicit rights and obligations with clear boundaries, and universal mechanisms for accountability and redress in domestic law while less affluent countries took different approaches. This research presents national law makers with both a checklist and a wish list for legal reform for access to medicines, as well as examples of legal texts. It may support goal 7 of the WHO Medicines & Health Products Strategic Programme 2016-30 to develop model legislation for medicines reimbursement.

The right to health as the basis for universal health coverage: A cross-national analysis of national medicines policies of 71 countries

Persistent barriers to universal access to medicines are limited social protection in the event of illness, inadequate financing for essential medicines, frequent stock-outs in the public sector, and high prices in the private sector. We argue that greater coherence between human rights law, national medicines policies, and universal health coverage schemes can address these barriers. We present a cross-national content analysis of national medicines policies from 71 countries published between 1990-2016. The World Health Organization's (WHO) 2001 guidelines for developing and implementing a national medicines policy and all 71 national medicines policies were assessed on 12 principles, linking a health systems approach to essential medicines with international human rights law for medicines affordability and financing for vulnerable groups. National medicines policies most frequently contain measures for medicines selection and efficient spending/cost-effectiveness. Four principles (legal right to health; government financing; efficient spending; and financial protection of vulnerable populations) are significantly stronger in national medicines policies published after 2004 than before. Six principles have remained weak or absent: pooling user contributions, international cooperation, and four principles for good governance. Overall, South Africa (1996), Indonesia and South Sudan (2006), Philippines (2011-2016), Malaysia (2012), Somalia (2013), Afghanistan (2014), and Uganda (2015) include the most relevant texts and can be used as models for other settings. We conclude that WHO's 2001 guidelines have guided the content and language of many subsequent national medicines policies. WHO and national policy makers can use these principles and the practical examples identified in our study to further align national medicines policies with human rights law and with Target 3.8 for universal access to essential medicines in the Sustainable Development Goals.

Dietary Protein Sources and Muscle Mass over the Life Course: The Lifelines Cohort Study

The influence of dietary protein intake on muscle mass in adults remains unclear. Our objective was to investigate the association between protein intake and muscle mass in 31,278 men and 45,355 women from the Lifelines Cohort. Protein intake was estimated by food frequency questionnaire and muscle mass was estimated from 24 h urinary creatinine excretion. The age range was 18⁻91 years and mean total protein intake was 1.0 ± 0.3 g/kg/day. Across increasing quartiles of total protein intake, animal protein intake, and fish/meat/egg protein intake, creatinine excretion significantly increased in both men (+4% for total and +6% for fish/meat/egg protein intake, p < 0.001) and women (+3% for total and +6% for fish/meat/egg protein intake, p < 0.001). The associations were not systematically stronger or weaker with increasing age, but associations were strongest for young men (26⁻45 years) and older women (>75 years). The association between total protein intake and muscle mass was dependent on physical activity in women (p interaction < 0.001). This study suggests that total protein intake, animal protein intake, and in particular fish/meat/egg protein intake may be important for building and preserving muscle mass. Dietary protein sources should be further studied for their potential to build and preserve muscle mass.

Access to essential medicines in 195 countries: A human rights approach to sustainable development

In 2008 the UN Special Rapporteur on the Right to Health published 72 right to health indicators in 194 health systems. We present a follow-up report of eight indicators for access to medicines to serve as a reference point for progress towards SDG Target 3.8 on essential medicines. Data for these eight indicators in 2015 were collected and compared with the 2008 report. Between 2008 and 2015 we observed increased numbers of constitutions recognising access to medicines (7-13 countries), countries with a national medicine policy (118-122) and with a national list of essential medicines (78-107). Public spending on pharmaceuticals decreased or rose modestly in most of the 44 countries. Median availability of a basket of lowest-priced generics increased in the public (63%-70% n = 9 countries) and private (84%-92% n = 10) sectors. Median child immunisation rates remained constant for measles (around 90%) and improved for three doses of diphtheria-tetanus-pertussis (79%-86%). These eight indicators are useful and feasible, but should be further strengthened and expanded. Future monitoring exercises should use these indicators to screen progress and guide national governments' action to ensure universal access to essential medicines as part of the right to health.