National Negotiations Research Articles

The Bhisho March and Massacre of September 1992: The ‘Leipzig Option’ and the Meanings of Mass Action in the South African Transition

ABSTRACT Amid repressive state violence and an escalating civil war in the Eastern Cape’s Border region, on 7 September 1992 more than 80,000 people marched to Bhisho, capital of the Ciskei Bantustan, to bring an end to the rule of its military ruler, Brigadier Gqozo. Widespread fears of a fatal showdown were realised when the Ciskei Defence Force opened fire, killing 29 and injuring more than 200. This critical event, understood as a most pivotal moment in South Africa’s transition to democracy, has rarely been subjected to historical scrutiny. This article casts new light on the events and politics surrounding the march, the contested meanings of mass action, the consequences of the massacre, and its subsequent narration by politicians in the wake of the tragedy. As the tragic culmination of the mass action campaign by the African National Congress (ANC), the Bhisho march became a theatre of the contested politics of mass action within the Tripartite Alliance. An initiative of local and regional alliance structures in the Border region, the march was exploited by national politicians to serve strategic agendas in the national negotiations, while the ANC’s narrative was carefully curated to legitimate its leaders and their national project.

The Mass Action Campaign of 1992: The Ciskei Crisis and the African National Congress in Transition

ABSTRACT The politics of South Africa’s transition to democracy played out beyond the negotiating rooms. In the Eastern Cape’s Border region, where democratic mobilisation faced violent repression by the Ciskei bantustan regime throughout South Africa’s years of transition (1990–1994), a confrontation escalated, which cast national politics into stark relief. By 1992, this developing crisis came to expose the uneasy compromises being made at the negotiation table; the complex politics of homeland reincorporation; and the disconnection between national negotiations and social realities on the ground. The dramatic and fatal march on Ciskei’s capital Bhisho on 7 September 1992, often understood as a pivotal moment of the transition, marked the culmination of a long local campaign to oust Ciskei’s repressive military ruler. This struggle was belatedly supported by the national leadership of the African National Congress (ANC), to clarify its own mass action campaign and to evidence the organisation’s mandate to negotiate. The politics surrounding the crisis in Ciskei and the ANC national leadership’s efforts first to rein in and then to harness the local campaign reveal the tensions at play as leaders sought to transform the organisation from its disparate strands into a party prepared for multiparty elections.

Advanced Therapy Medicinal Products: Availability, Access and Expenditure in Italy.

Advanced therapy medicinal products (ATMPs) are an innovative output of biomedical research, characterized by a high level of uncertainty on long-term efficacy and safety, elevated price tags and often complex administration. All these elements compounded make their European authorization, national price negotiation for reimbursement and subsequent dispensation and administration to the patient less straightforward and often less successful than for less innovative drugs. To assess if these hurdles have affected patient access and how are ATMPs used in Italy, we have analysed availability, access and expenditure of ATMPs in the period spanning from 2016 to 2023. We have analysed real world data on the duration of ATMP regulatory evaluations for authorisation and reimbursement, time to first patient access and expenditure for ATMPs through the Italian National Health System (INHS) expenditure data flow, as well as information on patient mobility and availability of health facilities specialized in administering ATMPs. Of the 18 ATMPs currently authorized in Europe, 9 are reimbursed by the INHS, but only 6 were actually used, generating a cumulative expenditure of roughly 300 Mln€ from 2016 to 2023, largely owing to CAR-T therapies. Time to patient access reaches an average of 340.6 days from the day publication in the official Gazette of the reimbursement decision to first patient treatment in one of the 107 health facilities authorized for ATMP administration, after an even longer evaluation time by regulatory agencies. Since the first reimbursement decision for an ATMP in Italy, back in 2016, these innovative drugs became progressively more and more available, both in terms of numbers and in terms of coverage across the country. Almost all Italian regions have at least one centre for ATMP administration and has performed a treatment in 2023. Notwithstanding their high per-treatment prices, ATMPs currently have a rather contained expenditure, however it is bound to keep growing in the next few years.

Impact of competition on reimbursement decisions for cancer drugs in China: an observational study

Annual Chinese National negotiations for including innovative drugs in the National Reimbursement Drug List (NRDL) reveal an increasing number of new drugs with overlapping action mechanisms of action and similar indications. Yet, it is unclear if competition affects reimbursement decisions. Thus, we explored the impact of competition on reimbursement decisions for cancer drugs in China. We identified the cancer drugs involved in NRDL negotiations from 2017 to 2022 and focused on the initial reimbursement decision for eligible newly negotiated drugs. Drugs were classified as within-class competitors based on their equivalent biological mechanisms of action and approved indications, including identified and potential competitors. Other variables included drug type, clinical benefit and safety, monthly drug cost, and disease incidence rate. We employed traditional univariate and multivariate Firth's penalized logistic regression to assess the association between reimbursement decisions and variables at the indication and drug levels. Between 2017 and 2022, 102 cancer drugs corresponding to 141 indications were studied, and 66 drugs (64.7%) covering 95 indications (67.4%) were added to the NRDL. The proportion of reimbursements for indications with identified competition was significantly higher than that for indications without identified competition (84.6% vs 52.6%, p<0.0001). However, the difference in reimbursement proportions between groups with and without potential competition was not statistically significant (66.7% vs 68.3%, p=0.84). Firth's penalized logistic regression showed that identified competition was positively correlated with successful NRDL inclusion, whereas potential competition had no significant effect on negotiation outcomes. Improved overall survival or progression-free survival were positively associated with NRDL inclusion, whereas disease incidence negatively impacted reimbursement decisions. Improved clinical benefit and identified competition were positively correlated with NRDL inclusion. In China's value-based negotiation model, clinical benefits served as a crucial foundation of price negotiation for cancer drugs, and market competition helped these drugs enter the NRDL at more reasonable prices. This has important implications for reimbursement decisions and accessibility and affordability improvement for innovative drugs worldwide. National Natural Science Foundation of China (No. 72104151).

Access to essential and innovative anti-cancer medicines: a longitudinal study in Nanjing, China

PurposeTo evaluate the availability, cost, affordability of anti-cancer medicines in Nanjing, Jiangsu.MethodsA longitudinal tracking investigation study was performed to collect information about 24 essential anti-cancer medicines (EAMs) and 17 innovative anti-cancer medicines (IAMs) in 26 healthcare institutions in Nanjing from 2016 to 2020. The availability, cost, drug utilization and affordability of EAMs and IAMs were investigated.ResultsThe availability of EAMs showed no significant changes in Nanjing, but the availability of IAMs showed a significant increase in 2018 and 2019 and tended to stabilize in 2020. For EAMs, the DDDc(Defined Daily Dose cost) of LPGs (Lowest-Priced Generics) showed no significant changes, and the DDDc of OBs (Originator Brands) and IAMs significantly decreased. The DDDs(Defined Daily Doses) of EAMs (LPGs) showed a decreasing trend since 2016 and rose again in 2019. Overall, the DDDs of EAMs (LPGs) decreased by 25.18% between 2016 and 2020, but the proportion selected for clinical treatment remained at 67.35% in 2020. The DDDs of EAMs (OBs) and IAMs both showed an increasing trend year by year, with a proportional increase of 207.72% and 652.68%, respectively; but the proportion selected for clinical treatment was only 16.09% and 16.56% respectively in 2020. EAMs (LPGs) had good affordability for urban residents but poor affordability for rural residents; the affordability of EAMs (OBs) and IAMs was poor for both urban and rural residents.ConclusionsThere were no significant changes in the availability and cost of EAMs (LPGs), whose lower prices showed better affordability. Although their relative change in drug utilization showed a decreasing trend, they still dominated clinical treatment. Driven by the national drug price negotiation (NDPN) policy, the availability of IAMs was on the rise. It is necessary to further develop and strengthen policies for essential medicines procurement assessment to improve the accessibility of EAMs.

Impact of national drug price negotiation policy on the accessibility and utilization of PCSK9 inhibitors in China: an interrupted time series analysis

BackgroundPCSK9 inhibitors are a novel class of lipid-lowering drugs that have demonstrated favorable efficacy and safety. Evolocumab and alirocumab have been added to China’s National Reimbursement Drug List through the National Drug Price Negotiation (NDPN) policy. This study aims to evaluate the impact of the NDPN policy on the utilization and accessibility of these two PCSK9 inhibitors.MethodsThe procurement data of evolocumab and alirocumab were collected from 1,519 hospitals between January 2021 and December 2022. We determined the monthly availability, utilization, cost per daily defined dose (DDDc), and affordability of the two medicines. Single-group interrupted time series (ITS) analysis was performed to assess the impact of the NDPN policy on each drug, and multiple-group ITS analysis was performed to compare the differences between them.ResultsThe NDPN policy led to a significant and sudden increase in the availability and utilization of PCSK9 inhibitors, along with a decrease in their DDDc. In the year following the policy implementation, there was an increase in the availability, utilization, and spending, and the DDDc remained stable. The affordability of PCSK9 inhibitors in China have been significantly improved, with a 92.97% reduction in out-of-pocket costs. The availability of both PCSK9 inhibitors was similar, and the DDDc of alirocumab was only $0.23 higher after the intervention. The market share of evolocumab consistently exceeded that of alirocumab. Regional disparities in utilization were observed, with higher utilization in the eastern region and a correlation with per capita disposable income.ConclusionsThe NDPN policy has successfully improved the accessibility and utilization of PCSK9 inhibitors in China. However, regional disparities in utilization indicate the need for further interventions to ensure equitable medicine access.

The influence of the national drug price negotiation policy reform on the medical expenses of patients in Xuzhou City: an interrupted time series analysis.

To reduce the burden of patients' medical care, the Xuzhou Municipal Government has initiated an exploratory study on the supply model and categorized management of nationally negotiated drugs. This study aims to understand the extent to which Xuzhou's 2021 reform of the National Drug Price Negotiation (NDPN) policy has had a positive impact on the healthcare costs of individuals with different types of health insurance. The Interrupted Time Series Analysis method was adopted, and the changes in average medical expenses per patient, average medical insurance payment cost per patient and actual reimbursement ratio were investigated by using the data of single-drug payments in Xuzhou from October 2020 to October 2022. Following the implementation of the policy, there was a significant decrease in the average medical expenses per patient of national drug negotiation in Xuzhou, with a reduction of 62.42 yuan per month (p < 0.001). Additionally, the average medical insurance payment cost per patient decreased by 44.13 yuan per month (p = 0.01). Furthermore, the average medical expenses per patient of urban and rural medical insurance participants decreased by 63.45 yuan (p < 0.001), and the average monthly medical insurance payment cost per patient decreased by 57.56 yuan (p < 0.04). However, the mean total medical expenditures for individuals enrolled in employee medical insurance decreased by 63.41 yuan per month (p < 0.001), whereas the monthly decrease was 22.11 yuan per month (p = 0.21). On the other hand, there was no discernible change in the actual reimbursement ratio. After the adoption of the NDPN policy, a noticeable decline has been observed in the average medical expenses per patient and the mean cost of the average medical insurance payment per patient, although to a limited extent. Notably, the reduction in employee medical insurance surpasses that of urban and rural medical insurance.

Rational preference knowledge influence on the evolutionary equilibrium of carbon reduction negotiation: An exploration based on timed petri net

In the digital economy age, carbon emission reduction is perhaps the most crucial contribution affecting national activities and international negotiations. In a potential carbon reduction conflict, a rational participant expects to select a suitable strategic opinion to reach another state with improved benefit. Participants’ preferences reflect their priority ranking on multiple possible conflict solutions, directly determining the evolutionary direction and equilibrium solutions. Referring to the potential carbon reduction conflicts, Timed Petri Net for Conflict Analysis (TPNCA) is proposed as a graphical tool to explore participants’ rational preferences, state transformation, and conflict evolutionary equilibrium. The generation rule of TPNCA is designed according to carbon reduction co-operators’ rational preference knowledge. From the long-term perspective, dynamic unilateral improvement is proposed to reflect decision-makers’ strategic initiative willingness to reach end nodes. Dynamic equilibrium conditions are conducted to determine the final stability state for a conflict. This study reveals how participants’ preference knowledge and time constraints influence conflict evolutionary and dynamic equilibria. Climate group should positively engage in carbon reduction negotiations and flexibly adjust national tasks, according to real-time carbon reduction contributions. This study (1) reveals the influence of preference knowledge on conflict evolution, (2) explores the role of time constraints in determining a terminated node, (3) proposes dynamic equilibrium from the long-term perspective, and (4) helps guide participants’ strategic decision-making for mutually solving carbon reduction.

Transformative circular futures in the textile and apparel value chain: Guiding policy and business recommendations in the Netherlands, Spain, and India.

Circular economy practices are gaining importance in the global textile and apparel value chain to promote sustainability. However, the lack of attention paid to the circular economy's social dimension is concerning, given its expected global implementation for 2050. Neglecting this social impact undermines both environmental and social sustainability, perpetuating industry inequalities. To address this problem, this study develops Transformative Circular Futures (TCFs) to inform policy and business decision-making in the textile and apparel value chains of India, the Netherlands and Spain. TCFs are co-created circular economy scenarios that are diverse, systemic, and embedded with social impact considerations. This research employs participatory methods to blend system-change, Circular Economy, social impacts (through a gender lens), and positive desirable futures approaches, resulting in 16 scenarios. The results emphasise the pivotal role of diverse stakeholder engagement in reshaping the textile and apparel value chain towards equitable and transformative circular economy futures. The TCFs-derived recommendations to reduce inequalities and improve workers' well-being are critical steps towards a more inclusive and equitable transition to circular practices in the textile and apparel sector. Common recommendations include normalising living wages for direct, indirect, and informal workers, implementing regulations challenging patriarchy, eliminating gender pay and establishing permanent global committees of social actors. This ensures that social considerations are integrated throughout national and international negotiations within the circular textile and apparel value chain.

“I am maybe half-and-half Swedish. 50-50.” – Young adolescents’ national identity negotiation in a diverse school setting

ABSTRACT To explore young adolescents’ negotiation of their national identity in an educational context, we individually interviewed nine students (ages 10–14) with different backgrounds attending an ethnically diverse school in Sweden. The transcribed interviews were thematically and qualitatively analyzed. Results show that students negotiated their national identity as being quantifiable, often as sized portions of a whole or percentages, and dichotomous (Swedish vs. non-Swedish). Their national identity negotiation further related to feelings of belonging as well as to birthplace, appearance, and language. Results suggest that national identity is more complex for youth with immigrant backgrounds and that the status conferred by being part of the majority group is recognized in ethnically diverse and segregated contexts. These findings on young adolescents’ national identity negotiations can inform future research or educational practices as well as curricula to support national identity development or feelings of belonging in diverse school settings.

An Appraisal of the Challenges and Limitations of Developing African Countries in Negotiations with Multinational Entities and Developed Nations: Proposed Interventions

The paper takes a look at the limitations and challenges that negotiators of developing African countries encounter with multinational entities and developed nations. It identifies that negotiators of multinational and advanced economies appear to be very competitive and confrontational as against negotiators of developing African negotiators, who appear cooperative and collaborative, a soft-styled approach to negotiations, these disparities arise from power, network and resource imbalance. Some of the challenges encountered by African negotiators include aggressive demands, unilateralism and setting self-serving agendas, negative impact of demographic variables as well as intercultural challenges. Others include inadequate cultural intelligence, negotiating process fatigue, political interest and inadequate competent and experienced human resource and financial limitations among others. The Doha declaration points to the fact that weak nations such as African countries and partners, even though may appear as weaker actors can attain a successful negotiated outcome, when in strategic partnership and networks with identified mutual interest and benefits. The paper recommends the need for the establishment of a networked governance strategy, a more formidable one to the TRIPs network, which delivered a BATNA. Within the state and regional levels, African countries must consciously endeavor to provide their domestic institutions such as Foreign Ministries, Trade and Industry Ministries, national negotiation agencies, with the requisite capacities and expertise needed to be very effective and competitive. Good political well of governments is central in avoiding conflict of interest and corruption at the expense of the State for a BATNA. This would enable them to be better prepared with the requisite confidence, knowledge, and skills to negotiate for a better outcome with multinational corporations and nations.

Cost-Effectiveness Analysis of 6 Tyrosine Kinase Inhibitors as First-Line Treatment for ALK-Positive NSCLC in China.

Lung cancer ranks first in both cancer incidence and mortality in China. The emergence of novel treatments for ALK-positive NSCLC led to an improvement in survival and quality of life for patients with advanced ALK mutation-positive non-small cell lung cancer (NSCLC). This study sought to assess the cost-effectiveness of 6 tyrosine kinase inhibitors (TKIs)-crizotinib, alectinib, ceritinib, brigatinib, ensartinib, and lorlatinib-as first-line treatments for ALK-positive NSCLC from the perspective of the Chinese health care system. A Markov model was developed to estimate the cost-effectiveness of these 6 TKIs. In this model, ALK-positive NSCLC patients were initially simulated to receive 1 of the 6 TKIs as first-line therapy, followed by different TKIs as subsequent treatment and salvage chemotherapy as last-line treatment. Survival data were sourced from the latest published clinical trials. Costs were derived from recent national health insurance negotiations and hospital information systems of selected health care facilities. Utilities for healthy states and adverse events were obtained from the literature. One-way and probabilistic sensitivity analysis as well as scenario analysis was conducted to assess the robustness of the results. Compared to ensartinib, crizotinib, alectinib, ceritinib, brigatinib, and lorlatinib demonstrated incremental quality-adjusted life years (QALYs) of -1.13, 0.39, -0.58, -0.09, and 0.35, respectively. The corresponding incremental costs were $10 677, $33 501, -$6426, $2672, and $24 358. This resulted in ICERs of -$9449/QALY, $85 900/QALY, $11 079/QALY, $29 689/QALY and $69 594/QALY, respectively. Crizotinib was considered to be absolutely dominated by ensartinib. Under a willingness-to-pay threshold of $38 223/QALY, ceritinib and brigatinib were cost-effective compared with ensartinib, while lorlatinib and alectinib were not cost-effective when compared with ensartinib. Overall, brigatinib emerged as the most cost-effective treatment among all the options considered.

Sponsorship bias in published pharmacoeconomic evaluations of national reimbursement negotiation drugs in China: a systematic review

BackgroundChina’s National Reimbursement Drug List (NRDL) has become the primary route for drug reimbursement in China. More recently, the authority has made pharmacoeconomic evaluation an integral part of the application...

The reimbursement decision speed for oncology new drugs in China and its determinant factors.

China has initiated national price negotiations to improve access to innovative drugs. Learning the factors that contributed to the time gap from marketing authorization to reimbursement leads to more clarity to decision-making, which remains under-researched in China. We collected new oncology drug approvals that were marketed before 30 Jun 2022, using the Listed Drug Database of the Chinese drug agency. Major information of each approval was obtained from the published review report, including the first approval region (China or the US) and the receipt of expedited review pathways (priority review and conditional approval). The reimbursement lists issued by China National Healthcare Security Administration from 2015 to 2023 were used to determine the reimbursement status of drugs. The duration from marketing authorization to reimbursement was defined as the reimbursement decision speed, and the Cox regression was performed to explore the underlying factors. A total of 186 oncology approvals were included. More than half of the approvals qualified for reimbursement (110[59.14%]), and the median reimbursement decision speed was accelerated from 540.5 days in the third-round negotiation to 448 days in the seventh-round. Domestic new drugs had a higher probability of being adopted by the Chinese payer than drugs developed by foreign companies (adjusted HR = 3.73, 95% CI 2.42 to 5.75; P < 0.001). Furthermore, new drug applications receiving the regular review pathway were more likely to be reimbursed (adjusted HR = 2.15, 95% CI 1.13 to 4.08; P = 0.020) compared to those approved under the conditional approval pathway. These findings indicate that the Chinese government is actively working toward improving access to new oncology drugs. The faster reimbursement decision speed for domestic drugs might be attributed to their pricing advantages and the regulator's efforts to stimulate innovation in the domestic pharmaceutical industry. However, concerns about the uncertainty in drug benefits can affect the reimbursement decision-making, which suggests the delicate tradeoff between drug accessibility and risk involved in the reimbursement process.

Analysis of the Impact of National Medical Insurance Negotiation Policy on the Use of Anticancer Drugs in a Hospital

To analyze the impact of national medical insurance negotiation policy on the use of anti- cancer drugs in a certain hospital. The usage information of anti-tumor drugs in the hospital from 2018 to 2019 was selected, and a comparative analysis of the usage situation of anti-tumor drugs was conducted. It found that the national medical insurance negotiation policy effectively promoted the use of anti-tumor drugs, reduced drug prices, and improved the accessibility of anti-tumor drugs.

The challenges of the United Nations about peacekeeping in Cyprus and protecting the human rights of its inhabitants

The peace plan known as the Annan plan was presented by the United Nations and many negotiations between the two sides were held under the supervision of this organization, which failed for several reasons. And the unification of the island has not been achieved. Ethnic conflict and Turkish and Greek nationalism, differences over how to distribute power, demographic, territorial issues, problems, and how Cyprus interacts with the two countries of Greece and Turkey as the guarantors of the island's independence, are among the main obstacles of the Cyprus problem. By relying on military forces, Turkey and Greece, by taking advantage of the historical and cultural scope, are trying to gain more sphere of influence in Cyprus and resolve this issue in their own interest. It is because of this issue that the United Nations has entered the issue and has tried to solve the related challenge with numerous resolutions. Based on this, we intend to pay attention to the subject of the challenges of the United Nations about peacekeeping in Cyprus and protecting the human rights of its inhabitants based on the analytical-descriptive method and in the form of a library. The results of the research show that the relevant organization has not been completely successful in its mission, but it has been able to manage the issue of peacekeeping and manage tension and physical conflict for decades, although the presence of Turkish military forces also provides the necessary balance in the practical field and in the politics.

Why do climate change negotiations stall? Scientific evidence and solutions for some structural problems

Climate change is perhaps the biggest challenge of our times. In order to cope with it, we have to organise action collectively. The most important way to cooperate globally is through United Nations negotiations, known as ‘conferences of the parties’. However, progress has been very slow, and disillusionment with the United Nations Framework Convention on Climate Change process has set in. From a scientific point of view, several obstacles surfacing in these negotiations have been well researched. Institutional analysis may provide suggestions or even solutions to some of these problems. Hence, we think that the United Nations Framework Convention on Climate Change negotiations could profit from scientific support. We provide scientific background for three prominent problems: how to reconcile different interests in a global public goods situation; how to ameliorate the consensus decision-making process; and how to design institutions to implement resolutions. Enhancing communication, trust and fairness, and enforcing sanctions, are suggested as key elements for that. Finally, we point to similar processes that have been brought to a successful end.

The impact of government reimbursement negotiation on targeted anticancer medicines use and cost in China: A cohort study based on national health insurance data.

High prices of targeted anticancer medicines (TAMs) result in financial toxicity for patients and the health insurance system. How national price negotiation and reimbursement policy affect the accessibility of TAMs for cancer patients remains unknown. In this population-based cohort study, we used national health insurance claims data in 2017 and identified adult patients with cancer diagnoses for which price-negotiated TAMs were indicated. We estimated the half-month prevalence of price-negotiated TAMs use before and after the policy implementation in September 2017. We calculated direct medical costs, out-of-pocket (OOP) costs, and the proportion of OOP cost for each cancer patient to measure their financial burden attributable to TAMs use. We performed segmented linear and multivariable logistic regression to analyse the policy impact. We included 39 391 of a total 118 655 cancer beneficiaries. After September 2017, the prevalence of price-negotiated TAMs use increased from 1.4%-2.1% to 2.9%-3.1% (P = 0.005); TAMs users' daily medical costs increased from US$261.3 to US$292.5 (P < 0.001), while median daily OOP costs (US$68.2 vs US$65.7; P = 0.134) and OOP costs as a proportion of daily medical costs persisted (28.5% vs 28.5%; P = 0.995). Compared with resident beneficiaries, the relative probability of urban employee beneficiaries on TAMs uses decreased after the policy (adjusted odds ratio (aOR) = 2.4 vs aOR = 2.2). The government price negotiation and reimbursement policy improved patient access to TAMs and narrowed disparities among insurance schemes. China's approach to promoting the affordability of expensive medicines provides valuable experience for health policy decision-makers.

Making the Case for Cosmopolitan Pathways for Canada’s Diversity

This article seeks to develop the argument that it is time for a national roundtable negotiation among Indigenous peoples, the two English and French settler nations, the BIPOC communities and the various immigrant groups to consider the merits of cosmopolitanism as a moral and cultural framework of our interrelated relationships and intercultural encounters in Canada. In an interdependent globalized world that is becoming “superdiverse,” I argue that it is time to shift from the language of “tolerance” of the “Other” to the language of “engagement” with “fellow human beings” guided by the moral and cultural cosmopolitanism for social and global justice, equality and equity, and inclusion through the fulfillment of human rights. The purpose of this public discussion is to urge the Canadian Council of Ministers of Education as well as the federal government to put this question on their agenda for consideration as a new framework for Canada’s educational, social, economic and political policies. This argumentative paper has the potential to benefit policymakers, curriculum designers, educators, and ministries of education across Canada and beyond to consolidate moral and cultural cosmopolitanism as a national and international approach to harmonious human coexistence.

Uptake of hepatitis C direct-acting antiviral treatment in China: a retrospective study from 2017 to 2021

BackgroundDirect-acting antivirals (DAAs) for hepatitis C treatment in China became available since 2017. This study expects to generate evidence to inform decision-making in a nationwide scale-up of DAA treatment in China.MethodsWe described the number of standard DAA treatment at both national and provincial levels in China from 2017 to 2021 based on the China Hospital Pharmacy Audit (CHPA) data. We performed interrupted time series analysis to estimate the level and trend changes of the monthly number of standard DAA treatment at national level. We also adopted the latent class trajectory model (LCTM) to form clusters of the provincial-level administrative divisions (PLADs) with similar levels and trends of number of treatment, and to explore the potential enablers of the scale-up of DAA treatment at provincial level.ResultsThe number of 3-month standard DAA treatment at national level increased from 104 in the last two quarters of 2017 to 49,592 in the year of 2021. The estimated DAA treatment rates in China were 1.9% and 0.7% in 2020 and 2021, which is far below the global target of 80%. The national price negotiation at the end of 2019 resulted in DAA inclusion by the national health insurance in January 2020. In that month, the number of treatment increased 3668 person-times (P < 0.05). LCTM fits the best when the number of trajectory class is four. PLADs as Tianjin, Shanghai and Zhejiang that had piloted DAA price negotiations before the national negotiation and that had explored integration of hepatitis service delivery with prevention and control programme of hepatitis C within the existing services demonstrated earlier and faster scale-up of treatment.ConclusionsCentral negotiations to reduce prices of DAAs resulted in inclusion of DAA treatment under the universal health insurance, which are critical elements that support scaling up access to hepatitis C treatment in China. However, the current treatment rates are still far below the global target. Targeting the PLADs lagged behind through raising public awareness, strengthening capacity of the healthcare providers by roving training, and integrate prevention, screening, diagnosis, treatment and follow-up management of hepatitis C into the existing services are needed.