Agricultural liberalization: An appraisal of the provisions and practice of the General Agreement on Tariffs and Trade in the context of export subsidies on primary products

This paper examines currently one of the most contentious provisions in international trade in agriculture: primary product export subsidies. The discussion is within the context of the General Agreement on Tariffs and Trade whereby I consider the provision which deals with this . In attempting to examine the export subsidy provisions of the General Agreement in a juristic study I consider two questions to measure the export subsidy provisions effectiveness. Firstly I consider the provisions nature and form so to understand the type of obligation entered into by the Contracting Parties. Secondly, I consider the Contracting Parties utilization of export subsidies to see whether they honour the obligation and its effect on international agricultural trade. The methodology is an analysis of the export subsidy provision in chronological order. It allows an overall appreciation of the structure finally chosen for the General Agreement, a method of comprehending the Contracting Parties view of the obligation and the elements which measure the obligation. This chronological approach also allows me discussion on the compatability of export subsidies with the aims of the General Agreement so that the paper may comment on the structure for international trade in agriculture. The analysis of the export subsidy provisions takes me back to an era in which agriculture received special treatment. I attempt to understand why this economic tool has been maintained as one of the prime national policies of many Contracting Parties although it is considered a major barrier to the principles of economic liberalism. The initial negotiations show the structure proposed to achieve a liberalization of agricultural trade and with the demise of the Havana Charter the only pillar really left to support such an aim is the discouragement of export subsidies in Article XVI:3 of the General Agreement and Article 10 of the Code on Subsidies. I discuss in very great detail the negotiations of the obligation so as to understand the nature of that obligation. Also, I discuss in great detail the elements which measure that obligation. This is an attempt to understand what the measure is supposed to achieve. The analysis of the measure of the obligation is extensive because from the form of the obligation it is difficult to unravel what it takes for an inequitable share to arise. Although the obligation lacks clarity of purposes and a precision in its language it has remained from the 1950's virtually unaltered. These negotiations show the conflicting approach not between North-South nations but traditional primary exporting nations and industrialized countries in the utilization of such measures. Contracting Parties of every hue use this form of intervention. The paper then moves onto discuss types of intervention which have resulted in dispute settlement procedures under the General Agreement of Tariff and Trade. My analysis initially compares the position between the negotiations and the Panel's findings. This initial analysis also discusses the Panel's methodology in approaching complaints about export subsidy measures. Although support for the provision was well grounded in the initial complaints the results have been overstated. Latter analysis of Panel findings on complaints not only compares the negotiations with the findings but includes discussion on independent research on the primary commodity in question. That analysis shows up the problem of Article XVI:3 and Article 10 not being a norm capable of legally binding obligations. Since the norm is only a broad hortatory statement it requires not only further diplomatic negotiations but must accommodate the intervention which it sanctions. These latter Panel complaints question the possibility of Article XVI:3 and Article 10 to achieve a liberalization of international agricultural trade since the utilization of this type of intervention cannot be restructured under those provisions. This links to further discussion on whether liberalization can occur. The paper finally questions whether agricultural liberalization can occur from such pillars as Article XVI: 3 of the General Agreement and Article 10 of the Code on Subsidies by discussing a link. The link is one of commodity surpluses generated by national autarkic policies which requires export subsidies to dispose of the surplus and results in trade restrictions. The trade restrictions affect particulary on the traditional primary product producers of all Contracting Parties and not the industrialized countries. This link is discussed and it does not lead to a conclusion that the pillar of Article XVI:3 and Article 10 achieve agricultural liberalisation but rather the Contracting Parties are still unable to deal in any framework with international agricultural trade. The operation of the export subsidies provisions of the General Agreement can provide a forum to establish an international framework but it cannot do so unless Contracting Parties wish it to occur. The effectiveness of the provision since it is a broad hortatory statement lies with the Contracting Parties

Agricultural liberalization: An appraisal of the provisions and practice of the General Agreement on Tariffs and Trade in the context of export subsidies on primary products

This paper examines currently one of the most contentious provisions in international trade in agriculture: primary product export subsidies. The discussion is within the context of the General Agreement on Tariffs and Trade whereby I consider the provision which deals with this . In attempting to examine the export subsidy provisions of the General Agreement in a juristic study I consider two questions to measure the export subsidy provisions effectiveness. Firstly I consider the provisions nature and form so to understand the type of obligation entered into by the Contracting Parties. Secondly, I consider the Contracting Parties utilization of export subsidies to see whether they honour the obligation and its effect on international agricultural trade. The methodology is an analysis of the export subsidy provision in chronological order. It allows an overall appreciation of the structure finally chosen for the General Agreement, a method of comprehending the Contracting Parties view of the obligation and the elements which measure the obligation. This chronological approach also allows me discussion on the compatability of export subsidies with the aims of the General Agreement so that the paper may comment on the structure for international trade in agriculture. The analysis of the export subsidy provisions takes me back to an era in which agriculture received special treatment. I attempt to understand why this economic tool has been maintained as one of the prime national policies of many Contracting Parties although it is considered a major barrier to the principles of economic liberalism. The initial negotiations show the structure proposed to achieve a liberalization of agricultural trade and with the demise of the Havana Charter the only pillar really left to support such an aim is the discouragement of export subsidies in Article XVI:3 of the General Agreement and Article 10 of the Code on Subsidies. I discuss in very great detail the negotiations of the obligation so as to understand the nature of that obligation. Also, I discuss in great detail the elements which measure that obligation. This is an attempt to understand what the measure is supposed to achieve. The analysis of the measure of the obligation is extensive because from the form of the obligation it is difficult to unravel what it takes for an inequitable share to arise. Although the obligation lacks clarity of purposes and a precision in its language it has remained from the 1950's virtually unaltered. These negotiations show the conflicting approach not between North-South nations but traditional primary exporting nations and industrialized countries in the utilization of such measures. Contracting Parties of every hue use this form of intervention. The paper then moves onto discuss types of intervention which have resulted in dispute settlement procedures under the General Agreement of Tariff and Trade. My analysis initially compares the position between the negotiations and the Panel's findings. This initial analysis also discusses the Panel's methodology in approaching complaints about export subsidy measures. Although support for the provision was well grounded in the initial complaints the results have been overstated. Latter analysis of Panel findings on complaints not only compares the negotiations with the findings but includes discussion on independent research on the primary commodity in question. That analysis shows up the problem of Article XVI:3 and Article 10 not being a norm capable of legally binding obligations. Since the norm is only a broad hortatory statement it requires not only further diplomatic negotiations but must accommodate the intervention which it sanctions. These latter Panel complaints question the possibility of Article XVI:3 and Article 10 to achieve a liberalization of international agricultural trade since the utilization of this type of intervention cannot be restructured under those provisions. This links to further discussion on whether liberalization can occur. The paper finally questions whether agricultural liberalization can occur from such pillars as Article XVI: 3 of the General Agreement and Article 10 of the Code on Subsidies by discussing a link. The link is one of commodity surpluses generated by national autarkic policies which requires export subsidies to dispose of the surplus and results in trade restrictions. The trade restrictions affect particulary on the traditional primary product producers of all Contracting Parties and not the industrialized countries. This link is discussed and it does not lead to a conclusion that the pillar of Article XVI:3 and Article 10 achieve agricultural liberalisation but rather the Contracting Parties are still unable to deal in any framework with international agricultural trade. The operation of the export subsidies provisions of the General Agreement can provide a forum to establish an international framework but it cannot do so unless Contracting Parties wish it to occur. The effectiveness of the provision since it is a broad hortatory statement lies with the Contracting Parties

Antibiotic prescribing patterns at a referral hospital in Kenya : a point prevalence survey

Background: Antibiotics are important in prevention and treatment of infections and the reduction in associated morbidity and mortality. Inappropriate use can lead to antimicrobial resistance, rendering them ineffective. Studies have shown variations in antibiotic prescribing patterns across different patient populations within the same hospital. Objectives: Our study aimed at establishing the prevalence and patterns of antibiotic use in a referral hospital in Kenya, with the aim of using the data for quality improvement. Methods: A point prevalence survey was conducted at a referral hospital in Kenya in April 2017. All patients who received antibiotics were recruited from all departments. Descriptive and inferential data analysis was done to establish the patterns of antibiotic use and the associations between variables. Ethical approval was obtained from the Kenyatta National Hospital/ University of Nairobi Research and Ethics Committee. Results: A hundred and seventy nine patients were enrolled in the study. The prevalence of antibiotic prescribing was 54.7%. The highest prevalence of antibiotic prescribing was found in critical care unit and isolation ward, both at 100%. Obstetrics and gynecology department had the least prevalence at 20.8%. Penicillins (46.9%) followed by cephalosporins (44.7%) were the most prescribed antibiotic classes. A larger proportion of antibiotic prescribing was for treatment (75.4%) as compared to prophylaxis (29.0%). Majority (76.9%, n=52) of the patients on surgical prophylaxis were on prolonged duration (>1 day). Empiric prescribing accounted for 82.6% of the total antibiotic encounters while targeted treatment was recorded in 17.4%. Conclusions: The study identified several areas for potential improvement in antibiotic prescribing such as the high prevalence of inpatient antibiotic use, prolonged duration of antibiotic use in surgical prophylaxis, extensive prescribing of broad spectrum agents such as ceftriaxone and the low prevalence of targeted antibiotic prescribing

Appropriateness of antibiotic prescribing and compliance to guidelines at a referral hospital in Kenya : a point prevalence survey

Background: A large proportion of antibiotics globally are prescribed, dispensed or administered irrationally. This is partly due to lack of local guidelines or non-adherence to available antibiotic use guidelines. The irrational use of antibiotics results in wastage of scarce health care resources, increases the risk of adverse drug reactions and increases the potential of development of resistance. This leads to poor health outcomes. Objectives: The aim of the study was to establish whether there was rational or irrational prescribing and adherence to guidelines in one of the referral hospitals in Kenya at a specific point in time. Methods: A point prevalence survey was conducted at a referral hospital in Kenya in April 2017. Stratified proportionate random sampling technique was used to select eligible patients who were on systemic antibiotics. Data was abstracted from the patient medical records into a predesigned patient form. Associations between predictor variables such as socio-demographic factors and outcome variables such as rational prescribing and guideline compliance were determined using Chi square. Stepwise backward binary logistic regression was done to determine the independent predictors of rational antibiotic prescribing and guideline compliance. Statistical significance was set at 95% confidence level and values with p≤0.05 were considered statistically significant. Approval to conduct the study was obtained from the Kenyatta National Hospital/University of Nairobi Research and Ethics Committee. Results: A total of 179 patients were recruited into the study. There was rational prescribing in 33.9% (n=121) of all the 357 antibiotic encounters. The neonatal medical ward had the highest prevalence of rational prescribing (80%, n=12) while the critical care unit had the highest prevalence of irrational prescribing (100%, n=4). The most powerful predictor variables of rational antibiotic prescribing were the department (AOR=0.778, 95% CI=0.640–0.945, p=0.011), a diagnosis of a neonatal infection (AOR=5.992, 95% CI=1.985–18.094, p=0.001), a diagnosis of skin, soft tissue, bone and joint infection (AOR=6.221, 95% CI=2.053–18.847, p=0.001) and a diagnosis of no defined site such as sepsis (AOR=5.540, 95% CI=1.486–20.648, p=0.011). There was guideline compliance in 45.8% (n=82) of the study population. The most powerful predictors of guideline compliance were a diagnosis of a respiratory infection (AOR=7.141, 95% CI=2.950–17.287, p<0.001), a diagnosis of a neonatal infection (AOR=10.603, 95% CI=1.671–67.280, p=0.012) and a diagnosis of a skin, soft tissue, one and joint infections (AOR=5.606, 95% CI=1.730–18.162, p=0.004). Conclusions: Rational prescribing was documented in only a third of all antibiotics prescribed. There was poor compliance to guidelines. Local guidelines were not available for a significant proportion of conditions. International guidelines were used in such scenarios

Assessing utilisation and expenditure on long-acting insulin analogues in Kenya; findings and implications for the future

Prevalence rates for patients with diabetes mellitus are rising across countries including sub-Saharan African countries, which will continue. As a result, there are an increasing number of patients with insulin-dependent diabetes across sub-Saharan Africa including Kenya. Growing prevalence rates are increasing the costs of treating patients with diabetes enhanced by associated complications. These include both microvascular and macrovascular complications, with hypoglycaemia and generally poor control of diabetes contributing to the burden. Long-acting insulin analogues were developed to reduce rates of hypoglycaemia associated with insulin usage, including nocturnal hypoglycaemia, and improve adherence through improving patient convenience. As a result, they are now included in the Kenyan Essential Medicines List. However, long-acting insulin analogues are typically considerably more expensive than standard insulins limiting their use in practice, especially in countries such as Kenya with concerns with affordability even for standard insulins such as Mixtard®. Consequently, a need to ascertain current utilisation and expenditure patterns for the different insulins including long-acting insulin analogues across Kenya starting with leading referral hospitals. Research in Kenyatta National Hospital (KNH) showed growing use of insulin glargine reaching up to 3.4 to 3.6% of total insulin utilisation in 2019 and 2020. However, prescribing was limited by considerably higher prices (3.4 fold higher) than standard insulins on a defined daily dose basis. Considerably higher prices resulted in no utilisation of long-acting insulin analogues in another leading referral hospital in Kenya. Overall, appreciably lowering the prices of long-acting insulin analogues through instigating local production and other activities should increase their use benefiting patients and the healthcare system in Kenya and wider. These are considerations for the future

Profiles of patients on warfarin anticoagulation therapy in a leading tertiary referral hospital in Kenya; findings and implications for Kenya

Background: Patients’ profiles affect the outcome with warfarin; however, this data, and its implications, is scarce in resource-poor countries without access to pharmacogenetics or regular INR testing. Objectives: To characterize the profiles of patients on long-term warfarin therapy and subsequently use these to guide future anticoagulation management. Methods: Cross-sectional study among 180 adult patients receiving warfarin therapy in at a leading referral hospital in Kenya. Sociodemographic characteristics were obtained through face-to-face interviews. Details of warfarin therapy, concomitant medication and comorbidities were retrieved from medical records. Associations between patients’ profiles and the clinical indications of anticoagulation were computed at p ≤ 0.05. Results: Warfarin maintenance dose was 6.17 (±2.75) mg per day. Venous thromboembolism (56.6%) amongst obese patients (p = 0.0019) and cardioembolic events (48.3%) among males (p = 0.0316) aged ≤50 years (p = 0.0436) whose body mass indices were ≤ 25 (p < 0.0001) were the most common indications. Two-fifths and 45.0% of the patients had at least one other disease and concomitant medications. Conclusions: Long term warfarin therapy among Kenyans is mainly for overweight or lean middle-aged individuals suffering from venous or cardioembolic diseases. Studies should correlate patients’ profiles with warfarin response to guide future management