Providing Life-Saving Medicines to the Poor - Interview with Thomas Pogge and Aidan Hollis
What prevents the poor today from having access to life-saving medicines?
Every year some 10 million people around the world die from lack of access to life-saving medicines. High prices generated by the intellectual property rights (IPR) system are partly responsible, leaving patients – especially in developing countries and emerging markets – unable to access the medicines they need. Pharmaceutical companies are often demonized for selling their products with high mark-ups facilitated by patents, in blogs and articles with headlines like "the profits that kill." But we should recognize that these firms need to recoup large investment costs: few industries face such exorbitant R&D costs, multiplied by high failure rates, in developing new products that can be easily and cheaply retro-engineered and mass-produced by generic competitors. We should also recognize that drugs developed by pharmaceutical companies have saved millions of people. Thus we face, apparently, a complex and unresolved moral dilemma: with high patent-protected mark-ups, patients are dying from lack of access to life-saving medicines; and without such mark-ups, there are inadequate incentives to develop new drugs that could benefit everyone in the future.
What can be done to ensure that the poor can afford to pay for life-saving medicines and benefit more easily from them?
First, there is the problem of drug prices. Even in the wealthiest countries, high prices for some new drugs are excluding some people from new and effective therapies; and in lower-income countries, the problem of cost is even more acute. There poor people face additional barriers in the form of poorly functioning distribution systems that increase costs and in the form of under-resourced health systems that fail to deliver accurate and timely diagnoses. We need a solution – or a set of solutions – that addresses all of these issues.
The Health Impact Fund (HIF) is a proposed mechanism that offers a feasible reform to how we pay for (at least some) drugs. It has been designed to overcome the limitations of the current system and ensures that incentives for pharmaceutical innovation and marketing are harmonized with the needs of patients everywhere. In addition, the HIF would help improve distribution systems and prescribing, since drug companies would have stronger incentives to make sure that their drugs reached the patients who would benefit the most.
The Health Impact Fund proposal is promoted by Incentives for Global Health, a non-profit organization devoted to advancing market-based solutions to global health challenges. The HIF proposes a new way of paying for pharmaceutical innovation by incentivizing the development and delivery of new medicines through pay-for-performance mechanisms. All pharmaceutical firms worldwide would have the option of registering new medicines with the HIF. By registering, a firm would agree to provide its drug at cost anywhere it is needed, and in exchange for foregoing the normal profits from drug sales, the firm would be rewarded based on the HIF's assessment of the actual global health impact of the drug. Governments and other donors would finance the HIF. Companies would have strong incentives to get their HIF-registered products to the patients who would benefit the most, and they would therefore constructively engage with distribution chains and health systems to get their products in the hands of patients, whether poor or rich.
* PBR = performance-based reimbursement
What are the obstacles to overcome to make this whole new process work?
Essentially, there are two main obstacles. The first relates to the technical feasibility of measurement of health impact on a large scale. Because the HIF makes rewards explicitly dependent on the performance of the drug, measurement of outcomes is especially important. Both pharmaceutical companies and governments need to feel confident that it is possible to assess outcomes with reasonable consistency. Fortunately, there is an increased interest in performance-based reimbursement of drugs in almost all health systems and the recently European Research Council awarded a grant for in-depth research *. And we are developing a pilot measurement project that will address some of the most difficult, real-world problems of assessing health impact in developing countries.
Second, governments will need to coalesce around the idea of funding such a program, and this will require international cooperation. We are seeing some of that spirit in the current World Health Assembly, which is recognizing the value of a pooled funding mechanism.
How can International Organizations, such as the UN and UNESCO, help in the efforts to make life-saving medicines better accessible to patients worldwide?
Realising a reform plan as complex as amending the international IPR system requires three main things.
1) In-depth high-quality research, which we are providing as part of the European Research Council funded project.
2) Pharmaceutical company buy-in, including for pilot studies to test and refine the reform plan. We are currently in the process of developing a pilot study in India.
3) Policy-maker and public buy-in to fund the scheme.
International Organizations such as the UN or UNESCO can help greatly in gathering support around specific reform plans. For instance, the bioethics section of UNESCO is heavily involved in capacity-building on ethical issues in developing countries. This is usually related to the setting up and training of ethics committees. However, in doing so, they are liaising with people in decision-making positions in countries that could benefit significantly from the creation and introduction of the HIF. Hence, popularising a specific reform plan such as the HIF would be one way that an organisation such as UNESCO could make a difference.
Good research and good intentions won’t suffice to achieve real and sustainable change: the support of international organisations and policy makers is crucial.
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* The grant was awarded to Prof Thomas Pogge from 2014 to 2019. The UNESCO meeting on 6 June 2014 has received funding from the European Research Council under the European Union's Seventh Framework Programme (FP/2007-2013) / ERC Grant Agreement no. 339239.