This summer, an All Party Parliamentary Group (APPG) on Tuberculosis of the UK Parliament produced a report on research and development for diseases that affect poor people. This was admirable, except that the report has little to do with global health R&D and instead concentrates on radical changes to the system of patents and intellectual property. It gets in a terrible muddle by confusing medicines for neglected tropical diseases — almost none of which are patented by the pharmaceutical industry — with medicines for chronic diseases.
The report is very long and was clearly written by someone who feels passionate about patents. It moves from an innocuous, if pointless, discussion of fifteenth century patent law in Venice (honestly) to modern-day proposals that would do terrible damage to the existing system of public-private product development partnerships. It is in these partnerships that most medicines for neglected tropical diseases are developed. The pharmaceutical industry often gives medicines that it has patented to the partnerships — something it could not do if the report’s suggestions were implemented.
We should not rush to blame the MPs on the APPG: they have few resources and no specialist expertise. They rely on services volunteered by outsiders. British MPs have a couple of staff and enormous demands on their attention. We should be grateful that any take time to focus on global health at all. We probably should, though, blame those who helped the MPs to write what could have been a very useful report.
Mary Moran of Policy Cures and I wrote to the APPG (the APPG posted it to their site as a response to the report). Readers will see that the letter has more of the erudite and moderate Dr Moran and rather less of me.
Anxious to show that I am neither erudite nor moderate, I could not resist posting a few extra thoughts
- The focus on intellectual property (IP) means that the report sets out the problems caused by a lack of incentives but does not ask whether there could be better incentives for research on diseases that affect poor people
Government-led activity should be focused on the needs of those who can do very little to help themselves: a citizen of the Central African Republic, for example, cannot tell her politicians to focus more effort and resources on health. Limited public resources should be focused on helping her not on subsidising the citizens of prosperous middle income countries who chose to spend their money on things other than health.
Brazil, for example, (with a PPP-adjusted per capita GDP of about $15,000) has far more in common with us (per capita GDP of about $36,000) than with the Central African Republic (per capita GDP of about $600). China is about to become the world’s third biggest pharmaceutical market. These are stark examples but even India (per capita GDP of about $5,500) is more similar to us than to the CAR. Most of the big middle income countries are democracies. We cannot doubt the ability of Brazilians, Indians or Indonesians to vote freely and make decisions about their own priorities
Our policies should support this democratic decision making, not seek to supplant it. What if we were we to use our diplomatic influence to persuade voters in middle income countries to shoulder their fair share of health spending? To give one example, if Nigeria were to spend what it has already promised to spend on public health and to meet the revenue ratios of its African peers, an extra $11 billion would have been available for hospitals, primary health care and medicines in 2012 (according to a Center for Global Development report this year)
Other middle income countries are worse. India and Indonesia spend, respectively, just 0.9 percent and 1.8 percent of GDP on government health spending. Even Brazil spends only about four percent (all according to the World Bank). Having many poor people probably means that the government of a middle income country should spend a higher proportion of its wealth on health than does the government of a high income country. Yet, the comparable figure in the UK (and across Europe and North America) is about nine percent. Increased domestic spending in emerging markets may be the only incentive required to get researchers and industry to focus on diseases that affect poor people in these countries.
Another incentive could come from extension of the tax breaks which reward innovation that the UK has pioneered. These could be adjusted so that they reward those companies which make discoveries that find a market in public and not-for-profit health systems in low and lower middle income countries. This would not require the UK to dictate to India what its priorities should be, simply that companies which succeed in selling to public and charitable health systems in India (and other low and middle income countries) would be rewarded for meeting the needs that Indian themselves have established.
- The focus on IP also ignores ways that governments could use research spending to reward countries (such as Malawi) which have very little but spend roughly the same proportion of their government revenues on public health as we do. Our governments could also confer fewer advantages on those which spend very little and distort their markets to favour inefficient domestic and state-owned enterprises. For example, many low income and lower middle income countries still charge VAT and other taxes on medicines or maintain high tariff barriers. Brazil, for example, adds 24 percent to the cost of medicines while Nigeria adds 30 percent. Should British taxpayers work to make medicines more affordable when some low and middle income countries are pulling the other way? Our current spending too often rewards these countries
- In the report, there is no discussion of the most obvious way of making treatment available to every poorer country where TB is a major problem: tiered pricing. Vaccines are available much more cheaply for countries with fewer resources and cost much more in Europe and North America. The pricing is broadly progressive and fair (although there are some disgraceful anomalies) and is based on per capita GDP and willingness to commit to national programmes. Taxpayers here tolerate the system. As a result, some of the poorest countries in the world have been able to protect children with the same brand new vaccines available to British and other European doctors. The report references this in a way that a very few experts might understand but which others will see as dismissive. The tiered pricing model makes many in pharma and NGOs nervous but it has worked. There may be a strong case for the UK to use influence, intellectual capital, tax incentives and research funding to extend it to most pharmaceuticals.