Combining health and social protection measures to reach the ultra ...

Introduction
required, the levels of funding may well soon exceed the
capacities of the philanthropic sector and it will be vital
to attract larger investments from the public sector if this
“push” mechanism is going to fulfil its promise 13 . It will
also be vital to ensure that the efforts of the different
philanthropic and public sector donors become better
aligned, avoiding duplication or competition to back early
“winners” and ensuring that the complete spectrum of
“neglected diseases” receives adequate support. The
Organisation for Economic Co-operation and
Development's (OECD) initiative with the Dutch
Government in the “Noordwijk Medicines Agenda”
represents one important strand in the current efforts to
develop a more coherent and collaborative approach to
meeting this challenge 14 .
✜ At the same time, “pull” mechanisms are being
developed that are intended to provide incentives for
investment, especially by the private sector, to create new
products where there has been a market failure. One
approach now being implemented is the “advance
purchase commitment” (AMC) through which
governments guarantee a viable market by means of a
binding contract to purchase a newly developed
pharmaceutical product if it meets pre-determined
criteria. Several countries have recently announced
support 15,16 for this approach and, in a pilot case
announced in February 2007, an AMC is being applied
to a new pneumococcal vaccine 17 .
✜ It has been argued in some quarters that part of the
cause of market failure in the creation of drugs for
neglected diseases is the patent system which has
evolved over the last two centuries. The large
investments needed to create high-technology products
such as pharmaceuticals are rewarded by the granting of
exclusive intellectual property rights for a period of time,
during which the inventor can charge high prices in order
to recover the initial investment and potentially earn large
profits before the patent life expires and generic copies
drive prices down. This matter has been extensively
debated during the work of the Commission on
Intellectual Property Rights, Innovation and Public
Health 18 and its successor, the Inter-Governmental
Working Group on Public Health, Innovation and
Intellectual Property 19 . A number of proposals have been
advanced for alternative systems to stimulate and reward
innovation and to lower barriers to more collaborative
and less competitive efforts. These include creating open
access drug companies and patent pools and de-coupling
the rewards for invention from the subsequent pricing of
the products, rewarding innovation by offering prizes or
compensation based on the amount of disease averted in
developing countries 20,21 . These variants on the wellestablished
patent system provide a “twist” to
supplement the “push” and “pull” mechanisms outlined
earlier, which work within the existing regime of
intellectual property protection.
✜ In the last few years, a number of new initiatives have
been developed for the purchase of available medicines
for neglected diseases. These include new bodies such
as the Global Fund to Fight AIDS, Tuberculosis and Malaria
and the GAVI Alliance, and fund-creating mechanisms
like UNITAID and the International Financing Facility for
Immunization 12 . Although they do not themselves fund
drug research, the existence of these funds, which assure
large-scale finances for the purchase of needed products
for a number of years to come, may also stimulate
greater investment in R&D to create new products.
Equity in research
The domain of research itself exhibits a range of inequities:
imbalances in the allocation of resources to different types of
research and to the health problems of people in different
situations; limitations of access to decision-making and
priority-setting about the use of resources, to participation in
research and to the interpretation and use of its results. Thus,
while research may be aimed at tackling problems associated
with inequities in access to health, the research itself must be
rigorously inspected to remove biases that may contribute to
the perpetuation of inequities.
The BIAS FREE Framework is an analytical tool published
by the Global Forum 22 . It has rapidly gained popularity in a
number of settings in both developed and developing
countries as a powerful methodology for uncovering biases in
research due to a wide range of discriminatory factors
deriving from social hierarchies.
Across the world, there is broadly a consistent relationship
between health status and the availability of skilled health
workers, with those countries having the highest levels of
burden of disease also being the ones with the fewest trained
health-care providers 23 . Increased attention is now being
directed towards the crisis in human resources for health,
including through the establishment of the Global Health
Workforce Alliance 24 , with efforts focusing on critical elements
of the recruitment, training and retention of health workers in
poorer countries. However, an equally stark lack of skilled
health researchers – especially in Africa – has received much
less attention, as highlighted in an expert consultation on
human resources for health research held in 2006 in
Nairobi 25 .
Enabling research to make a full contribution to addressing
health and health equity issues requires ensuring equitable
access to a range of resources, including: capacity
development and human resources; tools to measure equity;
and funding for health research in all its dimensions,
including those relating to creating conditions for health, for
health promotion, prevention, treatment and care. Access to
the process of priority setting is also vital and this needs to
involve the application of equity principles and criteria to
setting the priorities for use of limited research resources to
address health needs, especially of the poor and vulnerable 26 .
Decision-making and governance
The research agenda relating to equitable access to decisionmaking
and governance includes examining how:
✜ policy-making involves all stakeholders (in particular
those who historically have been excluded from decision-
Global Forum Update on Research for Health Volume 4 ✜ 015