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

Introduction
Type I
Type II
Type III
Prevalent in both rich and poor countries, with large
numbers of vulnerable population in each.
Prevalent in both rich and poor countries, but with a
substantial proportion of the cases in poor countries.
Overwhelmingly or exclusively prevalent in
developing countries.
Box 1: Categories of diseases according to their relative
prevalence in higher- and lower-income countries
The role of health systems 7 in challenging inequity has
been the subject of study by the CSDH Knowledge Network
on Health Systems. The report of this Knowledge Network 8
synthesises a large amount of available evidence on how
health systems can contribute to reducing health inequities
and provides a policy guide on actions that can be taken to
address these inequities, including mobilizing intersectoral
relationships, facilitating social empowerment, building up
universal coverage, revitalizing primary health care,
strengthening the process of developing and implementing
policies, and securing international support for nationally-led
health system transformation and action. While the focus of
the report is on the use of existing knowledge, it identifies
many gaps and also serves as a stepping off point for an
extensive agenda of new research. This is especially
important in the light of the fact that, as the report itself notes,
the experience of health systems is always context-specific.
Innovation
Research to improve health is best understood as a process
within a chain of health innovation that begins with a
concept, question or observation and proceeds through
experimental investigation towards the eventual application of
the results to the use of a new process or product in the field.
Innovation for health equity should not be regarded as being
restricted to the creation of affordable and appropriate
medical products and technologies 9 . It also includes
developing and applying understanding of how to improve
equitable access through novel health policies, services and
systems, interventions and support mechanisms; and
encompasses the application of health technology
assessment to assist in selecting the most appropriated and
cost-effective technologies to meet health needs, especially of
the poor and vulnerable. And it includes innovations in
understandings and measurements of health and health
equity.
Pharmaceutical products for diseases
endemic in developing countries
Diseases have been categorized into Types I to III according
to their relative prevalence in higher- and lower-income
countries 10 (Box 1).
For a range of diseases that substantially or predominantly
occur in poorer countries (Types II and III), access to
pharmaceutical products for prevention, diagnosis and
treatment has often been very poor. Two major elements of
this limited access can be identified:
1.For many of the diseases which have little or no prevalence
in high-income countries, there has been a dearth of
research and development (R&D) resulting in the
registration of new products. Thus, of the new
pharmaceutical products registered for human use in the
period 1975–1997, only 13 (around 1%) were for tropical
parasitic infections 11 . As a result, treatments are either not
available or depend on very old generic drugs that may
have significant side effects and efficacies that are limited
and declining due to emerging resistance. Where
diagnostic tools for these diseases exist, they may be slow,
insensitive or unsuited to field conditions prevailing in the
disease-endemic countries, requiring highly skilled
personnel or sophisticated laboratory settings.
2.In cases where newer and more effective drugs, vaccines
and diagnostics are available, these have sometimes found
relatively low levels of uptake and use in developing
countries, due to factors including affordability and the
availability of health systems for their delivery.
It is clear that, to a large extent, these two elements are
related to a common problem – that of market failure.
Substantial R&D investments are needed to create new
pharmaceutical products and these are unlikely to be made
by the private sector where there is not seen to be a good
market for recouping the investments. Drugs created for a
market in high-income countries, where per capita
expenditures on health run into thousands of dollars per year,
may prove too expensive for use in low-income countries
whose health expenditures are far less than 100 dollars per
capita per year.
Several different approaches have been explored or
proposed to solve the problem, varying according to the stage
in the chain of innovation and product delivery/uptake at
which the market failure is perceived to be occurring:
✜ For a range of “neglected diseases” – especially tropical
parasitic infections, but also HIV/AIDS and TB –
investments in R&D for drugs, vaccines and diagnostics
has come from the philanthropic sector, with the
Rockefeller Foundation taking a lead in the mid 1990s in
the creation of product development public-private
partnerships (PDPs) beginning with the International
AIDS Vaccine Initiative. The Bill & Melinda Gates
Foundation has made substantial contributions since
2000. More recently, a number of bilateral donors (e.g.
Ireland, Netherlands, Norway, UK) have started to
become increasingly significant supporters of this
approach 12 . PDPs have generally taken a portfolio
approach, creating a pipeline of candidate products in
development, some of which are now in or about to enter
clinical trials. Since the latter – especially Phase III trials
to prove efficacy and involving large numbers of patients
in the field – are very expensive, a major challenge now
facing the world is how to provide adequate funding to
ensure that effective new products reach registration and
enter clinical use in disease-endemic countries. Across
the range of diseases and products for which support is
014 ✜ Global Forum Update on Research for Health Volume 4