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

Introductionrequired, the levels of funding may well soon exceed thecapacities of the philanthropic sector and it will be vitalto attract larger investments from the public sector if this“push” mechanism is going to fulfil its promise 13 . It willalso be vital to ensure that the efforts of the differentphilanthropic and public sector donors become betteraligned, avoiding duplication or competition to back early“winners” and ensuring that the complete spectrum of“neglected diseases” receives adequate support. TheOrganisation for Economic Co-operation andDevelopment's (OECD) initiative with the DutchGovernment in the “Noordwijk Medicines Agenda”represents one important strand in the current efforts todevelop a more coherent and collaborative approach tomeeting this challenge 14 .✜ At the same time, “pull” mechanisms are beingdeveloped that are intended to provide incentives forinvestment, especially by the private sector, to create newproducts where there has been a market failure. Oneapproach now being implemented is the “advancepurchase commitment” (AMC) through whichgovernments guarantee a viable market by means of abinding contract to purchase a newly developedpharmaceutical product if it meets pre-determinedcriteria. Several countries have recently announcedsupport 15,16 for this approach and, in a pilot caseannounced in February 2007, an AMC is being appliedto a new pneumococcal vaccine 17 .✜ It has been argued in some quarters that part of thecause of market failure in the creation of drugs forneglected diseases is the patent system which hasevolved over the last two centuries. The largeinvestments needed to create high-technology productssuch as pharmaceuticals are rewarded by the granting ofexclusive intellectual property rights for a period of time,during which the inventor can charge high prices in orderto recover the initial investment and potentially earn largeprofits before the patent life expires and generic copiesdrive prices down. This matter has been extensivelydebated during the work of the Commission onIntellectual Property Rights, Innovation and PublicHealth 18 and its successor, the Inter-GovernmentalWorking Group on Public Health, Innovation andIntellectual Property 19 . A number of proposals have beenadvanced for alternative systems to stimulate and rewardinnovation and to lower barriers to more collaborativeand less competitive efforts. These include creating openaccess drug companies and patent pools and de-couplingthe rewards for invention from the subsequent pricing ofthe products, rewarding innovation by offering prizes orcompensation based on the amount of disease averted indeveloping countries 20,21 . These variants on the wellestablishedpatent system provide a “twist” tosupplement the “push” and “pull” mechanisms outlinedearlier, which work within the existing regime ofintellectual property protection.✜ In the last few years, a number of new initiatives havebeen developed for the purchase of available medicinesfor neglected diseases. These include new bodies suchas the Global Fund to Fight AIDS, Tuberculosis and Malariaand the GAVI Alliance, and fund-creating mechanismslike UNITAID and the International Financing Facility forImmunization 12 . Although they do not themselves funddrug research, the existence of these funds, which assurelarge-scale finances for the purchase of needed productsfor a number of years to come, may also stimulategreater investment in R&D to create new products.Equity in researchThe domain of research itself exhibits a range of inequities:imbalances in the allocation of resources to different types ofresearch and to the health problems of people in differentsituations; limitations of access to decision-making andpriority-setting about the use of resources, to participation inresearch and to the interpretation and use of its results. Thus,while research may be aimed at tackling problems associatedwith inequities in access to health, the research itself must berigorously inspected to remove biases that may contribute tothe perpetuation of inequities.The BIAS FREE Framework is an analytical tool publishedby the Global Forum 22 . It has rapidly gained popularity in anumber of settings in both developed and developingcountries as a powerful methodology for uncovering biases inresearch due to a wide range of discriminatory factorsderiving from social hierarchies.Across the world, there is broadly a consistent relationshipbetween health status and the availability of skilled healthworkers, with those countries having the highest levels ofburden of disease also being the ones with the fewest trainedhealth-care providers 23 . Increased attention is now beingdirected towards the crisis in human resources for health,including through the establishment of the Global HealthWorkforce Alliance 24 , with efforts focusing on critical elementsof the recruitment, training and retention of health workers inpoorer countries. However, an equally stark lack of skilledhealth researchers – especially in Africa – has received muchless attention, as highlighted in an expert consultation onhuman resources for health research held in 2006 inNairobi 25 .Enabling research to make a full contribution to addressinghealth and health equity issues requires ensuring equitableaccess to a range of resources, including: capacitydevelopment and human resources; tools to measure equity;and funding for health research in all its dimensions,including those relating to creating conditions for health, forhealth promotion, prevention, treatment and care. Access tothe process of priority setting is also vital and this needs toinvolve the application of equity principles and criteria tosetting the priorities for use of limited research resources toaddress health needs, especially of the poor and vulnerable 26 .Decision-making and governanceThe research agenda relating to equitable access to decisionmakingand governance includes examining how:✜ policy-making involves all stakeholders (in particularthose who historically have been excluded from decision-Global Forum Update on Research for Health Volume 4 ✜ 015