Former Executive Director of UNITAID
Today's major imbalances between the haves and the have-nots of the developing world and richer countries, together with the local and international conflicts of the 21st century, are pushing healthcare finance into a completely new era, where private players are also called upon to have a decisive role. Among the international organisations moving in this direction, UNITAID has achieved remarkable progress in a very short time: founded in September 2006 on the initiative of Brazil and France, with the goal of lowering the price of treatments for HIV / AIDS, malaria and TB in developing countries through market-based interventions, UNITAID already has a budget in excess of $1.3 billion, by including in its governance structure the UN, governments, private foundations (such as the Gates Foundation) and civil society, as well as a growing number of Member States. Denis Broun took up the post of Executive Director of UNITAID on 12 September 2011. Previously a specialist in pharmaceutical policies at the World Bank, and European director of Management Sciences for Health, he has worked in the fields of public health and health economics for more than 25 years. At Falling Walls he will shed new light on how to direct apparently contrasting interests towards the same global challenges.
Breaking The Wall Of Inaccessible Drugs. How Innovative Healthcare Finance Increases Treatment Coverage for HIV, Malaria and TB
Good afternoon or good evening, ladies and gentlemen. I am going to break with a lot of the tradition that you have had today by not having a PowerPoint. Sorry for the fact that your eyes, which have now been accustomed to look northwest will now have to change their direction. Now, when we are talking about the issue of access, and it is very much linked to what the previous speaker was talking about. We look at what is happening with access to drugs, and the situation has changed enormously in the last 25 or 30 years. In 1975, WHO was publishing that one third of the world population had access to essential drugs. In 2000, it was two thirds; in 2010 it is more than three fourths. So, things have changed enormously, but it still means that one and half billion people have no access to drugs.
Now this is a problem, but the question is: what does “access” mean? This is what I wanted to take you through: look at what are the various dimensions of access to drugs and how these dimensions have been addressed by various organisations and people in the recent years, what works, and what still remains to be addressed.
Now, “access” means a lot of things. Access is, as was described, is geography. If you have to walk three, five, ten hours to purchase a drug, access is not good. If it is just close by, it is definitely better. But then, it means you have a pharmacy close by. But if this pharmacy is empty—that is out of stock—then you have another problem: you don’t have access. So, if the products are not available, you don’t have access. Then, if you have products there, and you have a sick child, but the only thing you have is adult pills, and you have nothing adapted to the child, then it is still not access: you don’t have the products, which are adapted to what you have, and it may not be the products that you need for your own condition. Then after that, you arrive at a pharmacy, they ask you to pay for it, and you don’t have enough money to pay for it. This financial access, this affordability, of the drug is not there. So, you have a whole set of dimensions of what does really access mean when we come to pharmaceuticals. These dimensions have all been addressed by a whole set of initiatives. It is not perfect, but there has been so much progress in the last years, as Professor Kazatchkine was saying in his introduction, that it is definitely worth reviewing them rapidly.
The first is: do people get the right medicines? For years, when you looked at what is happening in the pharmaceutical front, you always heard: there is no research for the diseases of the poor; there is no incentives for the industry to make sure that the drugs, which are necessary for diseases which are exotic or only hit people who don’t have money—that the drugs would become available. This has changed. This has changed a lot. There have been a lot of international initiatives. Over the past 15-20 years, no more, public private partnerships for drug discovery, a whole set of new products have appeared.
When I started working in Africa, we were using old malaria drugs, which had been there for a very long time, and there was just no alternative. Today, we have a huge amount of new drugs for malaria. It is possible to treat people about anywhere in the world, and the pipeline of research development is full. We are going to get new drugs from malaria coming up every year, probably, in the coming five to ten years. We can say that in addition to the prevention, which was done with insecticide impregnated nets, people who are suffering from malaria are relatively safe. They can have access to appropriate treatment for the years to come.
In this coming year, 2013, two new drugs are going to be registered for tuberculosis. This had not happened for the past 20 years. So we have also a set of research coming up, new products coming out. The same applies to HIV. We have new treatments, a relatively good scope of different types of treatment, which can help people—not only for the first line when they are just starting on treatment, but also on second line, if they have become resistant. So, we have new mechanisms for research and development. New actors have come in, like the Bill and Melinda Gates Foundation, for instance, which has done phenomenal work in supporting research.
Now, of course, we still have ineffective products on the market. You see people who get treated for malaria; when they are lucky to be in Ghana close to the lab system, which was described to you, they will get an appropriate diagnosis, and most probably also appropriate treatment. But in most parts of Africa, people will try to go to the closest shop and buy a drug for malaria when they feel that they have high fever. They may have the flu—they may have something completely different—but they will still buy a malaria drug, and very often they are going to find a drug that is not going to work even on their malaria, because it is an old or inefficient drug. So, this is not finished, but the pipeline is there, and a lot of things have been done to make these products available.
What we see now also is that it is possible to find forms, which are adapted to the needs of patients. Paediatric forms, which is something that is so difficult to obtain in developing countries, are now coming up. Mechanisms of innovative financing, like the one that I am heading, UNITAID, which is in a large way financed by an air ticket levy, which is raised by nine countries at present, has allowed for the development of specific drugs, for paediatric forms of HIV or tuberculosis. We find now that there are new drugs for pregnant women. We find that there are drugs, which are injectable, but which are now put together with mechanisms of injection which cannot be reused: syringes that are not going to be reused once they have been dirty, which is unfortunately one of the big problems that we have had in several poor countries.
So, we have new drugs, and they are better. Now, are they closer? Do we get the drugs closer to the patients, closer than before? The problem is that it depends on a lot of factors, and it is, of course, a supply chain: are the drugs important, are they manufactured locally? But do you have wholesalers at work? And wholesalers: do they have an incentive to get these drugs to the peripheral level. That means: is there really a market? A wholesaler is not going to have a vehicle go to a small retail outlet if there is nobody there to buy drugs. So this has given rise to a lot of initiatives also on how is it possible to improve the local markets for drugs—not only in the private sector but also in the public sector to get a better system for ordering to get sure that the drugs would arrive to the most peripheral level, to use community health workers for the distribution of some essential drugs.
So, there are things, which are happening; it is not perfect yet. You have a lot of drugs, which are not available. A small drug shop in Ghana, for instance, and there are thousands of them, has the right to store 25 pharmaceuticals. The others are not allowed to have—actually very often they had them still, but they are not officially allowed, because you require more training than the shopkeeper has to distribute them. So, the people who live in these remote villages do not have access to treatment, and it is really difficult for them to find the geographic proximity to treatment.
But now lets imagine that the drug is there, it is close by, is it affordable? Now this is a major, major, problem. One of the biggest issues with access to drugs was the fact that they were not affordable to people. Why do we say ‘affordable’? Because, actually, most people pay for their drugs out of pocket. It is the case for most of the drugs in developing countries. And for us in Europe who have access to insurance, is something that does not resonate with us that much. You take people who live in Africa or in South Asia, most of the time they have to buy their drugs with their own money. Some surveys we did in Tanzania 15 years ago, some things have improved, we saw that more than half of the patients had to sell something to be able to buy their drugs—sell cattle, sell a piece of property, etc, because the drugs just could not be obtained without money from their own pocket.
We have drugs now, much better ones, and we have a lot of generic drugs, which have come. Generic drugs are cheaper, and we also have in the public sector a lot of procurement, which is done through tenders; so the drugs are cheaper also when the tenders are well done. A problem is that low price doesn’t always mean good quality, and there is an issue that I will conclude with.
We know also that when you push prices very low, there is a moment where people who compete on the tenders, always manufacturing old plants, because the moment they have to incorporate the depreciation of their new material in the price they are no longer competitive. So, there is a risk that we take sometimes of pushing prices very low. But, we have a lot of organisations that are displaying price comparisons, which are available. All of us can look at them on the web. It is possible to see at what price people are buying drugs in public tenders: through the Global Fund, WHO, Doctors Without Borders, International Dispensary Association. This is something, which is now improving a lot the situation.
As I told you, here, insurance systems pay for drugs. In developing countries it is out of pocket. The situation has improved. In the 80s, when the health systems collapsed, when there was a recession in Africa, people actually had to pay drugs, and with the price that they were paying, they were also financing the peripheral health system, because there was no one to pay the nurse, etc; so this was included in the price of pharmaceuticals. It was pretty awful.
This has improved, but still now people pay out of pocket mostly, and one of the next walls, when we speak of access for all, is definitely access for insurance and third- party finance. Now, I have told you briefly that very often there are stock-outs, and this is unfortunately the reality. It is important that new mechanisms of financing allow that there shouldn’t be stock-outs. The creation of the Global Fund for HIV, tuberculosis, and malaria, has really helped in removing stock-outs of these drugs. But still now, last year, more than 20% of people living with HIV had a moment when they could not obtain their drugs in developing countries—sometimes for a week, sometimes for a month. This is something that is really bad.
One of the things that we have been able to finance with innovative financing, for instance, has been revolving stockpiles—just capital: capital on stocks so that whenever there are shortages there could be a way to get the drugs to people. This has been done for tuberculosis, and in particular for the drugs for multi-resistant tuberculosis, which is complex to treat, and for which the treatment lasts two years. What has changed also is that it is no longer public sector versus private sector. There are really partnerships for distribution. There are mechanisms that have allowed that the quality of supply will be better and drugs will be more available.
Let me conclude maybe—because I am getting a bit long—on the issue of the drugs’ quality. For us, when we buy drugs here, we consider they are going to be of high quality, and it is the case. We have a very good quality control system, a very good registration system, and very good regulatory authorities. It is not the case in most developing countries. You have good manufacturing practice in several countries, but you don’t have a mechanism that can guarantee it. When you have an agency of a government, which gives you a stamp of approval saying, “This plant is of good quality”, you believe it here. There are some countries where you don’t believe this stamp, and sometimes you are right, because in some places you have enough corruption so that you can buy this stamp for not much.
So the problem of the quality of drugs is serious. With the improvement of access, a lot of market has been developed, and a market means opportunity for people who are selling fake drugs or poor quality products. This is probably one of the next issues that have to be addressed URGENTLY, and I hope you feel better soon. Thank you.