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1. Blueprint for a Market-Driven Value-Based Advance Commitment for Tuberculosis

Author:
Kalipso Chalkidou, Martina Garau, Rachel Silverman, and Adrian Towse
Publication Date:
02-2020
Content Type:
Special Report
Institution:
Center for Global Development (CGD)
Abstract:
Innovation—delivering new drugs, diagnostics, and devices—is a critical tool in the global fight against disease and premature death. Yet despite the potential for innovation to improve health around the world, the pharmaceutical industry’s investments in research and development (R&D) generally neglect diseases of the poor in favour of more lucrative high-income markets. Responding to this R&D gap, donor “push” investments have helped advance an innovation agenda to serve low- and middle-income countries. Though these investments have helped accelerate market entry of several important innovations, other donor-push products have fizzled upon market entry due to unaffordable or non-cost-effective pricing, disappointing efficacy, lack of political will, or lower-than-anticipated country demand. And with many large middle-income countries (MICs) poised to soon transition from donor aid, the sustainability of the current donor-led model is in question. Tuberculosis (TB), an infectious disease primarily affecting the poor and vulnerable, ranks among the top 10 global causes of death. Current TB treatment cycles are long and toxic, causing some patients to discontinue treatment, develop acquired drug resistance, and risk spreading a drug-resistant pathogen to others. Drug-resistant strains are more difficult to treat, traditionally requiring long-duration toxic regimens and high-cost hospitalization (though recent innovations offer a shorter, more tolerable, and more affordable treatment). Despite years of global investment in TB control, modelling suggests that global goals for TB cannot be achieved without major technological breakthroughs. One particularly desirable innovation would be a short-course universal drug regimen (UDR)—equally capable of treating drug-sensitive and drug-resistant strains, with a two-month or shorter treatment duration. Donors, particularly the Bill & Melinda Gates Foundation (BMGF), have funded substantial early-stage R&D to source new treatment compounds that could contribute to a UDR, but substantial additional investments in late-stage trials would be required to bring such a UDR to market.
Topic:
Health Care Policy, Drugs, Medicine, and Pharmaceuticals
Political Geography:
Global Focus

2. Can Transparency Lower Prices and Improve Access to Pharmaceuticals? It Depends

Author:
Kalipso Chalkidou and Adrian Towse
Publication Date:
04-2019
Content Type:
Working Paper
Institution:
Center for Global Development (CGD)
Abstract:
spending on pharmaceuticals and other healthcare commodities is high and makes up a large proportion of healthcare spending in rich and poorer markets alike. A popular response to the problem of escalating drugs budgets has been transparency of drug pricing within and across borders. In a rare alignment of policy priorities, the Trump administration, the US Senate, and the World Health Organisation are calling for more transparency of the prices paid for prescription drugs as a means of tackling the ever-growing pharmaceuticals bill. Recently Italy’s health minister joined in, calling for a World Health Assembly resolution which would mandate WHO to “provide governments with a forum for sharing information on drug prices, revenues, research and development costs, public sector investments and research and development subsidies, marketing costs and other related information.” But is price transparency really the answer to healthcare systems’ fiscal sustainability challenges as they strive to expand access to new technologies or even merely sustain provision within strained public budgets? Well, it depends!
Topic:
Transparency, Medicine, Pharmaceuticals, and Price
Political Geography:
Global Focus

3. Aggregating Demand for Pharmaceuticals is Appealing, but Pooling Is Not a Panacea

Author:
Cassandra Nemzoff, Kalipso Chalkidou, and Mead Over
Publication Date:
05-2019
Content Type:
Working Paper
Institution:
Center for Global Development (CGD)
Abstract:
As low- and middle-income countries reduce their reliance on donor aid, they are increasingly obliged to assume some degree of financial responsibility for donor projects. This challenge will be particularly complex in the procurement of health commodities. In recent decades, recipient countries have benefitted from donor-aggregated demand and pooling mechanisms, negotiated prices, purchasing, and delivery of commodities. However, as countries shift away from donor support, their challenge will be finding a way to aggregate demand in order to achieve the benefits that the pooled purchasing arrangements of vertical health programs now provide. As a first step in tackling this challenge, much can be learned from a diverse group of pooled procurement initiatives that have developed over the past 40 years in high-, middle-, and low-income countries. This note reviews the rationale and functions of these initiatives, notes their potential benefits and barriers, and draws lessons regarding how best to incorporate pooled pharmaceutical purchasing models into the design and implementation of health financing reforms in countries in transition. We first provide a brief background on the procurement challenges faced by countries in transition. In section 2, we provide an overview of different types of pooling initiatives, highlighting the key features of each. Leveraging our research and key interviews, we outline the real and potential benefits of pooling in section 3, and the most pressing barriers that organizations or countries will face as they seek ways to aggregate demand in section 4. In section 5 we discuss some of the issues that countries and development partners should address when considering pooled procurement initiatives and make two recommendations: (1) countries and development partners should conduct further research on the merits of pooled procurement, and (2) they should develop a straw model of a pooled procurement governance structure that could be tested using a series of pilots.
Topic:
Budget, Public Health, Medicine, and Pharmaceuticals
Political Geography:
Global Focus

4. Why Uncertainty in Global Health Interventions Matters—and What We Can Do About It

Author:
Kalipso Chalkidou, Anupama Dathan, and Francis Ruiz
Publication Date:
09-2019
Content Type:
Policy Brief
Institution:
Center for Global Development (CGD)
Abstract:
Global health interventions, like many public policies, are rife with uncertainty. Will a program, such as a malaria prevention strategy that looks strong on paper, work as intended? Will a new technology, such as a specific drug or device that appears effective in clinical trial settings, work in practice and provide good value-for-money? In the case of programs made up of a complex interaction of multiple interventions, implementers often create a theory of change and then meticulously track whether it is being followed every step of the way, from each input translating into the prespecified activity, and the activities yielding the right outputs and the expected outcomes. When observational data is available that permits quantitative analysis (evaluation), it may also be possible to estimate causal impact in a given setting by applying experimental methods (such as a randomized controlled trial) or quasi-experimental techniques (such as difference-in-difference analysis). Such program evaluations generally consider outputs (e.g. the number of bed nets distributed) and relatively short-term outcomes (e.g. malaria infections following bed net distribution). Many eval- uations also collect data years after the program to identify longer-term impacts. Cost-effectiveness calculations are sometimes conducted after ascertaining the cost and impact of the program, but such analyses aren’t necessarily considered when determining whether to implement a certain program or technology—especially when politics and other concerns get in the way. Discrete clinical interventions and technologies (which are defined as including clinical interven- tions, drugs, diagnostics and even public health programs) are usually the subject of health technolo- gy assessment (HTA) to inform coverage decisions in many contexts. The underpinning evidence base for HTA typically involves a synthesis of randomized trial data, designed to reduce bias in estimating causal inference and relative effectiveness. Trial data is then combined with information from other sources and study designs to develop models of the technology’s long-term health and cost impact in a given context. A key feature of both programs and technologies is uncertainty.
Topic:
Health, International Cooperation, Science and Technology, Humanitarian Intervention, and Pharmaceuticals
Political Geography:
Global Focus