PHA-Exchange> WHO and ARV access (2)

[Claudio]

From: "Peter Burgess" <Profitinafrica at aol.com>
>
> WHO and ARV access (2)
> ----------------------
> Dear Colleagues
>
> I have just read the posting of August 6 about ARV access, an article
from the Boston Globe........ it started:
>
> "The World Health Organization announced yesterday that it will cre-
> ate a new model to buy antiretroviral AIDS drugs in hopes of dramati-
> cally speeding distribution and reducing the cost of the life-saving
medication."
>
> and talked about:
> "The plan comes from a collaboration among tuberculosis experts,
> foremost among them the new WHO director general, Jong-wook Lee. That
> program, called the TB Drug Facility, purchases drugs in bulk on be-
> half of countries and then oversees the distribution."
>
> I am terribly sceptical. I think the "facts" are spurious and reflect
> more spin than reality. My background is numbers and understanding
> the impact of investment and expenditure on economic outcomes. The
> article continued:
>
> "Global health specialists have applauded the program because it cre-
> ated a larger market for TB drugs and spurred competition. That in
> turn drove down the cost of TB drugs, 30 percent for front-line, or
> commonly used, medication and 95 percent for secondary drugs."
>
> That is a pretty impressive statement. And totally out of line with
> the scale of the WHO intervention. My view is that this statement is
> complete "hogwash" and the Boston Globe should have known better than
> to report it without some serious caveats. Can this statement stand
> up to independent review and validation?
>
> "The program, which has reached nearly 2 million TB patients the past
> two years, also has provided an additional benefit: The WHO works
> with local partners to ensure that the drugs are being distributed
> properly, providing a safeguard against improper use, which can lead
> to drug resistance."
>
> How many TB patients are there in the world? Maybe there are as many
> as 2 million TB patients in a country the size of Malawi alone (I
> talk about Malawi because of my personal visits to Malawi in the
> quite long distant past and my surprise at the number of TB patients
> in the hospitals at that time).
>
> And the issue of meaningful numbers goes on. This bit that really
> bothers me.
>
> "At a cost of less than $20 million, the program has delivered drugs
> to 33 countries and decreased the price of the main TB drugs to as
> low as $11 for a six-month daily regimen of medicine".
>
> Do the arithmetic. WHO is a big agency, and a program that is averag-
> ing $600,000 per country is unlikely to be getting these really amaz-
> ing price drops. It is just not credible.
>
> There is nothing wrong with having ambitious goals. But talking about
> goals and delivering on them are two different things. The UN agen-
> cies and all the other alphabet soup of development agencies are long
> on talk and goal setting and very short on actually delivering bene-
> fits to those that need resource assistance.
>
> "The main issue is getting drugs to patients, and we've got to make
> it more rapidly available," said Ian Smith, one of Lee's top advis-
> ers. Lee has embraced a goal of treating 3 million people with anti-
> retroviral medicines by the year 2005. Now, about 300,000 people in
> the developing world receive those drugs."
>
> So now we go back to the planning stage. More money for plans and
> studies and another delay in getting down to the real work. And other
> agencies are planning to use the same delay model so that the real
> issue of getting down to practical help can be deferred again.
>
> "The WHO has pledged to draw up a plan by Dec. 1 to meet its goal.
> The plan, which the WHO hopes will begin in three to four months,
> also will cover anti-malarial medication. Others in the health field,
> including those working in family planning, are also examining the
> model and may adopt it, WHO officials said. "The primary goal in this
> is to dramatically increase access," Smith said. "We also want to re-
> duce the price, but that is a by-product of the program and not the
> primary aim."
>
> This is some good news. "Big Pharma" from the NORTH has been shamed
> into letting some modest amount of generic from the SOUTH get into
> the global market place. The advocates for PLWHA, NORTH and SOUTH
> combined to denounce the horror of the prevailing global intellectual
> property (IP) regime that protects big pharma profit at the expense
> of human life, especially the life of poor people. "The price of ge-
> neric antiretroviral drugs tumbled sharply last year to roughly $1 a
> day for people with AIDS in the developing world. The cost in the
> United States is about $10,000 a year. AIDS activists hope the price
> falls even further, and some believe the TB model holds great prom-
> ise."
>
> Paul Zeitz says the WHO program was very successful. He may be right,
> but I doubt it. What the WHO is saying is very favourable, but it
> does not make it right. I do not for a minute think that the WHO num-
> bers would stand up to statistical and economic peer review nor com-
> petent independent audit. I agree totally with Paul Zeitz that low
> cost quality generic producers should be engaged in the production of
> valuable drugs, and that there is a lot of work to be done to get
> drugs (and the other needed health interventions) available to every-
> one who could benefit from the treatments.
>
> "The principles of the program were very successful and we think
> could be applied" for AIDS drugs, said Paul S. Zeitz, executive di-
> rector of the Global AIDS Alliance, an advocacy organization. "It
> could be fantastic." Zeitz cautioned that developing countries still
> should explore options under consideration for pooling resources re-
> gionally, until a new WHO program proves successful. But he said, "If
> you can bring on other producers, and create competition among gener-
> ics, you'll have Thai producers, Brazilian producers, Chinese generic
> producers, all competing with the Indian producers, and as you create
> more and more demand for the drugs, we believe it will continue to
> drive the price down."
>
> The cost to manufacture incremental quantities of these drugs is
> tiny. The big expense is the development and the testing. But once
> they are just being manufactured the costs are modest. Pricing is not
> about cost. It is about profit and funding the next round of develop-
> ment. That is OK, as long as ALL the people needed the drugs have ac-
> cess.......... but it is not OK when almost 100% of the people need-
> ing the drugs cannot get access.
>
> "The price of generic antiretroviral drugs tumbled sharply last year
> to roughly $1 a day for people with AIDS in the developing world. The
> cost in the United States is about $10,000 a year. AIDS activists
> hope the price falls even further, and some believe the TB model
> holds great promise."
>
> The big danger in articles like this is that the general reader comes
> away with the idea that the WHO program is going to solve the prob-
> lem, when in fact the WHO program will at best address maybe 1% of
> the problem. The WHO looks good. The problem goes on the back burner
> for the reader once again.
>
> The WHO is not the only development agency that does this. All the
> official development assistance community (The World Bank, the IMF,
> the various bilateral donor agencies, all the UN agencies, even the
> NGOs) talk about how their programs are doing good work. To some ex-
> tent they are. But in aggregate their programs are totally insuffi-
> cient to make a big difference, and there is nothing happening to
> change the fund allocations so that the problems can get to be ad-
> dressed in a time frame that is meaningful for the present generation
> of PLWHA.
>
> There are some amazing things that are done by the development agen-
> cies, and especially by individuals in the system who are willing to
> put themselves in harm's way. But there is a serious systemic problem
> that is causing major damage to development performance. Development
> agencies do NOT have the resources to do the work that needs to be
> done, and they will not say this out loud and clearly. They hardly
> have enough money for their own staff (and the related pensions) and
> they are seeking desperately to stay funded. They need more re-
> sources. And development problems need more resources. In my view,
> the continuing cycle of study and "spin" is getting in the way of
> solving the underlying big problem of development "process" and de-
> velopment "resources".
>
> A lot of people reading this list know the problems. The challenge is
> to find a solution, and I will argue that a solution is going to
> found when we think much more about "people" instead of organization
> or program or procedure and we have a lot better "information" in-
> cluding the accounting and accountability dimension of information.

Peter Burgess
> ATCnet in New York
> mailto:peterb at iitc.safe-mail.net