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How to build a supportive public health economy

Simcha Jong
Professor and Director of the DBA Health programme at University College London
Rifat Atun
Professor of Global Health Systems at Harvard's T.H. Chan School of Public Health
Thierry Rayna
Thierry Rayna
Researcher at the CNRS i³-CRG* laboratory and Professor at École Polytechnique (IP Paris)
Key takeaways
  • In 2011, the pharmaceutical industry spent between $162-265bn on research.
  • But the industry tends to under-invest in certain areas, such as maternal and neonatal health.
  • Neoplasms carry the same medical weight as neonatal disorders but were the subject of 1,600 clinical trials in 2015, compared with 11 projects for neonatal health.
  • The reasons for this lack of support include regulations, limited knowledge, and financial profitability.
  • One solution is to encourage more public-private partnerships, as was the case for neglected tropical diseases in the 2000s.

It’s an under­state­ment to say that health­care requires major invest­ment: indeed, the phar­ma­ceu­ti­cal indus­try spends a huge amount every year prepar­ing the solu­tions of tomor­row. And yet, despite such huge sums, some sec­tors still suf­fer from under-invest­ment. While this phe­nom­e­non of under-invest­ment may be pre­dictable – cer­tain dis­eases are becom­ing increas­ing­ly rare – it is more sur­pris­ing when it affects areas such as mater­nal and neona­tal health, which are the sub­ject of far few­er projects and clin­i­cal tri­als. The rea­son is not, of course, a lack of rel­e­vance or inter­est in these sub­jects: the research con­duct­ed by Pro­fes­sor Sim­cha Jong high­lights the role played by reg­u­la­tions, the rel­a­tive lack of knowl­edge and expec­ta­tions of lim­it­ed finan­cial returns in this phe­nom­e­non. This research also indi­cates that pub­lic-pri­vate part­ner­ships are capa­ble of pro­vid­ing a solu­tion to the under-invest­ment in mater­nal and new­born health research, just as they were use­ful in accel­er­at­ing research into trop­i­cal dis­eases 20 years ago.

Thier­ry Ray­na, Tech4Change Chair

Eco­nom­ics can become a key fac­tor in pub­lic health: this is the hypoth­e­sis that has been the focus of our work over the last few years. On the one hand, drugs account for a major pro­por­tion of health­care expen­di­ture. On the oth­er, cer­tain inno­va­tions, such as treat­ment for hepati­tis C, anti­retro­vi­rals and can­cer immunother­a­pies, have the intrin­sic pow­er to mas­sive­ly reduce the impact of these dis­eases on our soci­eties. In 2011, the phar­ma­ceu­ti­cal indus­try spent between $162–265bn on research1. Encour­ag­ing bio­phar­ma­ceu­ti­cal com­pa­nies to invest in research and devel­op­ment (R&D) in med­ical fields with high mor­tal­i­ty and mor­bid­i­ty could there­fore reduce the bur­den of these dis­eases.  Our research sug­gests that pub­lic-pri­vate part­ner­ships are an effec­tive tool. Why pub­lic-pri­vate part­ner­ships? Because, left to its own devices, indus­try tends to under-invest in cer­tain dis­ease areas such as mater­nal and neona­tal health.

High demands, low investments

Pre­vi­ous work has mapped med­ical needs and their impor­tance in terms of glob­al health2. We have linked this data to the R&D efforts of phar­ma­ceu­ti­cal com­pa­nies for each dis­ease group, the lat­ter para­me­ter being cal­cu­lat­ed based on the num­ber of clin­i­cal tri­als. More than 62,000 projects were analysed, includ­ing near­ly 11,000 in active (pre)clinical devel­op­ment as of sum­mer 2015, cov­er­ing 1,202 dif­fer­ent dis­eases. In some cas­es, there is a clear match between the impact of the dis­ease and its fund­ing. For exam­ple, the bio­phar­ma­ceu­ti­cal indus­try allo­cates R&D resources to projects tar­get­ing dif­fer­ent types of can­cer on the basis of the glob­al impact that these dif­fer­ent dis­eases rep­re­sent. In oth­er cas­es, there is an imbal­ance between the scale of the health need and the R&D cov­er­age: this is the case, for exam­ple, with mater­nal and neona­tal health problems.

How­ev­er, if we use the num­ber of years lost due to dis­ease as an indi­ca­tor on a glob­al scale (DALY, for dis­abil­i­ty-adjust­ed life years), we see that neo­plasms, tumours made up of cells that pro­lif­er­ate exces­sive­ly, have a sim­i­lar weight to neona­tal dis­or­ders. But the com­mit­ment to clin­i­cal research that they gen­er­ate is in no way com­pa­ra­ble. In the sum­mer of 2015, there were 1,600 clin­i­cal tri­als for neona­tal tumours, where­as for the same peri­od there were only 11 active indus­tri­al R&D projects for neona­tal dis­or­ders. These child­hood patholo­gies are there­fore vic­tims of under-invest­ment in R&D. In a per­fect mar­ket, the indus­try’s R&D efforts would be more even­ly dis­trib­uted between these two cat­e­gories of disease. 

Of course, there are struc­tur­al rea­sons why bio­phar­ma­ceu­ti­cal com­pa­nies make such lit­tle com­mit­ment to R&D in neona­tal and mater­nal dis­eases. These include the par­tic­u­lar­ly pro­tec­tive reg­u­la­to­ry frame­work for these pop­u­la­tions, as well as the dif­fi­cul­ties in build­ing up a body of detailed bio­log­i­cal knowl­edge about these crit­i­cal peri­ods of life. We also need to con­sid­er the prof­itabil­i­ty imposed by the indus­tri­al sys­tem: a treat­ment for can­cer may be sold at a much high­er price than its equiv­a­lent for mater­nal dis­eases, because the for­mer affects pop­u­la­tions that are on aver­age wealth­i­er than the lat­ter. Can we cor­rect this imbal­ance in incen­tives? The exam­ple of neglect­ed trop­i­cal dis­eases shows that it can.

Encouraging public-private sector partnerships

This group of dis­eases was iden­ti­fied as a health pri­or­i­ty by the UN in the ear­ly 2000s. This deci­sion led to mea­sures to encour­age the cre­ation of pub­lic-pri­vate part­ner­ships such as the Med­i­cines for Malar­ia Ven­ture and DNDi, as well as invest­ment by pub­lic donors in research into these dis­eases, and gen­er­al­ly to a much more attrac­tive and less risky envi­ron­ment, for exam­ple by com­mit­ting the inter­na­tion­al author­i­ties to pur­chas­ing a cer­tain quan­ti­ty of anti-malar­i­al treat­ments at a pre-defined price. This pro­gramme has been deployed through a wide vari­ety of mech­a­nisms that help to reduce R&D risks for these dis­eases from the point of view of industry.

The indus­try tends to under-invest in cer­tain dis­ease areas such as mater­nal and neona­tal health.

This mod­el, devised for neglect­ed trop­i­cal dis­eases, has proved its worth. Between 1975 and 1999 of the near­ly 1,400 com­pounds approved by the health author­i­ties, 13 con­cerned neglect­ed and trop­i­cal dis­eases. Since then, there are 54 drugs on the mar­ket and 188 ther­a­pies in development.

Could this mod­el be applied to oth­er pub­lic health issues? Europe already has a strong R&D pol­i­cy, as demon­strat­ed by the Hori­zon 2020 and Hori­zon Europe pro­grammes. But when it comes to health, the pri­or­i­ties gen­er­al­ly focus on Euro­pean health issues. And, as the pan­dem­ic has vivid­ly illus­trat­ed, health issues can­not be cov­ered by a region­al approach. It is there­fore in our col­lec­tive inter­est to put in place ambi­tious pub­lic fund­ing poli­cies for all the neglect­ed fields of med­i­cine. Only then can we hope to encour­age the devel­op­ment of new treat­ments for mater­nal patholo­gies and neona­tal disorders.

1Moses et al. JAMA 2015
2Dis­abil­i­ty-adjust­ed life years (DALYs) for 291 dis­eases and injuries in 21 regions, 1990–2010: a sys­tem­at­ic analy­sis for the Glob­al Bur­den of Dis­ease Study 2010. Mur­ray, Christo­pher J L et al. The Lancet, Vol­ume 380, Issue 9859, 2197- 2223

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