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Ebola: Some thoughts from my time in Liberia By John Spray, ODI Fellow, Ministry of Commerce and Industry, Liberia.

 

A lot has been written about the Ebola crisis in West Africa in the last few weeks. Many excellent articles have highlighted the plight of those suffering with Ebola (Newsweek), and the people on the frontline trying to tackle the virus (Time) and the consequences on the affected countries as a whole (How we made it in Africa). However, the real tragedy is how an inherently preventable virus was able to spread like wildfire throughout West Africa and why public health facilities failed on such an enormous scale.

I first heard about Ebola in March 2013, four months after the first patient died of the virus in a small village in south-eastern Guinea, the first ever in West Africa.
With the death toll rising across the border in Guinea, discussions in Monrovia turned to the threat of it reaching the capital: “no previous outbreak has killed more than 300 people”, “it is easy to avoid just don’t go near sick people and you are safe”, and “the disease kills people so quickly it will die out before it reaches Monrovia”. The general message was “it is scary, but we can control it with basic public health.”

Despite these reassurances, everyday you check the news: how many infected? How many died? How many health clinics were beginning to shut due to healthcare workers leaving their posts? Despite the growing chaos, we in Monrovia continued to rationalize the situation. We knew things were getting worse but we didn’t act in time.

So when did it get “out of control”? Was it when MSF declared it to be so in June? Was it when the virus hit Conakry, Freetown and Monrovia, making control of the disease in crowded urban environment increasingly hard? Perhaps it was when the Liberian-American Ministry of Finance consultant died after flying to Lagos, inadvertently putting a planeload of passengers and Africa’s most populous country at risk.

Whenever it was, there is no question that we are now in the middle of an unprecedented crisis. Every day, I dread reading the news. The front page of every newspaper is full of articles discussing the bleak picture of Liberia’s largest slum quarantined like something out of a science fiction novel. I read about the almost complete collapse of the government’s health care facilities and the justifiable fear of the healthcare workers too scared to go to work. We hear terrifying stories of suspected cases being turned away from treatment centres because there is no space to treat them, and bodies left on the street for days without someone coming to pick them up. Most of all, I fear for the secondary threats should countries follow through on plans to impose economic embargoes on the country.

Already five airlines have stopped flying to Liberia through fear of the disease. Earlier reports that West African ports have refused entry to vessels which have docked in Liberia appear false, but raise an alarming prospect of the country cut off from essential imports. This is dangerous given that Liberia is completely dependent on imports with an import bill equal to 60 percent of GDP including two of the most important commodities, fuel and rice. Even without an economic blockade importers are worried.

Early reports suggest for the last four weeks the number of import certificates are down 30 percent from the previous year. Not to mention, the travel restrictions inside the country making movement of agricultural goods from farm to market next to impossible. These developments will raise the price of essential goods necessary for the Liberian economy to function and will harm the very poorest. They also raise the possibility of riots on the street and a return to the days of anarchy last seen during Liberia’s bloody civil war.

So how did this happen? The underlying causes of this outbreak are many and difficult and will be discussed for years to come. Fundamentally, they focus on the fragility of West African states and the failure of emergency planning to tackle the crisis when it was at a manageable level.
What can we do about it? Despite the fear, there are many brave West Africans and foreigners continuing to fight this disease. The Ministry of Health is working to open new treatment centres, MSF continues to fight the battle on the front line and are managing patient care alongside national governments. The World Bank has promised USD200million to fight the disease in West Africa. The African Development Bank has promised USD210million to build West African public health facilities. The World Food Program has begun the process of bringing in food to tackle the secondary crisis. NGOs on the ground, including Oxfam, have begun gearing up awareness campaigns to get the message out that Ebola is preventable. These things are vital to the immediate fight and the world needs to react, and react fast.

Once the immediate crisis is brought under control, we must consider measures to strengthen the state institutions especially the health service in order to effectively deal with health threats in the region.

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Lost in translation: reflections from the 20th International AIDS Conference (July 2014) By Gracia Violeta Ross: UNITAID Board Member for Communities Living and Affected by HIV/AIDS, TB and Malaria

With great enthusiasm I started my 33 hours flight from Bolivia to the big country-continent: Australia. But my first night in Melbourne was filled with tears as I turned on the television and heard of the attack to the Malaysian flight MH17.

The opening ceremony of the 20th International AIDS Conference paid respect to the scientists and advocates who died in this tragedy. Throughout the conference, almost all plenary speakers spoke about the “now more than ever” feeling and the importance of Stepping Up the Pace of the AIDS response. In this blog I share some of my reflections from my week in Melbourne.

The highlights

• I was reinvigorated by the effective activism on Hepatitis and HIV as activists protested against the hypocrisy of the big pharmaceutical industry pricing life-saving medicine beyond the means of people and governments

• It was interesting to learn about the issue of “Grey HIV” as we are seeing people living with HIV getting older in developing countries. Getting old with medications and with HIV looks scary for me because I am also living with HIV and I am already 37!

• It was inspiring to hear daring talks about sexuality in conservative contexts such as those in some Muslims countries and Christian conservative settings. I was pleased to hear that faith leaders are increasingly tackling this issue and talking to their peers

• Although the theme of the conference was “No one left behind”, I heard a lot of the discourse of “shared responsibility” in the AIDS response. Ultimately, this is the idea that countries will have to “find your own funding”. For Middle Income Countries (MICs), the pressure is already mounting and there is a real risk that these countries will be left behind

• I did not hear a lot about women and girls as a key population and the links to gender based violence and HIV. Moreover the debate on vulnerability to HIV infection and impact must recognize that each community and country has its own vulnerabilities that need to be considered in AIDS response

• Children living and affected by HIV were notably absent and this is a fundamental mistake, given the fact that this group is really voiceless and vulnerable. There are huge gaps in the coverage of treatment for HIV and TB for children. I am really enthusiastic about UNITAID because it invests in shaping the market for diagnosis and treatment of children

• As someone coming from Latin America, I felt the strong absence of my region, not only in that very few delegates from Latin American and the Caribbean were present, but also in the fact that the UNAIDS’ “global analysis” included incomplete data from these two regions. At the conference, I realized that there is much misunderstanding about Latin America and the Caribbean. Some donor countries seem to believe these two regions have universal coverage of treatment and prevention services. The reality is that Latin American countries vary a lot and there is huge inequality and disparity.

At the end, I left Melbourne without seeing the sun nor one Kangaroo!

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Reflections on AIDS 2014 – Stepping up the Pace and Leaving No one Behind By Georgia Burford (CAFOD)

Reflections on AIDS 2014 – Stepping up the Pace and Leaving No one Behind By Georgia Burford (CAFOD) The International AIDS Conference in Melbourne 20-25 July 2012 is the 20th gathering of the largest regular conference of any health or development issue, bringing together politicians, scientists, epidemiologists, practitioners, policy makers, the private sector and communities of people living with and affected by HIV. There is uniqueness in this fight against HIV in that it is a social movement, pulling people together and putting people at the forefront of the response to sustain our efforts on addressing HIV. It’s a powerful reminder that HIV has not gone away and is still affecting the lives of many today. The theme of this year’s conference was ‘Stepping up the Pace,’ summarised by Bill Clinton when he said ’It says much good work has been done, but it’s not an excuse to slow down. Right now we must redouble our efforts on areas like stigma and discrimination, which after 30 years is still increasing in some regions. We have the tools; we need to step up the pace.’ There has been remarkable progress since the 1980s, when HIV was a condition that had no name, no tools to diagnose, prevent or treat it. Today, there are 15 million people on treatment, yet there are still alarming challenges that must be tackled in order to even contemplate an AIDS free generation. Statistics from 2013 show there were 1.5 million HIV deaths, 2.1 million new infections and 35 million people living with HIV. Of the 35 million people living with HIV, 55% (19 million) don’t know they have the virus. They haven’t been tested and if they don’t find this out, they will die. The conference highlighted many reasons as to why people do not access or drop out of treatment. Reasons can be due to lack of services; however, a large part is due to stigma. Studies and personal testimonies have shown that:

  • Men are less likely to come forward for testing [1] when their wives are being tested during pregnancy because:” pregnancy is about women not men”. Men may be testing but not telling their partners, claiming that “they’re too busy”
  • Women, who may often discover a positive test whilst pregnant, will opt out of treatment and out of disclosing to their partners for fear of loss of trust, abandonment and violence from their partner for bringing HIV into the home[2],[3].
  • For youth, where 2 out of 3 new infections is amongst girls aged 15-19 years old, HIV remains the biggest killer of adolescent girls. This can be attributed to the lack of education around sex and HIV[4],[5], the stigma and barriers to youth friendly sexual health and HIV services[6] and links between poverty and transactional sex[7].
  • For Key populations, including sex workers, men who have sex with men and injecting drug users, many are inhibited from seeking testing and treatment because of legislative, structural and societal barriers – fear of judgement or reprimand[8],[9].

In many cases it may be easier to ignore the positive status than deal with the consequences of seeking support. The need for this is highlighted in a recent report produced by STOPAIDS Entitled “Increasing DFID’s contribution to Addressing HIV among key populations which makes a series of recommendations about ways to advance the rights of communities who are disproportionately affected by AIDS. The report was launched at the conference alongside a recent film focusing on people who use drugs in Moldova. We must tackle stigma and discrimination at every level including state policies. The AIDS 2014 conference organisers released the AIDS 2014 Melbourne Declaration, calling for an end to discrimination against people with HIV and the eradication of criminalising laws and practices. [10] Another key issue highlighted at the conference is the importance of monitoring viral load to ensure PLHIV are able to access necessary medication in order for treatment to be optimally effective. However, currently very few high-burden countries routinely offer viral load testing to people receiving HIV treatment. Since 2012, UNITAID has supported projects working to make viral load testing technologies available in resource-limited settings in Sub-Saharan Africa, but these do not yet address viral load monitoring needs on the large scale required. More efforts are needed to make new viral load testing technologies must be affordable and appropriate for poor resource settings in order to be used effectively. In Melbourne, UNAIDS launched the Diagnostics Access Initiative which calls for improving laboratory capacity to ensure that all people living with HIV can be linked to effective, high-quality HIV treatment services. Lack of access to Treatment is still a huge concern especially that there is a 10 fold price increase from 1st line to 2nd line treatment. In reality, the international community is facing huge challenges to control HIV. Therefore, governments, policy makers, funders, and civil society need to:

  • Have a renewed focus to work on the Key Populations and those most at risk and focus on stigma, discrimination and the legislative barriers
  • Address the dysfunctional health systems that hinder treatment
  • Continue campaigning for effective, affordable and appropriate new medicines and medical technologies (e.g. viral load equipment)
  • Challenge the notion that HIV is over and ensure that decision makers realise that  we are at a critical tipping point, where if we don’t step up the pace now we will miss the opportunity to contain the epidemic
  • Ensure the unfinished business of MDG 6 is taken forward post 2015 into the health goal

In the expressive words from Sir Bob Geldof, ‘We have come so far but there is a preposterous reluctance to fund the last mile. The advocates get tired, the same message goes out to the same people and it becomes less effective.’ I can’t help but think that many of the UK based members of the STOPAIDS network feel the same. It’s not only a challenge on the global stage, but often within many of the organisations we work in. We must not become those tired advocates beating the same drum, but come back from the conference championing the successes of our work over the last 30 years and enter a phase of renewed energy to ensure we step up the pace and most importantly leave no one behind.


 

References

[1] Intrahealth International at AIDS 2014 Conference

[2] Rev Phumzile Mabizela, INERELA+, Pre Interfaith Conference
[3] Jennifer Gatsi Mallet, Namibia women’s health network, ICW, Plenary Session AIDS 2014 Conference
[5] UNESCO poster at AIDS 2014 Conference
[6] YWCA, PNG, Pre Interfaith Conference
[7] Cluver, L, Boyes, M, Orkin, M, Pantelic, M, Molwena, T, Sherr, L. Child-focused state cash transfers & adolescent HIV infection risks: A prospective multi-site study in South Africa. The Lancet Global Health
[8] Rev Phumzile Mabizela, INERELA+, Pre Interfaith Conference
[9] Khuat T. Oanh, MD, Vietnam, Diane Havlir, MD, United States, Daisy Nakato Namakula, Uganda, James Ward, BA, Australia, Wednesday Plenary Session AIDS 2014 Conference
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World Hepatitis Day: Celebration of a new cure or commiseration for those who can’t afford it?

It’s not very often that we hear of a new medicine that actually cures a serious disease. This year, World Hepatitis Day comes with the exciting news of sofosbuvir; the new hepatitis C medicine with a cure rate of over 90%. Sofosbuvir can be used on its own in the form of one pill per day for 12 weeks. Existing treatments rely on a combination of daily oral ribavirin and weekly Interferon injections for around 48 weeks. The effectiveness of these old medicines is far below 90%, and they also carry painful side-effects in addition to the hassle associated with weekly injections.

So a new cure is good news? Unfortunately there is a big catch. The medicine is not affordable, even in high income countries. At the current price US $1000 per pill, the US public purse may have to pay over US $300 billion if the 3 million infected people are to be treated[1]. For example, it would cost the state of Oregon $360 million to treat its infected population. This would deplete the $377 million that the Oregon Medicaid program spent on all prescription drugs for its 600,000 members in 2013[2]. US insurance companies are rationing treatment and are telling doctors not to offer the medicine for all the patients that need it – keeping it only for very specific cases.

The situation in Europe is not much better. The cost of a 12-week treatment is €50,000 (US$68,000). The French health minister warned that such a high cost would have a negative impact on the French social security system, and called on the EU to collectively negotiate a lower price for sofosbuvir[3].

If cost is a major problem in the wealthier countries, then the impact of treatment price in middle-income and low-income countries will be even more dire. The majority of hepatitis C infected people – 80% – live in these countries. Countries with an infection prevalence rate higher than 10% are: Egypt at 14%, Cameroon 13.8%, Burundi 11.3%, and Mongolia 10.7%[4].

Clearly, none of these countries can afford the current high price. Gilead has entered into a deal with the Egyptian government to provide a 12-week course of treatment at US $900 per patient for the public sector[5]. At 14% prevalence in a population of over 82 million people, the potential number of people living with hepatitis C in Egypt is around 11.5 million[6]. To treat even just 5 million patients would cost Egypt the equivalent of nearly two-thirds of its total health budget (US $4.5 billion out of the current total health budget of US$ 7.22 billion for 2014/15)[7]. This cost is in addition to other drugs – pegylated interferon and ribavirin – which are needed in combination with sofosbuvir to reach the 90% cure rate for genotype 4, which is the strain of hepatitis C prevalent in Egypt.

Yet the price does not have to be this high, as illustrated in two ways. Firstly, a study by researchers at Liverpool University looked at the total real cost of the active pharmaceutical ingredients and the cost of manufacturing of the new direct anti-viral medicines class, of which sofosbuvir is one. They estimated the cost of a 12-week course of treatment with the combination of sofosbuvir and daclatasvir as US $78 per person[8].

Secondly, evidence shows that the price of medicines is slashed by generic competition. HIV treatment is a case in point: in 2000, at the height of the public outcry campaign against high medicine prices, it was very difficult to persuade any government or donors to pay for treatment, and millions of people in poor countries were left to die. The price of triple therapy for HIV was US $10,000 per patient per year. That was clearly unaffordable to patients, governments, and donors at the time. Thanks to generic competition from Indian companies, the price dropped almost overnight to US $360 per patient per year or US $1 day. Continuation of competition has resulted in the current price of triple therapy for HIV of approximately US $100 per patient per year.

Now that Trade Related Aspects of Intellectual Property Rights (TRIPS) is implemented in almost all countries, including those with manufacturing capacity such as India, it is much harder to scale up generic competition. However, TRIPS includes some flexibilities, which countries can use to help lower prices. For example, India’s patent law has a clause on “pre-grant opposition”, which allows any interested groups to challenge a patent application before the patent is granted. Civil society organisations have used this clause for sofosbuvir and therefore currently, it does not have a patent in India (although the final decision is awaiting a court ruling).

Compulsory licensing is an important legal TRIPS tool for governments to ensure affordable prices of new medicines. Use of this tool in India decreased the price of sorafenib (Nexavar) for the treatment of liver and kidney cancer from over US $5,500 per month to US $175[9]. In 2008, Thailand issued compulsory licenses for 3 cancer medicines, leading to a big drop in prices. For example, the price of one tablet of 2.5 mg of letrozole was slashed from the original Novartis price of US $£7.35 to the generic price of US $0.19-0.22 – a price differential of 30 times[10].

Obviously pharmaceutical companies and rich countries who support them do not like any government using this legal TRIPS tool. When Thailand issued compulsory licenses for medicines to treat HIV, cardiovascular disease, and cancer, it came under tremendous pressure from the US and the EU to stop[11]. Last year there was pressure by US businesses and Congress for the US government to take actions against India over its intellectual property regime[12].

The fundamental problem is the system of intellectual property rules which allows big companies to hold a monopoly on the price of medicines, thus giving them the power to set high prices. Moreover, financing for research and development (R&D) is still dictated by commercial interests rather than public health needs all over the world. Pharmaceutical companies are ferociously lobbying for stricter and stricter intellectual property protections as the only way to stimulate R&D and to ensure they can maintain their monopoly to set prices.

The price of the new hepatitis C medicine has given more momentum to the rising global movement that is challenging the high prices of new effective medicines for diseases ranging from cancer to cystic fibrosis[13]. As long as the cost of R&D is linked to drug pricing, pharmaceutical companies will continue to price medicines to ensure maximum profit, even if it means decreased access for people who need it. This is a public health travesty. .

The un-affordability of the most effective medicine that can cure hepatitis C today highlights the critical need to de-link financing for R&D from the price of medicines, and for finding new ways to finance R&D so that effective medicines are available at an affordable price to all who need them.

References

[2]http://www.washingtonpost.com/blogs/wonkblog/wp/2014/07/24/the-drug-thats-forcing-

americas-most-important-and-uncomfortable-health-care-debate/

[4] Lavanchy D.( 2011) Evolving epidemiology of hepatitis C virus. Clin Microbiol Infect.;17(2):107-15

[5]http://www.reuters.com/article/2014/03/21/hepatitis-egypt-gilead-sciences-idUSL2N0MI1ID20140321

[7] Forthcoming: New effective hepatitis C medicines must reach all patients. PLOS

 

 

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اليوم العالمي للالتهاب الكبدي: احتفاءً بعلاج جديد أو مواساة لمن لا يستطيع شراءه ؟

World Hepatitis Day: Celebration of a new cure or commiseration for those who can’t afford it?

مهجة كمال ي
Translated into Arabic by Nagy Kamal Yanni

قليلاً ما نسمع عن دواء جديد يشفي فعلا ًمن مرض خطير. لكن في هذا العام يأتي اليوم العالمي للالتهاب الكبدي مع الأخبار المثيرة عن دواء سوفوسبوفير الجديد لعلاج التهاب الكبد سي. ويحقق الدواء نسبةشفاء عالية-أكثر من 90٪ ويستخدم في شكل حبة واحدة يوميا لمدة 12 أسبوعا بدون حقن. متفوقاً عن العلاجات الحالية التي تعتمد على مزيج من ريبافيرين عن طريق الفم يوميا مع حقن الإنترفيرون أسبوعيا لنحو 48 أسبوعا. وفعالية هذه الأدوية القديمة أقل بكثير من 90٪، كما ان لها آثارا جانبية مؤلمة بالإضافة للمتاعب المرتبطة بالحقن أسبوعيا.

فهل يمثل هذا العلاج الجديد أخباراً سارة؟ للأسف هناك مشكلة كبيرة- فالدواء ليس في متناول الجميع، حتى في البلدان ذات الدخل المرتفع . فطبقاً للسعر الحالي -1000 دولار أمريكي للحبة الواحدة- قد تضطر الميزانية الأمريكية لدفع أكثر من 300 مليار دولار لعلاج كل المصابين والذي يقدر عددهم ب 3 ملايين شخص
. فعلى سبيل المثال، فإن ولاية اوريجون ستتكلف 360 مليون دولار لعلاج سكان الولاية المصابين بالمرض مما يستنزف برنامج الولاية الطبي (377 مليون دولار) والمخصص للصرف علي جميع الأدوية لحوالي 600 ألف مواطن أعضاء في برنامج الولاية لعام 2013 . ونظرا لغلو سعر سوفوسبوفير، فقد قررت بعض شركات التأمين الامريكية تقنين العلاج وأعطوا تعليمات لأطبائهم بألا يقدموا الدواء لجميع المرضى الذين في حاجة إليه – وأن يصفوا الدواء فقط لحالات محددة جدا.

أما الوضع في أوروبا فهو ليس أفضل منه في أمريكا، فتكلفة العلاج لمدة 12 أسبوعا هي 50 ألف يورو (حوالي 68 ألف دولار). حتي أن وزيرة الصحة الفرنسية حذرت من أن مثل هذه التكلفة العالية سيكون لها تأثيراً سلبياً على نظام الضمان الاجتماعي الفرنسي، ودعت الاتحاد الأوروبي للتفاوض بشكل جماعي للوصول لأقل الأسعار

وإذا كانت التكلفة هي مشكلة رئيسية في البلدان الأكثر ثراء، فإن تأثير ارتفاع سعر العلاج في البلدان المتوسطة الدخل والمنخفضة الدخل ستكون له عواقب وخيمه. حيث يعيش فيها غالبية المصابين بالتهاب الكبد سي – 80٪ من المصابين. والبلاد التي لديها معدل انتشار العدوى أعلى من 10٪ هي: مصر في 14٪، الكاميرون 13.8٪ ، بوروندي 11.3٪، ومنغوليا 10.7٪ .

وغني عن الذكر أن هذه الدول لا تستطيع تحمل الأسعار الحالية المغالي فيها. وقد دخلت شركة جلياد في مفاوضات مع الحكومة المصرية لتقديم كورس للعلاج مدته 12 أسبوعا بسعر900 دولار لكل مريض يتم علاجه في المستشفيات الحكومية . وإذا كانت نسبة الإصابة في مصر هي 14٪ من السكان البالغ عددهم أكثر من 82 مليون شخص، فإن العدد المحتمل للمصابين بالتهاب الكبد C في مصر قد يصل إلي 11.5 مليون شخص . وبهذا فإن علاج حتى 5 ملايين مريض فقط قد يكلف مصر ما يعادل تقريبا ثلثي ميزانية الصحة الإجمالية (4.5 مليار دولار أمريكي من إجمالي 7.22 مليار دولار أمريكي لعام 2014/2015) . وهذه التكلفة بالإضافة إلى نفقات الأدوية الأخرى (ريبافيرين وبجيلاتد انترفيرون) وهي التي يجب استخدامها مع السوفوسبوفير للوصول إلى نسبة شفاء 90٪ للنمط الجيني رقم 4، وهو نمط التهاب الكبد C المنتشر في مصر.

ومع ذلك فإنه ليس من المحتم أن يكون سعر الدواء بهذا الغلو وذلك لسببين. السبب الأول هو أن باحثون في جامعة ليفربول أجروا دراسة عن التكلفة الحقيقية لعدد من الأدوية الجديدة المضادة للفيروسات والتي تشمل سوفوسبوفير وقد تضمنت الدراسة بحث تكاليف المكونات الصيدلانية الفعالة للدواء وتكلفة تصنيع الأدوية. وقدرت الدراسة أن تكلفة دورة علاج مدتها 12 أسبوعا مع مزيج من السوفوسبوفير والدكلاتاسفير sofosbuvir وdaclatasvir هو 78 دولار أمريكي للشخص الواحد .

والسبب الثاني هو أن الأدلة تشير إلى أن أسعار الأدوية تنخفض بواسطة منافسة الأدوية الجنيسة . فقد كان ثمن علاج فيروس نقص المناعة البشرية في عام 2000 مرتفعاً جداً وذلك في ذروة حملة احتجاج شعبي ضد ارتفاع أسعار الدواء، وكان من الصعوبة بمكان إقناع أي حكومة أو جهة مانحة بدفع تكاليف العلاج، وبذلك تُرِك الملايين من الناس في البلدان الفقيرة للموت .فقد كان سعر العلاج الثلاثي لفيروس نقص المناعة البشرية حوالي 10 ألاف دولار أمريكي لكل مريض سنوياً. ومن الواضح أنه لا يمكن أن يتحمل المرضي ولا الحكومات، ولا الجهات المانحة في ذلك الوقت مثل هذه النفقات. ولكن بفضل منافسة الشركات الهندية بالأدوية الجنيسة، فقد انخفض سعر العلاج الثلاثي بين ليلة وضحاها إلى 360 دولار لكل مريض في السنة أي بمعدل دولار أمريكي يوميا. وقد أدى استمرار المنافسة إلي السعر الحالي للعلاج الثلاثي وهو حوالي 100 دولار لكل مريض سنويا.

وبعد تطبيق اتفاقية “الجوانب المتصلة بالتجارة من حقوق الملكية الفكرية (تربس)” في جميع البلدان تقريبا، بما في ذلك تلك التي لديها القدرة التصنيعية مثل الهند، فقد أصبحت منافسة الأدوية الجنيسة أكثر صعوبة. ومع ذلك، فإن اتفاقية التربس تتضمن بعض المرونة، والتي يمكن أن تستخدمها البلدان للمساعدة في خفض الأسعار. فعلى سبيل المثال، يحتوي قانون براءات الاختراع في الهند علي بند بشأن “المعارضة قبل منح براءة الاختراع”، والذي يسمح لأي مجموعة مهتمة بالطعن في طلب البراءة قبل منحها. وقد استخدمت منظمات المجتمع المدني هذا البند للطعن علي طلب براءة الاختراع لدواء سوبوسبوفير. وبالتالي فإنه حتي الآن لم تمنح الهند براءة الاختراع للدواء (وينتظر القرار النهائي حكم المحكمة).

ويمكن للحكومات استخدام مرونة الترخيص الإجباري -وهي أداة قانونية هامة في اتفاقية النتربس-وذلك لضمان أسعار معقولة من الأدوية الجديدة. وقد استخدمت الهند الترخيص الاجباري لدواء سورافينيب (نيكسافار) sorafenib (Nexavar) لعلاج سرطان الكبد والكلى فانخفض سعره من حوالي 5500 دولار أمريكي في الشهر إلى 175 $ في الشهر . وفي عام 2008، أصدرت تايلاند تراخيص إجبارية لثلاثة أدوية لعلاج السرطان، مما أدى إلى انخفاض كبير في الأسعار. فعلى سبيل المثال، تم تخفيض سعر القرص الواحد من عقارلتروزول letrozole 2.5 ملج من السعر الأصلي لشركة نوفارتيس وهو 7،35 دولار إلي من 0،19 الي 0،22 دولار- أي أقل 30 مرة من السعر الأصلي .

ومن الواضح أن شركات الأدوية والبلدان الغنية التي تدعمهم لا تفضل استخدام الحكومات لمثل هذه الأدوات القانونية الموجودة في اتفاقية التربس. فعندما أصدرت تايلاند التراخيص الإجبارية لأدوية علاج فيروس نقص المناعة البشرية وأمراض القلب والأوعية الدموية، والسرطان، فإنها وقعت تحت ضغط هائل من كلا من الولايات المتحدة والاتحاد الأوروبي حتي تتوقف عن استخدام الترخيص الإجباري . وفي العام الماضي كانت هناك ضغوط كبيرة من قبل الشركات الأميركية والكونجرس علي حكومة الولايات المتحدة لكي تتخذ إجراءات صارمة ضد الهند بسبب نظام الملكية الفكرية الهندي .

وتقع المشكلة الأساسية المؤدية لارتفاع أسعار الأدوية الجديدة في نظام قواعد الملكية الفكرية التي تتيح للشركات الكبيرة احتكار أسعار الأدوية، وبالتالي تمنحهم القدرة على التحكم فيها. وعلاوة على ذلك، فإن تمويل البحث والتطويرR&D) ) للأدوية لا تزال تمليها المصالح التجارية بدلا من الاحتياجات الصحية العامة في جميع أنحاء العالم. وتضغط شركات الأدوية بشراسة لحماية الملكية الفكرية ولجعلها أكثر صرامة باعتبارها السبيل الوحيد لتحفيز البحث والتطوير وللتأكد من أن هذه الشركات قادرة على المحافظة على احتكارها للتحكم في الأسعار.

وقد أعطى سعر الدواء الجديد التهاب الكبد سي المزيد من الزخم إلى الحركة العالمية المتصاعدة ضد ارتفاع أسعار الأدوية الجديدة الفعالة في مكافحة الأمراض ابتداء من السرطان إلى التليف الكيسي cystic fibrosis وطالما استمر ربط تكلفة البحث والتطوير بتسعير الأدوية، فسوف تستمر شركات الأدوية في تسعير الأدوية بما يحقق لها أقصى قدر من الأرباح، حتى لو كان ذلك يعني انخفاض إتاحة الأدوية للأشخاص الذين هم في حاجة إليها.
وتلك هي مهزلة الصحة العامة.

إن سعر الأدوية الأكثر فعالية والتي يمكنها علاج التهاب الكبد سي اليوم، يسلط الضوء على الحاجة الماسة للفصل بين تمويل البحث والتطوير وسياسات التسعير، وإلي الحاجه الماسة لإيجاد سبل جديدة لتمويل البحث والتطوير لإتاحة الأدوية الفعالة بأسعار في متناول جميع المحتاجين إليها.

المراجع

[1]http://www.bloomberg.com/news/2014-04-08/express-scripts-raises-pressure-on-gilead-for-drug-price.html

[2]http://www.washingtonpost.com/blogs/wonkblog/wp/2014/07/24/the-drug-thats-forcing-americas-most-important-and-uncomfortable-health-care-debate/

[3]http://news.yahoo.com/eu-nations-join-forces-against-exorbitant-hepatitis-c-193456820.html

[4]Lavanchy D.( 2011) Evolving epidemiology of hepatitis C virus.Clin Microbiol Infect.;17(2):107-15

[5]http://www.reuters.com/article/2014/03/21/hepatitis-egypt-gilead-sciences-idUSL2N0MI1ID20140321

[6]http://countryeconomy.com/demography/population/egypt

[7]Forthcoming: New effective hepatitis C medicines must reach all patients. PLOS

[8]http://cid.oxfordjournals.org/content/early/2014/01/06/cid.ciu012.full.pdf

[9]http://www.pharmatimes.com/article/13-03-05/Bayer_loses_appeal_in_Indian_compulsory_licence_case.aspx

[10]http://www.moph.go.th/hot/Second_white_paper_on_the_Thai_CL_%5bEN%5d.pdf

[11]http://www.wcl.american.edu/pijip/documents/mandelson07102007.pdf

[12]http://www.ip-watch.org/2013/06/20/170-members-of-us-congress-pressure-india-on-ip-rights/

[13]http://online.wsj.com/articles/costly-drug-vertex-is-denied-and-medicaid-patients-sue-1405564205

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Contrasting plans for Universal Health Coverage: Chile and Costa Rica

Civil society groups at the recent World Health Assembly criticized the continued focus on insurance schemes in the push for Universal Health Coverage (UHC), which all too often includes significant private sector participation. Evidence to support the claim for private sector involvement of this kind remains extremely thin and a new study by the Municipal Services Project shows it could jeopardize public health in the South.

The study compares health outcomes in Chile and Costa Rica, two countries that have come to epitomize contrasting approaches to ‘Universal Health Coverage’ in Latin America. Chile’s focus has been on insurance-based UHC while Costa Rica has built a single public health system. The research provides strong evidence to show that there are widespread and consistent advantages to promoting UHC through a strong public system that funds and provides all medical and preventive services to citizens rather than through a fragmented public-private mix.

It is important to note that both countries have achieved the lowest infant mortality rates and the highest life expectancies in the region thanks to major advances in primary care. But Chile’s health ‘market’ has led to inefficient use of resources, with higher administrative costs and more irrational medical procedures (e.g. caesareans) resulting from oligopolies and collusion among private providers.

One of the major goals of UHC is financial protection for poor households when they face illness. Yet Chileans systematically need to make higher out-of-pocket payments to get medical care in comparison with Costa Ricans. This situation is produced in part by the fact that Chileans pay for health conditions, services or products that are not covered by their insurance (e.g. prescription drugs).

In contrast, Costa Rica’s public health care system remains relatively affordable and more efficient, with total per capita health expenditure standing at US$811 compared to US$947 in Chile. Importantly, Costa Rica has also consistently prioritized preventive health care. Expenditure on prevention and public health services from 2002-2006 in Costa Rica is more than double that of Chile (6-7% vs 2-3%). This focus on prevention is more cost-effective and can yield greater public health impacts in the long term.

Using comparable data (Latinobarómetro), the Municipal Services Project study shows that twice as many people reported facing access barriers to health care in Chile compared to Costa Rica, citing distance to hospital, time to obtain an appointment, and cost of seeing a doctor as the major reasons. In addition, lack of access to health services as a result of financial barriers in Chile still stands at 4.2% compared to 0.8% in Costa Rica.

Costa Ricans continue to be largely satisfied with the quality of their healthcare services, more so than Chileans. Interestingly, LAPOP 2012 results show that most people in both countries think that government, rather than the private sector, should be responsible for health care (71.1% in Chile and 67.5% in Costa Rica).

According to the notions of “active purchasing” and “managed competition” – frequently used to promote insurance schemes – the existence of different providers competing for resources should have produced higher levels of quality at lower costs in Chile. The evidence presented in this report shows that such assumptions are not always true.
 
The Chilean health system is an example of how segmentation produced by the coexistence of private and public insurances is detrimental to efficiency and equity. Collusion among private providers and oligopolies are realities that are ignored in the competition argument.

Debates over the best institutional arrangements to organize universal health care are far from over, but this case study demonstrates that insurance schemes as promoted by some proponents of the UHC agenda are neither the only nor the best option.

Luis Ortiz Hernández is Professor in the Health Care Department, Universidad Autónoma Metropolitana Xochimilco, Mexico and visiting professor at Queen’s University, Canada. His most recent publication, “Chile and Costa Rica: Different roads to universal health in Latin America,” is available here.

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Global Health Check is edited by Anna Marriott, Health Policy Advisor for Oxfam GB, and welcomes contributions from different authors. If you would like to write an article for this site or if you have any queries please contact: amarriott@oxfam.org.uk.