E-DRUG: Strong medicine - Incentives for R&D on Neglected Diseases
[A Global FUnd for Neglected Diseases?
Under the tile "Whats the benefit of drug companies of making medicines for
the poor ?" Nature published a book review of
"Strong medicine - Creating Incentives for Pharmaceutical Research on Neglected
Diseases" by Micheal Kremer and Rachel Glennerster Princeton University Press :
2004. 152 pp. USD24.95, Copied as fair use. WB]
Access to essential drugs for poor people in developing countries has made
headlines several times during the last few years. Most of the media attention
has centred on a few specific topics within this broad theme : the debate about
access to antiretroviral drugs against AIDS; the hot economic and political
topics of patents and the World Trade Organization agreements; and the lack of
research and development (R&D) to create desperately needed new drugs for
'neglected diseases', conditions that predominantly affect poor people in
The central theme that links these together is how to encourage research and
development for new drugs and ensure that everyone has quick access to the
medicines they need. Only a few years ago the sole paradigm, recognised not
only by industry but also within most of the academic circles, was 'patent +
market => R&D'. But now alternative or at least complementary paradigms are
being considered. Michael Kremer and Rachel Glennerster, the authors of Strong
Medicine, favour the latter route. In their approach, they fall between those
who still think (or at least claim) that the current system only needs some
minor adjustments and those who want to see complete change on a global scale.
Kremer and Glennersters aim is to find practical ways to restart R&D for these
neglected diseases. They believe that market and public bodies have failed to
motivate R&D - only 1 % of drugs launched onto the market during the last 25
years target these diseases. They are convinced that appropriate policies and
public commitment could motivate private investment in this area. This strategy
has already been followed with rare diseases, through 'orphan drug' legislation
passed in rich countries, which grants tax incentives and guaranteed periods of
exclusivity to companies that invest in R&D for drugs to treat rare conditions.
The authors comment on the various tools that have been suggested or tested to
influence R&D. 'Push' mechanisms refer to financing research inputs such as
grants to academics, or tax credits for specific R&D activities. 'Pull'
solutions mean financing research outputs, such as a commitment to create a
profitable market for the expected products. Kremer and Glennester tend to
favour pull solutions, because they are less bureaucratic and closer to
market-like solutions (which the authors prefer in general). After a short
discussion of various pull solutions, the authors opt for one in which somebody
creates the market by committing to purchase a certain quantity of drugs at a
And this is where this book becomes really original. Kremer and Glennerster
enter into a computation for assessing the amount of sales that would be enough
to motivate private companies to embark on such a deal with a sponsor. Their
conclusion is that the system could work with a guaranteed price of $ 15-20 per
complete vaccination for the first 150-200 million individuals vaccinated, the
rest of the vaccines supply being priced at a modest mark-up over production
Who should pay for all this ? Kremer and Glennerster believe that this kind of
spending would be popular with governments of rich countries, as public money
would only be invested in concrete outcomes - not in research that might lead
nowhere. They also mention the World Bank and the Bill and Melinda Gates
Foundation (from which they acknowledge financial support). Finally, they
believe that a modest co-payment from recipient countries would be desirable.
The book does have some limitations. First, the reasoning is mainly based on
vaccines and focuses mostly on the three biggest killers: AIDS, malaria and
tuberculosis. These targets are worthwhile, but they are also the easiest,
because vaccines generally need only a few jabs to create a long-term benefit,
and because hundreds of millions of people are affected by these diseases. It
may be more difficult to convince the public and private sectors to do R&D for
the most neglected diseases, such as sleeping sickness or Buruli ulcer.
Another important limitation is that the solution proposed by Kremer and
Glennerster is mainly a tool. They recognise that a long-term political
commitment will be necessary, but they do not elaborate on how to achieve this.
This will frustrate those who believe that such a long-term commitment needs to
take the form of an international framework or treaty for neglected diseases.
Some people within the World Health Organization and Medecins Sans Frontieres
remember how difficult it was to mobilise the few million dollars necessary to
secure the production of a new combination vaccine against meningitis, just a
few months before the 2004 epidemic in Africa. It would have been much easier
if some kind of global R&D fund had been available.
This, some people might criticize this book for stopping mid-way. But Kremer
and Glennersters solution does imply that the private drug R&D activity could
be more appropriately directed by public will and money something that other
might consider a step too far already.
This book should interest anyone involved in international public health,
politics and economics. It is a valuable effort to find a practical solution to
a major problem, and most readers, when theyve finished the book, will
probably say "Let's just try it !"
Pierre Chirac is a public-health pharmacist with the Midecins Sans Frontihres
Access to Essential Medicines Campaign, 2 rue Chaligny 75012 Paris, France.