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Health Benefits

InjectionIt’s not rocket science, it’s medical science: get medicines to people who are sick in the developing world and they will get better – and development will be accelerated. ‘Access to medicines’ is the mantra and the signs are encouraging, reports Tatum Anderson.

A toddler lies semi-conscious at the hospital in Kilifi , a small town on the Kenyan coast. Tiny, compared to the metal adult bed she lies on, she has a deadly form of malaria and has been comatose for days. Her mother holds a vigil at her bedside and members of staff say her chances are touch and go. But there’s something rather curious about the hospital ward where she lies. It’s half empty.

Hospitals along this stretch of the Kenyan coast, have seen a massive drop in admissions for malaria. By March 2007 cases had declined by 63% in Kilifi alone. “This is the biggest killer of children on the coast,” says Dr Norbert Peshu, of Kenya Research Medical Institute, attached to the hospital in Kilifi . “The community in Kilifi district is very happy. They are seeing less of their children falling sick and dying of malaria.”

It is a phenomenon being replayed all over Africa. Cases are down 60% in Rwanda and deaths halved in Zanzibar, says Christoph Benn, from the Global Fund for AIDS, TB and Malaria, the organisation formed to fund projects combating these diseases. “We see quite amazing results in some countries,” he says. “These are not small changes.”

It’s not just malaria that’s receding. Tuberculosis has declined in Asia. Uganda has virtually eliminated Haemophilus influenzae type b (Hib), a deadly disease that causes severe meningitis and pneumonia in very young children. And several countries are close to eliminating diseases that are virtually unheard of in the west but affect a billion of the poorest people on earth. While Lymphatic Filariasis (LF), which causes huge painful swellings in the limbs, remains a global challenge, real progress is being made and in some countries it is no longer a public health problem. And 14.5 million people have been cured of leprosy since 1985.

The reasons for such improvements are simple – increased access to medicines, from malaria drugs to vaccinations. The numbers of people being treated are truly staggering – 62 million people across West Africa were treated for onchocerciasis, or riverblindness, in 2005 alone.

As a result, a large number of deaths and severe disabilities have been averted. The GAVI Alliance, which works on expanding access to routine vaccinations, calculates that 3.4 million childrens’ lives have been saved. The effects of better health are obvious. But for the poorest people in the world, there are many more benefits. Ill-health and death can exacerbate poverty, because so few can benefit from safety nets taken for granted in the west – a free national health service, basic social services, sick pay and life insurance.

Take an unvaccinated child, for instance. If they become sick, the family must pay for medicines themselves – a cost that can consume 80% of their income. They must pay for transport, hospitalisation and take time off work to provide long-term care too, especially if an illness results in lifelong disability, as Hib meningitis often does.

These costs can bankrupt a household. “It can be a huge emotional and financial burden on the family,” says Lois Privor- Dumm, Hib Initiative Communication Director based at Johns Hopkins Bloomberg School of Public Health. “Because the disease most often strikes poor families they are often forced to take loans to pay hospital bills, which can further spiral them into poverty.” But access to medicines does not only save lives, it can boost economies. That’s because, by treating many neglected diseases, children become well enough to attend school and eventually become productive citizens, while adults can spend more time working. Economic rates of return of large-scale tropical disease treatments – such as Guinea worm – can be as much as 30%. When malaria was eradicated in Bangladesh, crop yields increased 15% because farmers could spend more time on cultivation.

Vaccines are seen to be great investments too. Harvard researcher Dr David Bloom has predicted that rates of return on GAVI’s investments could be 18% by 2020. Newer pentavalent vaccines combine protection against five diseases in a single inoculation, and are likely to have even better rates of return.

If a healthier and longer-lived population is better all round, why have the remarkable gains happened only recently? The reasons are legion – logistics problems, lack of knowledge about good products and stigma can all affect access to medicines, according to two US researchers Michael R Reich and Laura J Frost. Often people live so remotely that healthcare is difficult. Dr Laurent Yameogo, who leads the African Programme for Onchocerciasis Control (APOC), says patients in Congo often walk 20km to the nearest clinic.

But perhaps the most important factor has been the cost of medicines. Dr Zarir F Udwadia a consultant TB expert at Hinduja Hospital in Mumbai has seen this at first hand. “My patients bankrupt themselves trying to fund treatment,” he says. “The lack of funds forces these patients to quit treatment mid-stream.”

The reality of the corporate world is that companies make medicines when the indications are that many patients can afford to pay for them. That way, the cost of developing the medicine can be recouped to ensure future research money for more new drugs.

In the case of vaccines, manufacturers often wait until they have recouped their costs in rich countries before offering them elsewhere. That can mean a timelag of 15 years.

Sometimes drugs do exist, but they may be wholly inappropriate for poorer patients. For instance, they may require refrigeration, which is not ideal for patients living in rural villages without electricity. Ironically, some technologies that might make a drug more appropriate, are often more expensive because they are newer.

There has been little incentive, also, to research new, better tools for diseases that disproportionately affect poor patients. For years patients with sleeping sickness have relied on an arsenic-based treatment unchanged since the 1940s and so toxic that it kills 5% of patients. There is no good test to diagnose leprosy, so sufferers can infect their own families before they begin showing symptoms.

And while there are already many cheap medicines and vaccines it remains a huge challenge to get them to everyone who needs them and many gradually become useless as parasites evolve resistance to them. By the late 1990s chloroquine – Africa’s cheap malaria drug of choice for decades – was failing to help half of Tanzanian children with malaria.

In recent years, there has been a huge change as a new generation of players has transformed global health and unlocked unprecedented resources that were undreamt of 10 years ago. 

The emergence of organisations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, The President’s Emergency Plan for AIDS Relief (PEPFAR) and the Bill & Melinda Gates Foundation boosted funding for AIDS 30-fold to $10bn over a decade; the US has promised $39bn to HIV and AIDS over the next five years. At the same time AIDS drugs that had cost $15,000 per year in many low income countries plummeted to as low as $148 as Indian suppliers, such as Cipla, entered the market. The organisations work in two ways. Some pay for existing drugs, vaccines or insecticide-treated bednets so poor patients don’t have to – GAVI, for instance, subsidises the Hib vaccine, which costs $3.41 per dose.

Others pay for research into new medicines for poorer patients. Indeed $2.5bn was spent on R&D on 30 diseases that affect poor countries by 134 funders in 43 countries in 2007.

Research shows that three events sparked the change. One: the Bill & Melinda Gates Foundation with funds for health (see page 16). Two: campaigns promoting access to medicine by charities such as Médecins Sans Frontières (MSF) and Oxfam, which put pressure on pharmaceutical companies. Three: crucially, a new breed of non-profit organisations, called product development partnerships (PDPs).

PDPs have devised innovative ways to secure promising research from pharmaceutical companies, as well as paying development costs to produce badly-needed drugs, vaccines and diagnostic tools.

Significantly PDP drugs are designed specifically for patients in poor countries. For instance, one PDP, Medicines for Malaria Venture (MMV), has just introduced a malaria medicine designed specifically for children. Affordable drugs are typically aimed at adults. George Jagoe, executive vice-president of global access at MMV says the organisation has assembled arguably the largest pipeline of malaria trial drugs ever, in order to ensure there are many more new drugs to come. “We have prepared the ground for an impact that will probably last for decades,” he says.

And unexpectedly, PDPs have also ended up encouraging drug companies to put more money into research. Around half the pharmaceutical money circulating is there purely because of PDPs, says Dr Mary Moran, study leader at the George Institute.

“There has been a real rejuvenation of the field,” she says. “Companies couldn’t do it before because they’d have to say to shareholders, ‘I have to take $300m of your dividends to make products that make no money’.”

This rejuvenation sparked by PDPs may just be the beginning. Momentum has led to lofty goals to eliminate malaria altogether and provide universal access to AIDS drugs. Recently GlaxoSmithKlein announced it would slash drug prices in developing countries and plough profits into health systems. Innovative finance mechanisms from airplane levies to bonds are being discussed worldwideKenya: a young boy gets a check-over prior to receiving a measles vaccination..

But there’s also a realisation that lots more must still be done to improve access to medicines. Money will be needed to fund large-scale clinical trials of PDP products in future years – only 28% of children have had the Hib vaccine and there is little or no research into tools for cholera and other big killers. Paul Sommerfeld of Action for Global Health, a group of 15 European health NGOs says: “We need more aid for health, and better spent.”

But access to medicines won’t solve everything. More is required to prevent the spread of many diseases – thousands still contract HIV every day for instance. And increasing access to medicines will not solve the chronic shortage of healthcare workers and hospitals. That is where the focus, now, has turned. 

Paying the medicine bill

The product development partnerships (PDPs) have inspired a host of innovative models to encourage manufacturers to create more drugs and vaccines. Today all sorts of models are being contemplated – from patent pools to prize funds.

But one mechanism has already been used to finance vaccines by GAVI since 2006.

The International Finance Facility for Immunisation (IFFIm) was developed in the UK with an aim to rapidly accelerate the amount of money available to buy vaccines.

The idea is that if vaccine manufacturers know that there is money available to buy vaccines, they will invest in developing new products. IFFIm raises funds on the international bond markets. The so-called vaccine bonds are sold and backed by long-term, legally-binding grants from governments including the UK, to the tune of $5.3bn to IFFIm over 20 years.

The bonds issued so far have attracted a diverse set of buyers from pension funds to insurance companies, and the money raised has been used to boost supplies of the pentavalent ‘five-in-one’ vaccine as well as for polio, yellow fever vaccine and maternal and neonatal tetanus.

Speaking at a conference organised by Action for Global Health earlier this year, Dr Julian Lob-Levyt, chief executive officer of GAVI, said: “We have made a connection for the first time with the finance community.”

DFID and health in Africa

Increasing transparency and accountability in pharmaceutical systems on the price, quality, availability and promotion of medicines is the task of the Medicines Transparency Alliance (MeTA) which is being piloted with Ghana, Uganda and Zambia.

Speeding up the introduction of new medicines and improving the regulation of drugs by harmonising the registration of pharmaceuticals in Africa countries. Working alongside the New Partnership for Africa’s Development, WHO, Bill & Melinda Gates Foundation and the Clinton Foundation.

Strengthening drug procurement and supply systems through DFID’s new £148m PATHS2 Health Systems Strengthening programme in Nigeria.

Improving access to essential medicines in Burundi – DFID is the lead donor working with the Burundi government.

Increasing technical capacity on pharmaceutical policy in 14 African countries working together with WHO.

Strengthening civil society to work with WHO and governments to increase access to medicines, active in Ghana, Kenya and Uganda.

Improving the quality and reducing the price of selected malaria and HIV medicines by working with Indian manufacturers and with African partners to improve capacity to forecast the demand for these medicines. DFID is collaborating with the Clinton Foundation.

Supporting drug and vaccine procurement in Africa through funding to the Global Fund to fight AIDS Tuberculosis and Malaria, GFATM, UNITAID and the Global Alliance for Vaccines and Immunisation.

In Rwanda malaria cases are down 60% and deaths have halved in Zanzibar.