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Journal of the Academy of Hospital Administration

Notes, News and Journal Scan

Author(s): Rajiv Kumar Jain*, Sidhartha Satpathy**

Vol. 15, No. 1 (2003-01 - 2003-06)

Key Messages:

  • Drug companies should cut prices for developing countries - G-8 report
  • WHO supports EU proposal for cheap drugs
  • Vaccine against cervical cancer passes "proof of principle"
  • Donors are distorting India's health priorities, say protestors
  • World Body reviews doctors links to drug industry.
  • Drug companies should cut prices for developing countries - G-8 report

Robert Walgate states that the report of the U.K. Working group on "increasing Access to Essential Medicines in Developing World" was commissioned by the G-8 group of world's richest counties and involved UK drug companies and developing countries in lengthy negotiations before publication. Although UK firms have "signed up" to its conclusions; the U.S. pharma giants were notably absent.

The British Prime Minister, Mr. Tony Blair discussed the report of the working group with WHO Director General and doyens of UK pharma companies like Glaxo, Smithkline, Astra Zeneca etc. However, according to Dr. Brundtland, improving access to medicines will not be easy. "It is a complex struggle where, governments, a range of actors in private sector and civil society all play important roles" - she said. Most firms said they were ready to accept this challenge, and offered "sustainable, not for profit preferential prices on certain drugs to all consumers" in the least developed 65 countries including sub-saharan Africa. The report will now be discussed in the next G-8 summit in France where the reception by the assembled governments will then decide the future of proposals. The full report is available from URL:

Bulletin of WHO 2003, 81(1) 72-73

WHO supports EU proposal for cheap drugs The WHO publishes a priority list of medicines of its own - the Essential Medicine/Drug list, already in the 10th edition. Jonathan Quick of WHO's Essential Drugs & Medicines Policy department says that "it was never intended to be a global standard - as it's a model that needs to be adapted. It contains some 325 drugs; about the number least developing countries can buy; middle income countries typically use 600; and high income countries around 1200; the bottom line has to be flexibility".

"The way WHO operates, ultimately, countries decide what is of importance to them; we provide advice and the best possible data. Last April we said there are best 12 antiretrovirals for HIV/AIDS, and there are first, second and third most effective combinations; but we could not say "therefore these are the only drugs you should buy" he added.

If a country considered it needed to import generics for some condition, according to the EU proposal, WHO's role could be to provide evidence and advice on the magnitude of the disease and to recommend treatment - "on or of patient". The legal steps would then be up to WTO. Bulletin of WHO, 2003, 81(3) p=150

Vaccine against cervical cancer passes "proof of principle" - Robert Walgate reports of a non-recombinant vaccine against human sexually transmitted papilloma virus type HPV-16; thought to cause as many as half of all cervical cancers which has been shown to prevent long term HPV-16 infections in a trial of 2400 young women. This Merck HPV vaccine is based on the same principle as Hepatitis B vaccine; a recombinant capsid protein. It has come out with flying colours in a trial designed to measure HPV infection, and has so far measured protection for only 1.5 years.

Sonia Pagliusi of the WHO Initiative for Vaccine Research told the Bulletin "This is a very interesting vaccine for developing countries as they have 80% of the world's cervical cancer. and have few other options. They can do the Pap {smear test, requiring cytological observations} but it's not very effective-it's not working. People take the test, but follow-up is difficult".

According to Andreas Ullrich, who works on national cancer control planning issues at WHO, "Cervical cancer is a high priority: it's first or second in developing countries, among all cancers".

Vaccines are the most cost-effective interventions to prevent life threatening infections "And we hope we will need to vaccinate only once in a woman's lifetime, before they become sexually active-with a three-shot course like Hep B" said Pagliusi.
Bulletin of WHO, 2003, 81(1)

Donors are distorting India's health priorities, say protestors
Rupa Chinai reports that International donors are driving India's national health agenda in the wrong direction, says a growing movement of Indian health policy experts and non-governmental organizations (NGOs). For example, although AIDS mortality is still low in the country, there is an excessive focus on HIV/AIDS prevention, with little linkage to primary treatment, they say. Meanwhile, grass-roots concerns and larger immediate public health needs are being ignored, they claim.

The recent visit of the Microsoft tycoon Bill Gates, with his US$ 100 million grant for AIDS prevention in India, sparked the debate. At that time, the view of the Government of India and part of the Indian media was that they should not "look a gift horse in the mouth". Public health experts, however, argued that this was a myopic approach that failed to recognize grass-roots reality.

Alka Gogate, Director of the Mumbai AIDS Society claimed that it was "well recognized" that if primary health services were neglected, the huge load of infectious disease patients would be pushed onto the city's tertiary services - which cannot cope with this pressure.

The epidemiology of HIV/AIDS in India has recently generated heated controversy between the Government of India and International agencies. The National AIDS Control Organization (NACO) estimates that four million people suffer from HIV infection in India. AIDS is not reported as a cause of death in the death registers, but NACO states that between 1986 and November 2002 there were 42,411 cases of full blown AIDS in the country. NACO also claimed that the epidemic is now plateauing because of its efforts. Others are skeptical, and reliable data, that all sides can agree, are urgently needed.

The current donor interest in HIV/AIDS in India is boosting HIV/AIDS spending by approximately an additional US$ 80 million a year, causing spending on this one disease to reach US$ 110 million a year, thus making HIV/AIDS the main target of India's spending on disease control.

Moreover all AIDS funding is routed through NACO and state AIDS Societies, bypassing state health departments, so contributing little to improving the country's struggling health system.

Western and Indian government perceptions can differ widely not only from each other but from grass-roots realities, several studies have shown. A survey of published studies by Ramila Bisht, a senior lecturer in the department of health services at Mumbai's Tata Institute of Social Sciences, found that donor funding between 1985 and 1995 for specific disease programmes did not match evidence of the prevalence of these conditions in the community. For instance, despite being a major killer, TB was not a priority for funders until the 1990s, she says.

"Unless we strengthen the primary health care base we won't go anywhere," says Sheela Rangan of the Pune-based Centre for Health Research. "These is an urgent need to build management systems, fill vacant posts and train front-line health workers in comprehensive care, so they understand the linkages between diseases.

"The emphasis on AIDS works to the detriment of other communicable diseases, which could stage a resurgence," claims Bisht. "We need to integrate AIDS funds into strengthening the general health services. Improving the primary health system will have an impact on a range of killer diseases, including AIDS."

World Body reviews doctors links to drug industry.
Susan Mayor reports from London that no individual should receive direct payment from commercial companies to cover traveling expenses, room and board at a conference, or compensation for their time, according to proposed guidelines from the World Medical Association.

The association is developing the guidelines to clarify the relationship between doctors and commercial enterprises, including the pharmaceutical industry. Underpinning the proposals is the need for doctors to disclose and avoid competing interests.

The guidelines, discussed at a recent meeting of the association, acknowledge the complex nature of the relationship between doctors and industry. They also acknowledge that a potential conflict of interest clearly exists when a commercial enterprise, such as a pharmaceutical or medical supplies company, has direct or indirect influence over doctors' behaviour because it offers financial support.

However, the association acknowledged that industry support was often important, enabling medical research, scientific conferences, and continuing medical education. So, rather than forbidding any connection between doctors and industry it argued that it was better to establish guidelines for ethical relations.

The draft statement, based on guidelines already established by the World Health Organization, national medical associations, and the pharmaceutical industry, includes recommendations for industry sponsorship of conferences, research, and gifts to doctors.

For example, it would be acceptable for companies that sponsor medical conferences recognized as continuing medical education to ask for a certain topic be included in the programme. But companies should have no influence on the content, presentation, choice of speakers, or publication of results. Ideally, proposed the association, several companies should sponsor a conference. The names of any companies providing financial support should be publicly disclosed. Funding for a conference can be accepted as a contribution to the general costs of the meeting but not as payment for any specific lecturer or participant.

But more controversial is the recommendation that no doctors should receive payment to cover traveling expenses, room and board at a conference, or compensation for their time. Many doctors rely on support from drug companies towards travel and hotel costs for attending international medical conferences, which they would otherwise be unable to attend.

Other guidelines are that doctors involved in commercially funded research doctors should be subject to legal, ethical, and professional regulations and must not be subject to external pressure on the results of their research or its publication. Doctors can be compensated for their time and effort in conducting research, but this compensation should in no way be connected to the results of the research. Any doctor working for an institution that funds research centrally should be compensated through the central fund. Sponsorship of research should be disclosed in any publication of results. Doctors with a significant financial interest in a company should not accept research should be disclosed in any publication of results. Doctors with a significant interest in a company should not accept research funding from that company if there is a risk of conflict of interest, unless the case is approved by an ethics committee. Finally, companies should offer doctors only gifts that are of nominal value and are related to their work.

The association has set up a working group to take the issue forward for further discussion at the general assembly in Helsinki in September.
BMJ=Vol. 326, 31st May, 2003

Deputy Chief Medical Director, Indian Railways Medical Service, New Delhi, India (for correspondance, 157/4, Officers' Flats, Railway Colony, Basant Lane, New Delhi-110055, India, E-mail: [email protected] and [email protected].

** Associate Professor, Deptt. of Hospital Administration, AIIMS, New Delhi. E-mail: [email protected]

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