Toronto, Canada Peter Evans is the former Chief of Procurement at WHO and UNFPA and Chief of Medical Procurement at UNICEF
Why Medicines for Africa and why now?
Because Medicines for Africa represents a sustainable approach in the long term, building on what is in place, leading to the best comprehensive health care that the countries can afford, with the least dependence on donors.
“Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.” Currently, the “teaching” is often limited to learning how to advance each Agency’s objective and the provided “fish” are dumped in ways that cause long term collateral harm.
Donors more and more insist on almost immediate confirmation of success and choose target disease reduction, as a validation of success. The effectiveness, of investments in health systems, is difficult to measure and therefore difficult to fund. Over the past few decades, the transfer away from financial and technical support for health infrastructure, towards targeted support limited to specific diseases, has been significant. Indicators of success usually concentrate on dollars spent in a given time period, how many health units provided, then how many health units used and finally how much health was achieved. However, as far as I have seen, no one measures how much other health care was displaced.
The health gains from attention to the targeted diseases are significant and to be applauded but while all major international health programmes pay lip service to providing support to the basic health infrastructure of each country, the reality is that support is mostly given to the elements that require the vertical programme (disease-specific) to achieve success and not to the horizontal support (population-specific) required for all other health improvements.
The level of funding to support health care in developing countries is staggeringly high yet the funds spend on improving the health infrastructure diminishes year by year, and has few champions.
Procurement, of Agency funded health care items, is being centralised and conducted by Agency staff. Support to develop national skills is limited to areas where the Agency project needs an improvement, to succeed. Frequently simple data gathering systems have been replaced by state of the art computer management systems, ideally structured to support the Agency needs. Forecasting, based on data, may be taught, but source selection, negotiation, make or buy decisions or quality assurance is not, as the Agency makes those decisions. The National Regulatory Authority (NRA) of the recipient countries is all but ignored, as the provided health commodities have been produced to standards demanded by the richest countries. For Agency supplied items, the NRA is no longer required to have a published set or requirements, a system of sampling and release, the use of a laboratory, regular inspections for GMP, evaluation of clinical performance or a system of surveillance. These responsibilities are for the most part undertaken by the Agency or ignored.
If the country produces some of the needed medicines, the local producer will be disregarded, as the Agency will have already decided which global producer will supply. The local producer can look forward to large amounts of product being dumped into his market making it impossible for him to compete.
The gains in health due to the focus by various Agencies on specific diseases are real, important and measurable. The negative impact on the basic health systems, are also real and important, but are unmeasured and in some cases unquantifiable.
The state of the art inventory management systems require all staff to be retrained, usually by external experts. The maintenance problems which inevitably occur also require external experts to be brought in to resolve. Independent, and usually adequate, systems have been displaced by systems which build in full dependency on the external Agency. The new systems may be suitable for high volume, high value items but must also be used for low volume and low value items, for which the benefits may not warrant the necessary input effort. Additional health supply systems do not exist in isolation and all other government controlled items continue to rely on legacy systems, still operating but in parallel.
Bypassing the NRA for Agency provided items, rather than supporting them, results in a general decline of the NRA through lack of respect and lack of investment. The lack of investment means that poor systems gradually get worse. Goods purchased by the Government, or produced within the country, receive less and less adequate scrutiny and control.
The importing of large volumes of health commodities and providing them at subsidized cost or free of charge, displaces local production. This loss of business raises the overhead costs for all other produced items. Investments to upgrading capacity or improve quality, ceases, and the industry declines. In the past one Agency has supported local production while another Agency dumps the same goods onto the market, free of charge, putting the newly created local producers out of business. The countries become more and more dependent on outside producers and Agency donations.
For long-term sustainability there is a need to get back to basics. To concentrate on all health needs and not just the disease of the moment, to consider the long term results and not just the immediate gains and to respect the autonomy of each country, confirming they allocate an appropriate level of funding and avoiding dependency.
The starting point for international health support, needs to be somewhere behind each Government, not a think tank in an industrial capital. An assessment is needed of the infrastructure already in place and the health needs within target countries. If the infrastructure is inadequate to meet the health needs, then it must be strengthened, not bypassed. Providing any form of external support should be within the context of the country and decided by the country.
All countries undertake procurement and purchase from internal and external sources for a wide range of products, going well beyond health care needs. The systems used may not be state of the art but, for the most part, are meeting the country needs. If they are to be improved then the first choice should be using expertise within the country. If more help is needed, then seek and utilise experts in neighboring countries with similar problems, preferably in some form of contracted partnership. If the volumes required are inadequate to provide sufficient clout in the market place then partnerships with neighboring countries should not only increase the volume but also arrive at a consensus of what medicines are needed and inevitably, how they will be used. Limiting access to markets is a powerful negotiating tool. Using resources from outside of the partnerships will always be an option but should be made by the countries themselves with full knowledge of why the external options is the best choice for their needs.
There are brilliant examples of such partnership, the largest of which are the countries of the Americas. While Agencies, such as PAHO are invited to provide advice, it is the Ministries of Health which take all decisions, by consensus. Not only is the dependency on donors significantly reduced but when a new technology becomes available, introduction is rapid. Another successful collaboration is the Gulf Cooperation Council (GCC). While addressing far more than health, all health decisions, including procurement, are made on a consensus basis with Saudi Arabia leading the technical support. Another successful collaborations is the Pacific Islands with their small volumes and challenging logistics, joining together to decide on health interventions using a common voice.
Such partnerships also decide on the medicinal standards to be applied and the level of quality assurance needed. Such quality standards are the most appropriate for the countries involved. Once standards have been set and the process of assurance agreed, then the countries can work in unison relating to inspections analysis and approval for distribution and use. The process is applied to all purchased and produced products and includes a wide range of health commodities, well beyond the narrow interest of the international Agencies. The efficiency of the process improves year by year with diminishing support from external experts and creating independence not dependency.
All countries produce many of their own medicines but many production plants fail to meet basic quality standards. In many cases the decision to buy, rather than make, is correct. To be able to produce economically and to invest at levels that can provide a high level of quality assurance, requires an assured market size. Entering into partnerships with neighbouring countries increases the assured market size and gives the possibility of production meeting the agreed standards, while remaining economically viable. Once there is an agreed set of standards and quality assurance procedure, the market for companies unable or unwilling to invest and conform quickly disappears. Good producers prosper and others close down.
What to do?
If the purpose is to only save the lives of people who are alive today, then vertical programs, supported by international funds involving the parachuting in of needed supplies with the addition of very efficient parallel systems, is the way to go. If the purpose is to provide independent but improved health services for generations to come, then empowering the governments to do the best they can, with the resources available, will be far more effective.
Alas, donors are fickle and priorities change as often as Presidents change. Diseases are not static and who could have predicted that the child survival gains of the 80’s would be wiped out by the new disease of AIDS or that Ebola would go from a few cases per year to tens of thousands a year, for no discernable reason. With an increasingly mobile global community and the reduced effectiveness of today’s anti-biotics, building infrastructure to handle whatever comes along, is more important than firefighting every new threat.
What is needed is an Agency not being judged and funded based on immediate health gains, to stand with each government to help them create the national and international links that would help them monitor their health situation and build up their infrastructure from the perspective of procurement, quality assurance, production and access to health through contracts with their neighbours for services, as equal partners.
First, looking inwards to make the most of resources existing within the country. Then working with their neighbors to share expertise and services, building up the capabilities of all participating countries. Only when these elements have been exhausted should other international resources be sort, to support what the government needs. International support should be limited to supporting the government with its health situation. If the national infrastructure is considered inadequate by the international Agencies, deficiencies must be eliminated, not bypassed, as part of the support.
The time frame is longer, decades rather than months but the gains are incremental from the very beginning. Current disease control strategies will be slowed initially, as they necessarily become integrated into and support, existing national systems rather than stand-alone international initiatives. However, when the partnerships are working, disease initiatives will be implemented far more rapidly, folding into robust infrastructures.
The cost efficiencies achieved by the internal Agencies will eventually be matched by the country systems but the efficiencies will apply to thousands of products and not just the few championed by the Agencies. Quality assurance will be appropriate for the country but the new higher standards will be applied to all of the products used in health, not just those parachuted in.
National and Regional production will be expanded, for the companies willing and able to upgrade to the new requirements The other substandard producers will be closed forcefully or by attrition through lack of sales.
Donor funds and external expertise will always be welcomed and such backing will support faster implementation, but the direction of progress will not be diverted should donors change their priorities.
Progress will be measured in the broadest of criteria representing overall health gains rather than specific disease reduction.