Accelerating Access: serving pharmaceutical companies and corrupting health systems

[Guest guest]

Accelerating Access: serving pharmaceutical companies and corrupting health

systems

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May 11, 2002 marked the second anniversary of the ³Accelerating Access²

initiative, launched by UNAIDS in a partnership with several UN agencies

(WHO, FNUAP, UNICEF and the World Bank) and five pharmaceutical companies

(Boehringer Ingelheim, Bristol-Myers Squibb, Glaxo Kline, Merck & Co.,

and Hoffman-La Roche [1] ). Since the end of 2001 this initiative has been under

the responsibility of the WHO.

According to the UN, Accelerating Access means " a redoubling of the efforts

of the cosponsors and the UNAIDS Secretariat to finance health care for

people living with HIV/AIDS.² This initiative was supposed to provide

developing countries with access to medicine at the lowest possible prices,

as well as provide technical support for the implementation of national

access programs for antiretroviral treatment.

Two years later, people with aids examine the results. Accelerating Access

serves, above all, pharmaceutical companies who profit from a partnership

with international institutions while using the program to keep their

monopolies and to limit any reductions in price.

According to the most optimistic of estimates, after two years Accelerating

Access has only resulted in getting an additional 0.1% of people with aids

on treatment (indeed, WHO rates at 10 million the number of people requiring

immediate antiretroviral theraopy). Further, many of these treatments are

actually based dangerous drug regimens - such as single-drug therapy, which

has been banned from Northern medical practice for the last 10 years.

********* Why such bad results? *********

Because the pharmaceutical companies involved have mostly been busy

negotiating agreements with developing countries that allow them to control

the supply of ARVs and to stave off competition from generic makers. The

companies¹ core strategy revolves around limiting price drops and imposing

access restriction on developing countries.

Accelerating Access fails to offer any real progress in terms of price in

the sense that because the proprietary pharmaceutical corporations have been

content to just align their prices with those of the generics producers. But

more significantly, their philanthropic discounts have systematically come

with strings attached: discounts restricted to very specific drugs,

quantities, countries, distribution sectors and medical settings, as well as

tied to government commitments to increasing patent protection and not

resorting to generic competition.

Far different from commercial, blanket price reductions, AAI discounts are

philanthropic actions accompanied the signing of an agreement between each

company and the health minister, setting convoluted conditions under which

the reductions are applicable (governments are usually required to keep

these agreements entirely secret and leave all media communication to the

company).

Moreover, AAI has completely failed to create significant price discounts

for the drugs that have no generic competitor yet. For example, Swiss drug

giant Roche continues to sell its leading protease inhibitor Viracept® for

an astounding USD 3139 a year through Accelerating Access.

Because the WHO and UNAIDS have not provided any assistance to countries to

enable them to launch or expand treatment access programs. Many countries

have taken on the Accelerating Access offer and have still to receive, two

years later, any technical assistance from WHO or UNAIDS, or to show a

single treatment access program for their trouble (Togo, Congo, Burkina

Faso, etc.). Also, no specific aid has been put into place by these agencies

to ensure the quality and sustainability of AAI-mediated ARV provision.

Because the WHO and UNAIDS have proved unable to ensure that negotiations be

transparent, respect basic ethical standards and eventually achieve results.

There are no guidelines for relations between companies and developing

countries. In each case so far, pharmaceutical companies have taken their

negotiations directly to the government or to the providers of health

services, country by country, each in an independent way, without any

supervision by UN agencies.

This means that the Accelerating Access label is attached to‹and serves as a

guarantee for‹negotiations that the WHO and UNAIDS have no power over and

cannot even really follow up on.

Because by only including proprietary pharmaceutical companies, United

Nations agencies have pushed aside the producers of generics and trapped

developing countries in unequal negotiations. Generic competition [2], the

only sustainable way to get low prices, has been pushed aside in favor of

subjecting countries to the goodwill and demands of multinationals.

********* Countless negative consequences*********

But, after two years, Accelerating Access has more to show for itself than

just bad results in terms of medicines provided and lives saved. This

initiative is responsible for numerous negative consequences that the WHO

and UNAIDS have not only been incapable of stopping but that they have even

supported. These include instrumentalisation of international health

institutions, discrimination between recipient countries, market fixing,

short-circuiting national drug circulation systems, and spurring irrational,

dangerous prescriptions.

1. The WHO label, marketing added value for pharmaceutical companies

For two years Roche Pharmaceuticals has bragged about its participation in

the Accelerating Access initiative and of its work facilitating access to

treatments in developing countries, while in fact Roche has so far refused

to grant price discounts on its products. There are no generic competitors

for Roche¹s HIV products, which means it is not forced to reduce its prices.

At the end of April, Mr Nabarro, Executive Director of the WHO, acknowledged

that he ³had problems with some companies² and ³wished Roche would start to

play by the rules² as soon as possible.

2. Accelerating Access: a tool that discriminates among poor countries

Apart from the fact that WHO¹s Accelerating Access Initiative concerns not

multilateral (like WHO) but bilateral negotiations (one country at a time,

one drug at a time, precluding regional, purchasing-power negotiations), it

discriminates between developing countries in terms of the extent of price

of price discounts arrived at through the ³negotiations².

Thus in poor countries considered " too rich " , such as Morocco or Thailand,

drug firms refuse to grant the same reductions as in sub-Saharan Africa. Yet

no one ignores that in Morocco and in Thailand people are already poor

enough that every dollar added to the price deprives many of those

lifesaving medicines. Further, pharmaceutical companies feel free to

threaten countries with calling the discount deal off should find out that

the government is buying from generic producers (Thailand).

3. Captive markets

After the defeat of pharmaceutical companies in South Africa in spring 2001,

drug companies stepped up their efforts to recruit developing countries to

Accelerating Access and thus impose themselves, their power and their vision

of intellectual property on these countries.

The consequences are plain to see. Despite the immediate advantages that it

represents for them (lower prices, no stings attached), very few countries

have dared to turn to generics. In Burkina Faso, the international summit on

access to generics, which should have taken place in the capital from May

3-7 2001, was canceled after the minister of health signed an price discount

accord with some of the pharmaceutical companies.

Indeed, through Accelerating Access companies force countries to sign

confidential agreements that seek to ensure their continued monopoly by by

hindering resort to generics. These include intellectual property clauses

which impose restrictions stronger than those mandated by the World Trade

Organization (³TRIPS+²) as well as renewed purchase commitments over several

years (BMS, Merck).

Thus, even countries which have no legislation on intellectual property are

forced to buy all their antiretrovirals from proprietary multinationals.

In certain countries, in order to access cheaper medicines, people with aids

have to buy generic medicines imported by NGOs (MSF in Cameroon, ANSS in

Burundi, etc) rather than from the AAI providers. The control of medicine

circulation, which should have been centralized by the government and which

Accelerating Access is supposed to guarantee, is, in fact, nonexistent.

4. Corrupting national procurement networks

Since it was created, Accelerating Access has operated in parallel to

national health care systems. Right now, this initiative bypasses official

procurement networks.

For years WHO has been promoting the creation of central purchasing offices

on a national scale, which work on the basis of transparent public tender.

Today, however, WHO supports the signing of contracts between Ministries of

Health and pharmaceutical companies on the sale of medicines that create a

system of procurement parallel to that of national pharmacies, a lack of

transparency with regards to prices, no competitive bidding and thus no

competition.

The pharmaceutical industry thus bypasses public procurement systems,

increases its power over a few officials or doctors as well the

opportunities for corruption by setting up a totally opaque system.

5. Irrational and Dangerous prescriptions and drug uses

Since Accelerating Access only includes a reduced number of pharamaceutical

companies and price reductions only apply to certain medicines, this means

that the entire therapeutic palette necessary to treat aids patients is not

available. Even though one of the prerequisities for countries¹

participation in Accelerating Access is supposed to be the guarantee of a

³secure, efficient system of distribution,² in reality this initiative has

caused irrational prescriptions that are based on economic imperatives‹a

choice of medicines based on the discounts granted by industry. What follows

are prescriptions for therapeutic combinations that are inefficient and even

dangerous in terms of their side effects, all under the name of clinical

trials or treatment access programs.

Certain companies, playing on their influence over doctors, push them to

prescribe completely bizarre therapeutic combinations. In Kenya, Merck & Co.

promote a bitherapy including two of its medicines‹indinavir (Crixivan®) and

efavirenz (Stocrin® or Sustiva®) ­ a risky combination since efavirenz

requires a higher dose of indinavir which itself requires higher levels of

hydration and increases the risk of renal toxicity. In South Africa, BMS

continues to promote the prescription of its three medicines ddI, d4T and

hydroxyurée, a combination that researchers have shown to be potentially

dangerous.

Accelerating Access is a striking example of a dishonest compromise between

international institutions and the pharmaceutical industry at the expense of

people and public health.

The WHO must not allow developing countries to enter into agreements with

private companies unless they can guarantee transparent negotiations that

respect basic ethical standards and provide some results.

The WHO must change its strategy immediately.

For the price of medicines to really be affordable, several measures must be

taken:

-the developing of international and regional purchasing of medicines [3],

on a large scale that will allow for the best price negotiations;

-the reinforcement of capacities and technology transfer in order to promote

local drug production in developing countries;

-compulsory licensing and parallel imports;

- competition between brand-name medicines and generics.

Access to generics is a major issue for developing countries and the only

long-term option for access to the largest and most complete variety of

treatments at the lowest prices.

The WHO must provide countries with the most complete information possible

on the sources of medicines, naturally and necessarily including generic

producers.

It is particularly necessary for public central buying offices and any other

potential users to have access to unbiased information on the prices of

ARVs.

The WHO must support the development of bulk purchases of medicines for

countries at the lowest price, as well as local production.

The WHO must provide countries that wish to set up treatment access programs

with genuine technical help.

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Appendix I : List of countries involved in Accelerating Access (March 22,

2002)

Countries having signed an agreement with pharmaceutical companies: Benin,

Burkina Faso, Burundi, Cameroon, Congo, Cote d¹Ivoire, Gabon, Mali, Morocco,

Rwanda, Senegal, Uganda, Barbados, Chile, Honduras, Jamaica, Trinidad and

Tobago, Romania.

Countries in the process of negotiation as of last March: Botswana, Republic

of Central Africa, Chad, Ethiopia, Gambia, Guinea, Kenya, Malawi, Nigeria,

Swaziland, Togo, Tunisia, Guatemala, El Salvador, Mexico, Venezuela,

Ukraine, Vietnam.

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Notes:

1 - Later, Abbott and Pfizer also joined the initiative.

2 - In 2000, the production of generic antiretrovirals in some developing

countries (India, Thailand, Brazil) drastically lowered the prices of these

drugs. In October 2000 an Indian producer launched a generic tritherapy for

800 US dollars per year, a reduction of more than 90% compared to the prices

of multinational corporations. In February 2001 the price offered by this

company dropped to 350 US dollars. In October 2001 another producer's price

was reduced to 295 US dollars. The marketing of such low-cost generic drugs

quickly forced western companies to adjust their own prices to match those

of generic producers. Until then, they had refused to grant important

reductions to developing countries, despite the entreaties of UN agencies.

The marketing of generic antiretrovirals proved two things:

-that medicines can be sold at prices considerably lower than what the drug

industry had previously claimed

- that the absence of a monopoly and competition among producers are the

most efficient ways to obtain a drastic and lasting reduction in the price

of medicines, much more efficient than so-called philanthropy or charitable

work of pharmaceutical firms.

3- Such as the system operated by UNICEF to supply vaccines and

contraceptives.

--

Olivier Jablonski

North / South Commission

Act Up-Paris

http://www.actupp.org

+ 33 1 49 29 44 81

Fax : + 33 1 48 06 16 74

BP 287 75525 Paris Cedex 11

France

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