“ As part of our move to better accommodate and adjust our business model according to the different stages of the development continuum, we have developed a new multi-agency initiative to help expand access to essential health commodities,” Mark Dybul wrote in his Executive Director’s Report to the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria, for its meeting last November. If the sentence had ended there, it might have gotten a positive, if expectant response. But the sentence continued: “through a multi-tiered pricing framework.”
It was a solution, advocates said, that would exacerbate the problem it was meant to solve.
Tiered pricing, which allows drug makers to make up for a lower price charged in a country categorized as “low-income,” with a high price charged in a company deemed “middle-income,” advocates have pointed out, has led to countries that are home to more people in need of affordable medicine paying prices in excess of 60 percent higher than those paid in “low-income” countries. That is because, as Dybul acknowledges in a May update on the plan, more than 100 countries classified as “middle income” are home to 75 percent of the world’s poorest people and to the greatest disease burdens.
The May update of the Equitable Access Initiative summary, the first document on the plan to be released officially and publicly since Dybul met with advocates in December, discards the term “tiered pricing,” saying it was used “in error.” It was released after 220 civil society organizations signed on to a letter criticizing a plan that would give pharmaceutical company representatives a role in establishing how to improve access to affordable medicines and retained a goal that would “validate and institutionalize a single failed strategy.”
Those concerns have not been allayed by the newly released document, or by assurances by Dybul, who met for an hour with advocates at the recent World Health Assembly, that he would continue to take their points under consideration at a meeting set for June 20th.
One reason for that is timing. According to the released summary, that is the meeting at which a draft of the plan is set to be completed.
In addition, a summary of civil society concerns and correspondence on the plan so far says, the definition of the problem itself remains a point of contention.
“It should be focused on the problem of classification of countries and the ability of poor people in those countries to receive donor-funded support for crucial health needs,” said Brook Baker, a law professor at Northeastern University and policy analyst for Health GAP, who wrote the summary. Baker emphasizes that middle-income countries should be expected to shoulder the responsibilities they can bear for public health care. But, he added, the income classification tiers don’t recognize continuums that exist in developing countries.
“They are arbitrary boundaries,” he said. What they don’t take into account, he added, is the strength of countries’ health systems, the degrees of inequality within countries and how much of the population lives in poverty, and disease burden.
And while the Global Fund and other charities voice a need to prioritize poor countries, at the current rate of transition, “by 2020, there aren’t going to be any,” Baker said. “They’re all going to be like Zambia – they’ll have five more dollars per person.”
But, he adds, “going from significant funding to no funding” is not the answer. “It is not a natural response to the persistence of poverty, inequality and disease burden.”
While that is a problem the Global Fund, and other donors should contemplate, he said, it should not be taking a leadership role in determining what prices countries can and will pay for medicines their populations need.