Where technology may fail to deliver

Political economy of technology transfer

Anna Donald, lecturer. 

Department of Epidemiology and Public Health, University College London, London WC1E 6BT

a.donald{at}ucl.ac.uk

Every year, new health products and know-how become available: statins, new antibiotics, telemedicine, insurance know-how, imaging techniques, and genomics, to name a few. At the same time, major barriers to transferring information and technology between countries are falling with expansion of the internet and online health training programmes, the growth of information about the relative effectiveness of different technologies,¹ and the liberalisation of trade. It might be reasonable to expect that global transfer of health technologies would take place more rapidly and in greater quantity to benefit "haves" and "have nots" alike. There is no evidence, however, that this is taking place. On the contrary, appropriate health technologies may become more unequally distributed than ever. Why?

	Demand factors

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Economic demand for health technologies by individuals, governments, and insurers is determined by factors such as purchasing power, technological capability, purchaser priorities, and unequal information.

Purchasing power
One of the main reasons why people cannot get the health technologies they need is because they cannot afford them. For example, few African parents can afford the antibiotic ceftriaxone, the most effective treatment for one of the main causes of infant death each year, Streptococcus pneumoniae.² Nor will most people be able to afford medicines for cardiovascular disease, the biggest projected killer in developing countries by 2020,³ as they exceed the annual incomes of most patients (table 1).

Technological capability
People may not get the technology they need because the country or region lacks the structural capacity to use and maintain it. Effective technologies for people in developing countries, such as limb microsurgery, telemedicine, and primary care services, require a skilled workforce, equipment, and spare parts as well as a functioning economy and political systemrequirements that many countries lack. Technological capability can be improved by aid agencies, but usually much greater structural change is required to enable widespread use of new technologies. International literature is littered with examples of well intended aid plans that underestimated requirements for technological capability.¹²

(Credit: MARTIN MEJIA/AP PHOTO) View larger version (81K): [in this window] [in a new window]   An Andean soothsayer inhales hallucinogenic ayahuasca from a shell: if the United States succeeds in patenting the ayahuasca plant, many South Americans will have to pay for it

Purchasers' priorities
Another reason for people not getting the most appropriate technology is the priorities of those who purchase health technologies on their behalf. For example, many Roman Catholic and Islamic women have no access to birth control because their health systems and governments do not allow it. Donor countries and companies may buy technologies for poorer countries according to their own needs to expand markets or to dump irrelevant, old, or even harmful technologies.¹³ Common problems affecting pharmaceutical company donations include drugs being close to expiry, irrelevant to local people's health problems, unsorted, mislabelled, and not complying with local standards or administrative procedures.¹⁴

Unequal information
Finally, people may not get appropriate health technology because they and health professionals are swayed by poor quality information, such as advertising, rather than by independent, objective information about the relative benefits, harms, and costs of the technology. Few countries have health technology assessment programmes to help discriminate between technologies; and many poor countries have no needs based health system. In most countries branded drugs are more popular despite being more expensive and of no better quality than non-branded generics. This is largely because of advertising and the absence of easily accessible information on cost effectiveness for patients and health professionals. ^{15 16}

	Supply factors

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On the supply side, technology transfer is affected by how supplierscompanies, governments, non-profit making organisations, and international organisationsappraise the costs, risks, and likely benefits of making health technologies available.

Cost and risks of supplying technologies
Suppliers are unlikely to spread technologies if they think the costs and risks of doing so are too great. Costs of supplying health technologies can be increased or offset by local tax and subsidy policies, including assistance from research and development programmes. Such policies usually require a stable government and legal and money lending systems, which again are typical of richer rather than poorer countries. Suppliers are also unlikely to sell technologies or invest in joint ventures with countries facing the risks inherent in major political unrest or war. The supply of medical technologies all but collapsed, for example, in war torn Colombia and Serbia. ^{17 18}

Returns on investment
Suppliers' perception of benefits (returns on investment) is perhaps the greatest factor affecting supply and distribution of health technologies. Few suppliers are interested in developing technologies for people unlikely to be able to pay much for them. For example, oily suspension of chloramphenicol is as effective and easier to use than ampicillin for treating epidemic bacterial meningitis caused by Neisseria meningitidis and one tenth its price, but no drug company seems interested in making it as profits would be relatively small.² On the other hand, companies are keen to get as much return on past investment as possible, sometimes even for products found to be ineffective or harmful. For example, the drug dipyrone was withdrawn from Germany in 1987 because of adverse effects but continues to be sold in most developing countries. It was one of India's top selling drugs in 1995.¹⁶ Mass migration of highly trained health professionals continues from poor countries to rich ones, where salaries are higher and political security assured; 75% of all migrant doctors work in the five countries Australia, Canada, Germany, the United Kingdom, and the United States.⁵

	Political factors that determine demand and supply

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Not all technology transfers are desirable. Many technologies are not cost effective and some are harmful. In terms of health gain, more important than people's capacity to obtain technologies is their ability to choose between them using sufficient information about their benefits, costs, and harms. In turn, choice of technology depends on the political relationship between those buying and selling technologies, as well as between purchasers of health care and its recipients.

Most developing countries, with gross national products far below the total sales of many large companies (table 2), lack the political muscle to set the rules determining international trade, such as the TRIPS agreement. Furthermore, individuals in many of those countries, who have no effective political representation in government or evidence based health systems, are unlikely to demand the health technologies they need and resist the ones they do not. Experience suggests that in the absence of strong, highly skilled and non-corrupt health systems, private suppliers readily sell inappropriate technologies to people ill equipped to demand anything better.

Many people hope that liberalising information and trade will result in a trickle down of beneficial technologies to poor people. Yet there is no evidence that trickle down is likely unless enforceable mechanisms are developed to promote and distribute technologies according to health gain rather than simply for profit. These might include national and international laws to protect indigenous peoples against patents that would deprive them of local technologies or to ensure that they get a share of the profits; crossborder technology transfer arrangements; subsidies to promote the development of less profitable interventions; economic development to create sustainable markets for effective drugs, and mechanisms to increase access to reliable information about health technologies.

Several substantial programmes are currently under way. The quality of donations by pharmaceutical companies has recently improved, perhaps with increased awareness of problems and the development of guidelines. It may improve further with more widespread monitoring and adherence to recent recommendations about drug donations developed by a consensus of stakeholders (companies, recipient governments and health facilities, the WHO, and private voluntary organisations).²² Several programmes currently use a variety of mechanisms to increase access to vaccines, including subsidies and tax credits, research gifts in kind from pharmaceutical companies, preferential investment in companies that agree not to enforce patents in poor countries, and cash donations.¹⁹ So far, however, none of these seems likely to sustain research and development for poor countries at affordable prices without the kind of global backing given to treaties like TRIPS. It remains to be seen whether heart-lung transplants will make it to Niger.

	Acknowledgments

I thank Michael Anderson, Trisha Greenhalgh, and Sam Vincent for help with this article

	Footnotes

Competing interests: AD has advised two pharmaceutical companies about the implications of evidence based medicine for the pharmaceutical industry in the United Kingdom.

	References

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1.	Warner DC. The globalization of medical care. In: Zarrelli S, Kinnon C, eds. International trade in health services: a development perspective. Geneva: UN Committee on Trade and Development, World Health Organisation, 1998:71-77.
2.	Pècoul B, Chirac P, Trouiller P, Pinel J. Access to essential drugs in poor countries: a lost battle? JAMA 1999; 281: 361-367[Abstract/Free Full Text].
3.	Murray CJL, Lopez AD. The global burden of disease: summary. Cambridge, MA: WHO, 1996:37.
4.	British Medical Association, Royal Pharmaceutical Society of Great Britain. British national formulary. London: BMA, RPS, 1998(No 36.)
5.	World Health Organisation. The world health report 1998. Geneva: WHO, 1998.
6.	Heymann SJ, Brewer TF, Wilson ME, Fineberg HV. the need for global action against multidrug-resistant tuberculosis. JAMA 1999; 281: 2138-2140[Free Full Text].
7.	Simms A. Selling suicide: farmers, false promises and genetic engineering in developing countries. London: Christian Aid, 1999.
8.	Rural Advancement Foundation International. Conserving indigenous knowledge: integrating two systems of innovation. An independent study. New York: UN Development Programme, 1994.
9.	World Bank. Knowledge for development. Oxford: Oxford University Press, 1999.
10.	Abbasi K. The World Bank and world health: focus on South Asia.1. Bangladesh. BMJ 1999; 318: 1067.
11.	Wuyts M, Mackintosh M, Hewitt T. Development policy and public action. Oxford: Oxford University Press, 1992:99-100.
12.	Ferguson J. The anti-politics machine. "development," depoliticization, and bureacratic power in Lesotho. Minneapolis: University of Minnesota Press, 1994.
13.	Chetley A. Struggling for clear policies. In: A healthy business? world health and the pharmaceutical industry. London: Zed Books, 1990:68-93.
14.	World Health Organisation. Guidelines for drug donations. Geneva: WHO, 1996.
15.	Waud DR. Pharmaceuticals promotiona free lunch. N Engl J Med 1992; 327: 351-353[Medline].
16.	Chowdhury Z. The politics of essential drugs. The makings of a successful health strategy: lessons from Bangladesh. London: Zed Books, 1995.
17.	Veeken H. Colombia: the winner takes all. BMJ 1998; 317: 1649-1650[Free Full Text].
18.	Black ME. Collapsing health care in Serbia and Montenegro. BMJ 1993; 307: 1135-1137.
19.	Balms for the poor. Economist 14 August 1999:69.
20.	World Bank. Knowledge for development. Oxford: Oxford University Press, 1999.
21.	Survey: the pharmaceutical industry: the alchemists. Economist 21 February 1998.
22.	An assessment of us pharmaceutical donations: players, processes, and products. In: Reich MR, ed. Boston: Harvard School of Public Health, 1999(www.hsph.harvard.edu/faculty/reich/donations)