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GRENOBLE ECOLE DE MANAGEMENT – IRIS SUP’
Pharmaceutical industry: why industrial development in India and
China does not ensure access to health for local people?
International Business / International Relations – Master’s thesis
Doriane VERDIN
19/09/2014
1
2
ABSTRACT
India and China have experienced unprecedented growth during these last few years.
China is now the second largest economy in the world, and India the tenth. Their
populations represent the sixth of the global population: both countries now have a
considerable influence on the international scene. However, economic development seems
to have occurred at the expense of public health, which has, for long been neglected, both in
India and in China. Although a large pharmaceutical industry has developed in the two
countries, as a result of rising demand for cheaper drugs and of patent laws flexibilities,
providing generic affordable drugs for the local market, the Indian and Chinese populations
still lack access to basic health services.
This paper intends to show how the Indian and the Chinese pharmaceutical industries
emerged as a response to the lack of access to drugs in developing countries. They indeed
massively used the flexibilities of their national patents laws, and later, of the international
framework applying to intellectual property rights, to become what we now call “the
pharmacies of the world”. The drop in drugs prices, incurred by the local production has
significantly improved access to health for Indian and Chinese populations as well as for the
rest of the developing world. However, it has not guaranteed the right to health for every
individual. Access to health is indeed part of a larger sphere, which goes beyond the simple
affordability of drugs. India and China are now both trying to build comprehensive
healthcare systems but the reforms and policies aimed at implementing it only are at their
first stages. This paper will therefore try to understand and analyze the rationale lying
behind the Indian and the Chinese healthcare systems, their key success factors and their
flaws, to better understand the reasons why, despite a promising pharmaceutical industry
development, Indian and Chinese people still lack access to health.
3
Acknowledgements
I have been privileged to enjoy the assistance, guidance and support of many people. I am
grateful to all of them. I would like to express my deep gratitude to these people who
contributed to the realization of this present document, and especially to:
Delphine Abramowitz, who accepted to supervise my project, for her help, and for
being patient enough to read this paper,
Alexandru Zgardan, for stirring my curiosity about intellectual property rights and the
World Trade Organization, during an international law course last year,
Fanny Chabrol, for her advice and her time and for sharing her experience in
Botswana and Cameroon,
James Arkinstall, who enabled me to learn more about the Médecins Sans Frontières
Access Campaign and drugs availability in the world, for his patience and for the knowledge
he provided me with,
Sreedhar Subramanian, for his kindness and enthusiasm, for his constructive advice
and for sharing his personal views regarding the Indian overall healthcare system,
All the survey participants, for their help and their time, and for providing me with a
better understanding of the existing healthcare systems around the world,
IRIS Sup’, my teachers there and the administration team, for encouraging me to get
a more detailed insight on topics I have always been interested in, through writing this
Master’s thesis,
Grenoble Ecole de Management, the MIB Beijing teachers and my classmates,
friends, and family, who have been of great support in this project.
I would finally like to spare a thought for HIV/AIDS researchers and activists who
perished in a plane crash in July, heading to the 20th International AIDS conference, for their
amazing work, involvement, and commitment to such a global cause.
4
Contents
Acknowledgements ................................................................................................................................. 3
List of abbreviations ................................................................................................................................ 5
Introduction ............................................................................................................................................. 9
1- India and China: from difficulties to access patented drugs to the development of local
technologies .......................................................................................................................................... 13
A – Patents, a barrier to access new drugs and medicines in the developing world ..................... 13
The logic of patents: commercialization of research and science ................................................ 13
Patents: a research stimulus, an impediment to public health .................................................... 14
Health as a public good, science should serve the general interest: the example of HIV/AIDS and
international mobilization ............................................................................................................. 21
B – Promoting innovation while promoting general interest: the international regulatory
framework......................................................................................................................................... 26
Introduction of the TRIPS agreement, to strengthen intellectual property rights........................ 26
The Doha Declaration: public health prevails ............................................................................... 27
C – India and China, a developing pharmaceutical industry: the emergence of generic
manufacturers................................................................................................................................... 32
The pre-TRIPS period: new flexibilities in the Indian Patent Act to stimulate local innovation and
to promote access to affordable drugs within local population ................................................... 33
A flourishing local pharmaceutical industry and the emergence of a generic drugs hub ............. 33
TRIPS and implications .................................................................................................................. 36
Thanks to the production of affordable drugs in India and China, an enhanced access to
medicines for local populations .................................................................................................... 39
2- But lack of efficiency of health policies prevents local population from accessing health services
............................................................................................................................................................... 44
A – India and China, undertaking the first step to reform their healthcare system ...................... 45
China, towards universal health coverage .................................................................................... 45
India: slow progress towards a comprehensive healthcare system ............................................. 51
B – Access to healthcare for everyone in India and China, still a long way to go ......................... 55
Disparities jeopardize “health for all” ........................................................................................... 56
An urgent need for public funding to reduce out-of-pocket payments ........................................ 61
Medical staff: a key pillar for healthcare provision ....................................................................... 63
C – Access to health: global action for a global concern, the emergence of global health ............ 65
Conclusion ............................................................................................................................................. 71
Bibliography ........................................................................................................................................... 76
5
List of abbreviations
ACHAP African Comprehensive HIV/AIDS Partnership
AIDS Acquired Immunodeficiency Syndrome
CGHS Central Government Health Scheme
CIA Central Intelligence Agency
CNY Chinese Yuan
DIPP Department of Industrial Policy and Promotion
DPCO Drugs Price Control Order
ESIS Employees State Insurance Scheme
EUR Euro
FDA Food and Drug Administration
GATT General Agreement on Tariffs and Trade
GDP Gross Domestic Product
HIV Human Immunodeficiency Virus Infection
ICAAP International Congress on AIDS in Asia and the Pacific
INR Indian Rupee
IPR Intellectual Property Rights
JAS Jan Aushadi scheme
JSY Janani Suraksha Yojana
MFA Medical Financial Assistance
MSF Médecins Sans Frontières
NEDL National Essential Drug List
NGO Non-governmental Organization
6
OECD Organization for Economic Co-Operation and Development
NLMEI National List of Essential Medicines of India
NRCMS New Rural Cooperative Medical Scheme
PEPFAR President’s Emergency Plan for AIDS Relief
SIPO State Intellectual Property Office
TRIPS Trade-Related Intellectual Property Rights
UEBHI Urban Employee Basic Health Insurance
URBHI Urban Resident Basic Health Insurance
USD United-States Dollar
WHO World Health Organization
WIPO World Intellectual Property Organization
WTO World Trade Organization
7
8
“People have to figure out that they don’t have to accept a
pessimistic crappy future. They can change things. You can change
things, I can change things, we can change things”
Zachie Achmat, founder of the Treatment Action Campaign
9
Pharmaceutical industry:
why industrial development in India
and China does not ensure access
to health for local people?
Introduction
The health sector is one of the key pillars of the United Nations’ development goals for
the millennium: these goals are calling for the developing world to review its health
strategies and policies and to implement effective health systems and healthcare coverage.
These goals also imply a major change regarding the international framework to regulate the
health sector and especially, may call for greater flexibility regarding international patent
laws. There have been, over the last few years, significant improvements in healthcare:
global life expectancy keeps rising, which reflects sharp increase in medicine, infrastructure
access, sanitation and nutrition. Prevention and treatment have also made strong advances
in recent decades: protection through vaccines is now mainly accessible everywhere, basic
drugs and antibiotics are available (96% of the drugs listed under essential medicines by the
World Health Organization (WHO) are not currently protected by patents1), medical services
coverage and networks are extending, and new treatments are discovered at high pace.
However, there still exist large disparities regarding access to healthcare between and within
the world different countries.
1 WORLD INTELLECTUAL PROPERTY ORGANIZATION (WIPO), “Patents and Health: comments received from
members and observers of the standing committee on the law of patents (SCP)”, Standing Committee on the
Law of Patents (18th session), May 25th
, 2012.
10
India and China (appendix 1) represent a sixth of the global population and both
experienced considerable growth during the last few years. However, they still account for a
significant part of the global burden of disease. The Human Development Index ranks China
91 out of 187 countries, whereas China is the second largest economy in the world. India still
lags far behind and is ranked 135, just after Tajikistan and Kiribati, and just before Bhutan
and Cambodia2. Despite the good overall economic performance of both countries, much of
their population is still lacking access to basic healthcare services.
Drugs and medicines availability and affordability is often presented as a key pillar for
access to healthcare. In December 2013, the Food and Drug Administration (FDA) approved
a new treatment for hepatitis C: Sovaldi (sofosbuvir), developed by the United-States based
biotechnology company, Gilead Science. The treatment could save lives of an estimated 130-
150 million people in the world living with chronic hepatitis C virus infection3. Up to 500,000
deaths per year are actually caused by the disease. The release of this new treatment was
therefore considered as a key milestone for science and health, and was highly welcomed by
both scientists and individuals from all around the world. However, this discovery, which
presents cure rates of over 90%, has been tempered by key challenges, the first of which
being the astronomic cost of the new treatment. Gilead Science is indeed charging USD
84,000 for a twelve-week course of treatment in the United-States, which makes the new
drug inaccessible for most people. Even if you add up research and development costs for
the new drug (considering that many drugs actually fail to enter the market), the selling price
of Sovaldi is still ten times as high as its actual final manufacturing cost. In August 2014, the
British National Health System refused approval for a new breast-cancer treatment, Kadcyla,
developed by the Swiss pharmaceutical company Roche, and sold for more than EUR
150,000 per patient and per year. The refusal was not on grounds of efficiency of the
treatment (it is one of the most efficient treatment for aggressive forms of breast cancer),
but on price grounds4. The British National Health System could actually not afford such a
2 UNITED NATIONS DEVELOPMENT PROGRAMME (UNDP), 2014 Human Development Statistical Tables,
(http://hdr.undp.org/en/data). The Human development index calculation combines three major dimensions: life expectancy at birth, education (mean years of schooling and expected years of schooling) and standard of living (gross national income per capita).
3 WORLD HELATH ORGANIZATION (WHO), Hepatitis C fact sheet,
(http://www.who.int/mediacentre/factsheets/fs164/en/) 4 PLUMRIDGE H, “UK health service panel rejects Roche cancer drug on price grounds”, The Wall Street
Journal, August, 8th
, 2014.
11
treatment. Such refusal could actually set a precedent for drugs disapprovals in developed
countries, because of their expensive price, that healthcare systems cannot cope with.
Having to face such excessive amounts for accessing new drugs, developed countries are
eventually addressing problems South countries are regularly facing to treat their
populations: life-saving drugs are not made available at affordable price, endangering the
lives of millions. Since the 1970s, the World Health Organization (WHO) has been promoting
“the right to health”, in order, among other things, to increase the accessibility of essential
drugs for populations. Since 1977, WHO therefore publishes a list of essential medicines,
which are intended to be available at all times, “at a price that the individual and the
community can afford”5. A key priority regarding access to healthcare is actually to offer
affordable drugs for people who need treatment. However, both Gilead Science and Roche,
claim that the price tag reflects the high costs of development of new drugs. One of the main
challenges actually is to make services affordable for the consumer, but at the same time
viable for the companies providing it, so they would keep trying to innovate and improve
people lives around the world. The issue of the accessibility of medicines for the developing
world dates back to years, but has been widely covered by the media since the 1980s only,
to focus on the HIV/AIDS outbreak and on access to antiretroviral drugs6. “The right to
health” actually questions the patented status of life-saving drugs. It is therefore important
to discuss the influence of intellectual property rights (IPR) evolution on drug accessibility in
developing countries, and to understand how raising concerns about public health
transformed into new flexibilities within strong IPR regimes.
These flexibilities have enabled India and China to become leading hubs for production
of generic low-cost and efficient drugs for both the developing and the developed world. The
local pharmaceutical industry production exploded in both countries, and the local market
was flooded with affordable medicines for the population. However, has access to health for
local people benefited from this industrial development? Access to drugs does not seem to
5 WHO, The right to health factsheet (www.who.int) “The WHO Constitution enshrines the highest
attainable standard of health as a fundamental right of every human being. The right to health includes access to timely, acceptable, and affordable healthcare of appropriate quality”.
6 WHO, Use of antiretrovirals for treatment and prevention of HIV infection, July, 2014
(http://www.who.int/hiv/topics/treatment/en/). “Standard antiretroviral therapy (ART) consists of the combination of at least three antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease”
12
be the only problem the developing world has to face regarding the overall health of its
population: even when drugs are made affordable and available for patients, many
developing countries lack basic health infrastructure to distribute them. Moreover, most
healthcare solutions for instance are focused on providing services in urban areas.
Considering that about two-third of the population of India lives in rural areas, access to
healthcare services and infrastructure there is paramount to build a comprehensive
healthcare system. Therefore, although many generic manufacturers emerged in such
countries as China or India, local population in these countries still carry a high proportion of
the global burden of disease7. Is “big pharma” the only one to blame regarding access to
health in these countries? Or should other factors be considered, such as availability and
affordability of healthcare services, or training of medical staff?
This paper will focus on emerging countries, and especially on India and China. It will
analyze their attempts to improve health among their population. We will discuss, in a first
part, the impact of patent laws on access to healthcare and to affordable drugs, both in India
and China and in the rest of the world. We will see how India and China emerged as key
players to answer the lack of access to affordable drugs in developing countries, and how
they positioned themselves as generic drugs hubs. In a second part, we will try to show that
access to affordable drugs is not enough. Indeed, many people in India and China still lack
access to basic healthcare services. The pharmaceutical industrial development in India and
China offers cheaper drugs for the population, but because of flaws in the overall healthcare
system in both countries, people have not been able to fully benefit from this opportunity to
improve their overall health.
To support our analysis, I conducted a survey about access to health, among 135
participants from different countries around the world, based on a questionnaire (appendix
7). Any person could take part in the survey, regardless of their age, country of origin, etc.
The survey findings are presented throughout the following pages to illustrate some of our
arguments, and are detailed in the appendices (appendices 7 to 11).
7 WHO, Global burden of disease (http://www.who.int/topics/global_burden_of_disease/en/)
13
1- India and China: from difficulties to access patented drugs
to the development of local technologies
A – Patents, a barrier to access new drugs and medicines in the
developing world
The logic of patents: commercialization of research and science
Both Kadcycla (the breast cancer drug developed by Roche) and Sovaldi (the hepatitis C
treatment developed by Gilead Science) are issued from biotechnology research and
development. As Gary Pisano points8, a new business model was introduced in the scientific
field with the emergence of biotechnologies, highly impacting pharmaceutical industry: a
science-business model. Biotechnology is a very profitable business segment. With patents
on pharmaceutical blockbusters coming to an end, scientific players all try to benefit from
additional value created by biotechnologies. Therefore, while research and business used to
be part of two very distinct spheres in science, with universities and public laboratories
carrying research and companies and firms involved in commercialization, research in
science and commercialization of science are now more and more interconnected.
Multinational firms are now implied in scientific research, and universities and public
institutions are active participants in the commercialization process of the science they
developed. It is estimated that Columbia University patents on recombinant DNA brought
the university about 400 million dollars in revenues over twenty years. Science is not only
driven anymore by major discoveries and improvements in health outcomes, and is more
and more profit-driven.
The emergence of biotechnologies was therefore perceived as a major scientific
achievement, which would radically improve lives of millions of people. At the same time,
the emergence of biotechnologies offered a source of high potential revenues for the
scientific sector; hence the growing number of private research contracts with public
laboratories, interests groups between public institutions and multinational firms, etc. The
science business model is mainly based on monetization of patents. Genentech, the first
8 PISANO G.,“Can Science be a Business, lessons from biotech”, Harvard Business Review, October 2006,
13p.
14
biotechnology firm, was founded in 1976, by Robert Swanson, a businessman and Herbert
Boyer, a teacher at the University of California. The firm developed a market for knowledge
and innovation, on which small research companies could grant existing companies with
their intellectual property rights, in exchange of funding. In 1978, Genentech and Eli Lilly (a
major pharmaceutical company) signed an agreement: Eli Lilly would fund the development
of recombinant insulin, and pay Genentech royalties on its sales, in exchange of production
and marketing rights. This was the first time a pharmaceutical company outsourced its
research and development activity to a lucrative company. This is now common practice.
This monetization of patents breaks down one of the highest barriers to entry for small
firms on the pharmaceutical sector: astronomical costs for many years to develop a new
drug. The emergence of this new business model, however, perfectly illustrates the conflict
between patents and ethics. Science, by becoming more and more commercialized, and by
attracting profit-driven entrepreneurs, tends to move from its initial goals and public
interests, and not to focus on its core objective anymore: improving people’s lives.
Patents: a research stimulus, an impediment to public health
By being more and more profit-driven, and by tending to achieve commercial goals,
science might therefore become an impediment to public health. “My idea of a better
ordered world is one in which medical discoveries would be free of patents and there would
be no profiteering from life or death”, declared Indira Gandhi, at the World Health Assembly
in 1981. Therefore, are patents promoting research and innovation, or are they jeopardizing
public health?
Drugs are very expensive to develop. Indeed, the pharmaceutical industry is one of the
most research-intensive sectors. The ratio of overall research and development expenditure
to total revenue is about 5% in chemicals, compared to 13% in pharmaceutical industry, and
more than 40% in the biotechnology sector9. Therefore, scientific actors created a business-
oriented model to finance research and development costs for new drugs. Indeed, it costs on
average USD 4 billion for a company to get a drug into market, and this amount can reach
9 BURONNE E., Les brevets au coeur de l’industrie de la biotechnologie, WIPO
(http://www.wipo.int/sme/fr/documents/patents_biotech.htm)
15
USD 11 billion. Moreover, the research and development process is time-consuming: on
average, it takes a company more than 10 years to develop a new drug (exhibit 1).
Drug development lifecycle
Exhibit 1 – Drug development lifecycle
Therefore, without the inventor being rewarded, no one would probably take the risk of
developing a new drug, and no one would ever innovate, especially when the research and
development period is so long than in the pharmaceutical sector, and when the failure rate
in drugs development is over 95%: more than 9 out of 10 drugs fail during the clinical trials
stage, since most of them are not safe or effective for human-beings10. Patent laws are
therefore promoting innovation, and aim at promoting social well-being at the same time,
through encouraging pharmaceutical companies to carry out research for developing better
treatments11. Research and development costs are therefore passed on to the drug selling
price.
However, the drawback is that since pharmaceutical companies bear the research and
development costs, patents guarantee them monopolies and exclusive rights. This has at
least two noxious consequences on research and development of new drugs, and on
10
HERPER M., “The truly staggering cost of inventing new drugs”, Forbes, October 2nd
, 2012 11
According to the World Health Organization, “a patent is a title, granted by the public authorities, conferring a temporary monopoly for the exploitation of an invention on the person who reveals it, furnishes a sufficiently clear and full description of it and claims this monopoly”.
16
availability of drugs, the first of which being the high prices of patented drugs, which are
often many times the price of a generic drug. Patent laws typically give the inventor of a
medicine a legal monopoly for its production and sales for twenty years. As a consequence,
the inventor would take this opportunity to maximize his profits, by setting high price tags
for the medicines he developed. This results in new drugs being unaffordable and out of the
reach for a large part of the world population for at least twenty years, since generic drugs
cannot theoretically be produced as long as the generator product is under patent. Yusuf
Hamied, chairman of Cipla, an Indian pharmaceutical company, in an interview, gives the
example of AZT, the first drug for AIDS: AZT was discovered in 1963. It has first been used as
a treatment for HIV in 1985, and a patent monopoly was granted to GlaxoSmithKline at that
time, running until 2005. The drug was sold for USD 10,000 per year and per patient in 1987,
whereas even in a developed country such as the United-States, more than 35% of HIV-
positive people did not have any health insurance to pay for their drugs12. Just before
GlaxoSmithKline patent on AZT expired, the pharmaceutical company declared that AZT, in
order to be efficient for HIV-treatment, should be used in combination with Zeffix
(lamivudine), which patent has been granted until 2017. Yusuf Hamied therefore concludes
that GlaxoSmithKline has benefited from a 54-year monopoly over AZT, the first
antiretroviral drug, since its invention in 1963.
The pharmaceutical industry, like any other private business industry is indeed there to
make money and to maximize shareholders revenues. A second consequence of the patents
monopoly is the fact that pharmaceutical companies, in order to make profits, only develop
drugs for the developed world: they target solvent markets able to afford expensive drugs,
therefore generating high revenues. These markets are therefore targeted on commercial
grounds, such as the size of the market or the purchasing power of potential consumers
(exhibit 2), rather than on health conditions grounds. The patent system therefore is a
severe impediment to the research and development for new drugs to cure developing
world diseases, such as ebola, malaria, sleeping sickness or even tuberculosis. Profit
expectations for the development of tuberculosis drugs are indeed very low, since the
disease mostly affects poor people in developing countries, who will not be able to afford
expensive treatments. As Neil Schluger, Professor at Colombia University puts it, “drug
12
The New-York Times, “AZT’s inhuman cost”, The New-York Times, August, 28th
, 1989
17
companies want to make drugs for chronic diseases that people in Western countries are
going to take for the rest of their lives”, such as cancer drugs. Indeed, the continent of Africa
as a whole accounts for just 1% of drugs sales, whereas the United-States market represents
half the revenue from sales of pharmaceutical companies (exhibit 3). An article, published in
2003, revealed that 80% of drugs (in value) were consumed by only 20% of the global
population13.
Projected expense on drugs in developed and pharmaceutical emerging countries
Exhibit 2 – Projected per capita expense on drugs in 2016 in developed and pharmaceutical emerging
countries. Source: IMS Market Prognosis, May 2012.
Exhibit 3 - Global drug industry sales (in revenue). Source: Fire in the Blood documentary
13
MONTASTRUC J., M’BONGUE B, “Le médicament, une marchandise pas comme les autres”, Pratiques, n° 21, April, 2003
18
Some pharmaceutical companies, however, are seeking to improve their image, and are
making more and more efforts to benefit the developing world as well. Johnson and
Johnson, for instance, accepted to conduct research and development for tuberculosis, while
other pharmaceutical industries were just closing their tuberculosis research section. The
British company AstraZeneca, for instance, shut its Indian laboratory in January 2014, where
it was conducting research over tuberculosis, malaria, and other tropical diseases,
mentioning reduced research and development budgets. One of the top executives at
Johnson and Johnson, Paul Jannssen, has been extremely involved in tackling tuberculosis
since the death of his sister, as a result of the disease. Consequently, the pharmaceutical
company invested huge amounts for research and development of new drugs, and Sirturo
(bedaquiline) was eventually approved last year as a treatment for multi-drug resistant
tuberculosis, and will probably save many lives in the future. Wim Parys, at the research and
development department of Johnson and Johnson declared: “We have been extremely
fortunate that we have people right to the top level of the company who have supported
this product, not for any commercial reason, but because it was the right thing to do”. But
this is an exception. Indeed, pharmaceutical companies are private companies that owe
good results to their shareholders.
In 1997, due to the fact that most drugs were unavailable for the developing world (cf
high prices and pharmaceutical companies strategic policies), Nelson Mandela took a key
decision: to answer lack of access to affordable drugs for local population, and to tackle the
AIDS outbreak in South Africa as the President of South Africa, he passed a Medicine Act,
aimed at enabling the government to import or manufacture generic versions of patented
drugs. However, feeling threatened by such a change in South African patent laws, thirty-
nine multinational pharmaceutical companies sued the government of South Africa. Even
though the pharmaceutical companies, facing pressure from individuals and non-
governmental organizations (NGO) from all over the world such as Médecins Sans Frontières
(MSF) eventually dropped the case in 2001, this international dispute has stressed the profit-
driven nature of the pharmaceutical industry14.
In 2000, thanks to high drug prices, the ten biggest pharmaceutical companies on the
Fortune 500 list profits amounted to USD 35.9 billion. This figure was bigger than the
14
SEN S., “British NGOs support Pretoria against pharmaceutical firms”, Inter Press Service, April 16th
, 2001
19
combined profits of all the other 490 companies (USD 33.7 billion). Although the
pharmaceutical companies claim that high-drugs prices are mainly due to research and
development costs, only 1.5% of drugs revenues on average is actually allocated to research
and development for new drugs15. Even if Peter Rost, former vice-president of Pfizer gives
more optimistic figures (he estimates that 20% of pharmaceutical companies revenues go to
drug development), he is also critical of the pharmaceutical sector and stresses that at least
40% of the revenues go to marketing, towards healthcare providers and direct users. He
therefore describes the pharmaceutical industry as a marketing-driven machine, with
research and development foundations, and compares it to the mafia: both are making a
fortune, and apply policies that kill enormous amounts of people16. The pharmaceutical
industry keeps justifying its pricing policies and its profits citing high research and
development costs for developing new drugs. But in reality, 88% of worldwide research for
the development of new drugs is actually funded by government and public sources, through
governmental laboratories for instance. Pharmaceutical companies only fund 12% of drugs
research and development.
Therefore, although granting the inventor a patent monopoly could be totally justified,
to cover research and development costs and to finance new drugs development programs,
there are obviously some abuse from drug developers regarding patents monopolies use.
Innovators should definitely be rewarded for their contributions, but when it comes to
health, which is often considered as a public good and a fundamental right, alternative
rewards should be considered. An example of alternative reward, suggested by James
Arkinstall (appendix 6), could be for the states to provide the inventor of a new drug, with an
initial prize, or grant, proportional to its contribution to humanity (the inventor of a new
drug to cure tuberculosis would receive a more significant prize than the inventor of a new
drug to prevent hair loss, therefore rebalancing targeted markets). This package, or prize,
would reward the inventor for its contribution and would defray research and development
costs. The invention would then be placed directly in the public domain for other firms to
use it to manufacture cheaper drugs, or pursue further innovation. The underlying question
15
ANGELL M., The truth about the drug companies: how they deceive us and what to do about it?, Random House Trade Paperbacks, August, 2005, 319 p
16 ROST P., Pfizer Former Vice-President, Short Hills, New Jersey, extended interview for Fire in The Blood.
Peter Rost is the author of The Whistleblower: confessions of a healthcare hitman, in which he describes the unethical practices of the pharmaceutical companies he worked for.
20
is the following: who would pay for the prize that has to cover research and development
costs? And according to James Arkinstall, the answer is actually quite easy to figure out:
taxpayers. Indeed, taxpayers are already paying for the development of new drugs, through
governmental research funds, but also through the high price tag of the drugs they buy. This
alternative system, would use public sources for the granting of the initial prize, but after
that, given that the invention would be in the public domain (and would not be protected by
a monopoly), drugs would actually be sold at a much lower price, enabling taxpayers to pay
less for their medicines.
Another alternative to make science focus on its primary goals (improve people’s health)
rather than on profits, according to Michael Porter and Mark Kramer, would be to promote
the creation of “shared value”. Pharmaceutical companies, as of today, seem to be
prospering at the expense of the society, thanks to the patent system. But according to
Porter and Kramer, production of shared value would enable them to innovate and to grow.
Shared value could be defined as the creation of “economic value in a way that also creates
value for society”. Shared value is often driven by the economic environment in which the
companies are working: clusters, implying both actors from the private sector (multinational
pharmaceutical companies, trade associations, etc.) and from the public sector (institutions,
universities, public laboratories, etc.), may favor the creation of shared value and knowledge
sharing: science could build its model on knowledge-sharing rather than on competition.
Therefore, the governments should impulse the creation of clusters, in order to make
companies act for the overall well-being. An example of cluster in the health sector is the
example of Singapore biocluster. In 2000, the government of Singapore declared it would
create a hub for innovation and technology. Five key-priority clusters were first developed,
including the biotechnology cluster. Moreover, the government took several measures to
promote the development of closer ties between the different actors. Singapore biocluster is
still at its early development stage, but is already very promising for the future of the
population health.
21
Health as a public good, science should serve the general interest: the example of
HIV/AIDS and international mobilization
If there is one disease that has been at the epicenter of the patent dilemma these
last few years, it is for sure HIV/AIDS. AIDS was first scientifically observed in 1981, but had
caused many deaths before in Africa and Haiti. The virus entered the United-States, and
eventually spread so fast that it finally stopped being unnoticed. AIDS caused over 10 million
deaths between 1996 and 2003. In the early 1990s, in many provinces in China, a lot of
farmers, encouraged by the local government, started selling blood for money. Due to poor
disinfection and isolation work, many villages were infected with the HIV virus. In Wenzhou,
a village located in Henan province, 60% of the population had been infected with the HIV
virus.
Thanks to the introduction of AZT and other antiretroviral treatments, individuals who
have access to good pharmaceutical care are now unlikely to die prematurely from
HIV/AIDS. But antiretroviral drugs are very expensive: patented drugs used to sell for more
than USD 10,000 per capita and per year, far beyond the reach of millions of people. Rich
communities, with strong universal health care systems may have been able to bear the
costs, but this is not the case for most individuals in developing countries. Moreover, a
patent used to make it illegal for others to make, sell or import unpatented generic drugs,
which typically cost much less. Pfizer launched Diflucan (fluconazole) in 1990, a drug to ease
pain on patients suffering from AIDS-related infections. The drug, sold at USD 30 a capsule,
was under patent in South Africa, which guaranteed Pfizer a total monopoly on the market.
In 2000, the average weekly wage in South Africa, the richest country in Africa, was USD 68.
A generic version of the drug was made in a government factory and available at USD 0.5,
but this was in Thailand. And because of the Pfizer patent, it was considered illegal for South
Africa to import the generic drug from Thailand. The only solution for people unable to
afford patented drugs to get treatment for their HIV condition was to use smuggled generic
drugs.
Unlike other diseases (such as tuberculosis), HIV/AIDS, also affects significant numbers in
rich nations, hence a growing interest of the global community about access to health for
HIV-positive people. HIV-positive people from the developed economies indeed joined the
22
developing countries cause to protest against unaffordable drugs: they were concerned by
the disease, and felt that if drugs were made available for them, they should also be made
available for every people living with HIV. Fire in The Blood is a documentary about the fight
of many people against the patent monopolies of pharmaceutical companies, to promote
access to antiretroviral drugs for everyone. The documentary portrays several activists who
have taken part in this fight, including the Constitutional Court of South Africa judge, Edwin
Cameron, or the Treatment Access Campaign founder, Zackie Achmat. Protestors started to
stand against pharmaceutical companies: life-saving drugs, though available, were just way
too expensive. “We are never going to stop, until everyone in Africa, everyone in Asia,
everyone in Latin America has access to drugs. But we will also not forget the poor people in
Europe and the poor people in North America” declared Zackie Achmat during the 13th
International AIDS conference held for the first time in Africa, in Durban, in July 2000. “Why
should I have the privilege of purchasing my life and health when thirty-four million people
in the resource-poor world are falling ill, feeling sick to death and are dying”, asked Edwin
Cameron, at the same summit (exhibit 4).
Exhibit 4 – Political cartoon: Aids drugs for the third world, by Zapiro, published in Sowetan on July, 7th,
1999
While some developing economies, such as Thailand or Brazil had begun addressing the
issue of access to affordable drugs by locally producing low-cost generic drugs, governments
in other developing countries seemed to refuse challenging Western patents on drugs,
arguing that this would definitely harm their economy: indeed, the United-States
23
government and the Western pharmaceutical companies were threatening developing
countries of severe measures, in case they would allow imports of low-cost generics. Zackie
Achmat, as an internationally-renowned activist, therefore announced that he would
boycott antiretroviral drugs until they would be made available to everybody: “I won’t buy
life while others die”, he declared. Nelson Mandela himself got involved in the issue and
asked Achmat to take his drugs.
To address this issue, Cipla, an Indian pharmaceutical manufacturer, based in Mumbai,
founded in 1935 and headed by Yusuf Amid, developed a USD 1 per day therapy. Cipla had
begun making generic drugs in the early 1990s, over the Indian government instructions. The
idea of India producing its own medicines goes back to Gandhi himself, who had promoted a
self-reliant India, through the swadeshi movement17. According to Fire in The Blood, Yusuf
Hamied was the one who convinced Indira Gandhi to amend India’s Patent Act in order to
have more flexible patent laws in India. Before the amendment, India indeed had some of
the highest drug prices in the world, and its average life expectancy was very low. Thanks to
the Patent Act amendment, India was able to produce cheap generic versions of patented
medicines, and therefore, to save millions of lives in the developing world.
With the introduction of antiretroviral generic versions of patented drugs in India, and
the following drop in prices of antiretroviral drugs, Western pharmaceutical companies
started launching large advertising campaigns against counterfeit drugs, therefore
suggesting that generic drugs could actually be counterfeit drugs and substandard (exhibit
5). India fought back with a campaign presenting itself as the Pharmacy of the World, and its
drugs as high-quality drugs, similar to its Western pharmaceutical industry products.18 And
actually, many of the active ingredients for branded drugs sold in Western countries,
including in the United-States, were outsourced in India, and produced in the same
laboratories than generic drugs for the Indian market and for other developing countries.
17
The Swadeshi (a Hindi word meaning self-sufficiency) movement is part of the independence movement, and was a key focus of Gandhi political vision
18 TAYLOR N., “Indian minister rails against anti-generics smear campaign”, In-Pharma, May 9
th, 2012
24
Exhibit 5 - Pfizer advertising campaigns to fight counterfeit drugs. Source: Pfizer Counterfeit Drugs
Brochure, 2009
However, many developing countries governments still refused to import generic
antiretroviral drugs from India or China, due to commercial pressure from the United-States.
But just after 9/11, the United-States realized that they were vulnerable to patents
monopolies as well: a series of fatal anthrax attacks occurred. Bayer had a patent monopoly,
valid until 2003, on Cipro (ciprofloxacin), the only efficient antibiotic to treat anthrax. For a
moment, the United-States government was afraid about access to medicines, the attacks
sparking fears of a global wave of infections, and pressed the German pharmaceutical
company to relax its patent on Cipro for “public health emergency”. At that time, seventy-
eight Indian drug manufacturers were already producing the antibiotic for one thirstiest of
Bayer’s drug price, and the United-States considered importing some19. Following this
episode, the Ugandan government came to the point that the United-States government
would not blame Uganda for doing something similar to what they had themselves
considered regarding Cipro. The government therefore eventually allowed imports of
antiretroviral generic drugs. Most of the imported drugs actually came from India.
Following Uganda example, many other countries started importing generic
antiretroviral drugs under “public health emergency”. Soon after, in 2002, Kofi Annan, the
United-Nations Secretary, launched the Global Fund to Fight AIDS, tuberculosis and malaria.
In 2003, George W. Bush, in his State of the Union address, asked the Congress to commit
USD 15 billion during the next five years to fight AIDS in the developing world, through the
President’s Emergency Plan for AIDS Relief (PEPFAR), aiming at buying generic drugs from
India and China and distributing them to those who needed them most. Indeed, as Bush
stressed during his speech, the price of a treatment for HIV/AIDS had dropped from USD 12,
000 a year to less than USD 300 a year: the program would therefore save millions of lives.
19
HERPER M., “Cipro, Anthrax, and the perils of patents”, Forbes, October 17th
, 2001
25
However, because of the pharmaceutical industry powerful lobbying, the appointed person
responsible for leading PEPFAR program was Randall Tobias, chief executive officer of the
pharmaceutical company Eli Lilly, from 1993 to 1999. He probably is the one who decided to
use the PEPFAR money to buy branded drugs rather than generic drugs. According to
PEPFAR statements, in 2004 and 2005, the program allocated 95% of its antiretroviral drugs
budget to branded medicines, and only 5% to generic drugs20. But progressively, the price
gap between generic drugs and branded ones became so broad that PEPFAR eventually
committed to buying generic antiretroviral drugs.
The battle to access antiretroviral drugs has seen a widespread mobilization around the
world. However, despite the success of the HIV/AIDS battle, other diseases, such as
tuberculosis have been totally forgotten: resources are indeed mainly allocated to global
diseases rather than to diseases that only affect the developing world. Despite HIV and
tuberculosis bearing similar deaths toll, the United-States National Institutes of Health
spending for research on HIV/AIDS in 2013 was eleven times higher on HIV/AIDS than on
tuberculosis21.
With HIV/AIDS battle though, individuals started to realize the extent of the issue, and
fought for greater healthcare access, and for the availability of cheap generic versions of
branded drugs. Health should be considered as a public good, and should be made available
to everyone. Contrary to other products or services, health should have nothing to do with
business, and should not be subject to market-forces only, since it is a fundamental right.
As we have seen, the main challenge regarding patent laws is to find a balance between
encouraging research for the development of new drugs that could cure new diseases and at
the same time, privileging society and science as a whole. Patents should actually benefit
both the inventor and society. For society, the main challenge is to guarantee access to new
efficient drugs and treatments and to promote a large diffusion of these inventions, so that
they can benefit everyone. For the inventor, the challenge is to benefit from a distribution
monopoly, in order to be able to recover research and development investments and to
20
ISMALL A., “PEPFAR policy hinders treatment in generic terms”, The Center for Public Integrity, December 13
th, 2006
21 FINANCIAL TIMES, “Killer of the poor now threatens the wealthy”, Financial Times, March 24
th, 2014.
United-States National Institutes of Health spent USD 266 million for research on tuberculosis and USD 2.9 billion for research on HIV/Aids in 2013
26
finance further costs. These opposing, or at least diverging interests are at the heart of
patent laws evolutions and modifications.
B – Promoting innovation while promoting general interest: the
international regulatory framework
Introduction of the TRIPS agreement, to strengthen intellectual property rights
Under the United-States and Western pharmaceutical companies pressure, and to
ensure innovation and the ability of the pharmaceutical industry to develop new drugs,
patent protection was strengthened in the whole world with the ratification of the trade-
related intellectual property rights (TRIPS agreement) in April 1994 in Marrakech, at the end
of the World Trade Organization (WTO) Uruguay Round (1986-1994). To get more details
about the functioning of the WTO, please refer to appendix 3. The international framework
for patents is therefore no longer managed by the World Intellectual Property Organization
(WIPO) but by the WTO. Reaching a consensus for the TRIPS agreement was not easy-task.
Developed nations promoted the need for an international strong IPR regime protecting the
patents of multinational companies, while developing countries argued that intellectual
property aspects were definitely not a trade-related issue and should not be part of the
WTO. The very fact that IPR, including IPR on drugs and medicines are part of the WTO
appeared as a paradox for numerous people: indeed, WTO main goal is to promote free-
trade, and imposing IPR seems at the opposite of free-trade. The Indian-American economist
Jagdish Bhagwati is very critical towards the WTO framework, stressing that it includes non-
trade topics, and wrote in an article that “intellectual property does not belong in the WTO,
since protecting it is simply a matter of royalty collection”22. Joseph Stiglitz, economist and
Nobel laureate emphasizes that intellectual property stands as a restraint on trade, and that
the monopolies induced raise prices and restrict production23.
Eventually, the TRIPS agreement introduced a strong IPR regime, by regulating patents
for both products and process and by extending patent-life to twenty years and patent 22
BHAGWATI J., "From Seattle to Hong Kong", Foreign Affairs, September 2014 23
STIGLITZ J., Economist and Nobel Laureate, Colombia University, New-York, extended interview for Fire
in the Blood
27
applicability to all WTO signatories. All member-countries of the WTO have to adapt their
own legislation to comply with this international framework24. Article 7 of the TRIPS
agreement (“Objectives”) states that “the protection and enforcement of intellectual
property rights should contribute to the promotion of technological innovation and to the
transfer and dissemination of technology, to the mutual advantage of producers and users of
technological knowledge and in a manner conducive to social and economic welfare, and to
a balance of rights and obligations”25. So that from January, 1st, 1996, developed countries
had to adapt their national legislations over patents in order to comply with the TRIPS
agreement. The developing countries, however, have had 10 years to align legislation and
policies to the TRIPS agreement (therefore adapting their legislation on January, 1st, 2006),
and the least developed countries benefited from a 20-year moratorium.
The Doha Declaration: public health prevails
To fit public health challenges and priorities, some flexibilities were introduced as
provisions in the TRIPS agreement, so that patents could be circumvented in particular
situations and would not impede public health priorities. These flexibilities include parallel
imports: a country can purchase patented drugs in another country, and sell it on its
domestic market, without the patent holder’s consent. This flexibility can prove extremely
useful for developing countries when a particular drug is overpriced on the domestic market
compared to other markets: Bayer’s Cipro (ciproflaxin) for instance, sells for USD 740 for 500
mg in Mozambique, whereas the price-tag in India for the same quantity is USD 15 (due to
local manufacturers’ competition). Therefore, Mozambique can import the product from
India without Bayer’s permission, under TRIPS flexibilities26.
24
WTO, Members and Observers, June 26th
, 2014 (http://www.wto.org/english/thewto_e/whatis_e/tif_e/org6_e.htm). WTO includes 160 member-states and 24 observer-states, that are to start the accession negotiation process Countries that are neither members nor observers and that are part of the United-Nations are the following: Eritrea, Federal States of Micronesia, Kiribati, Marshall Islands, Monaco, Nauru, North Korea, Palau, San Marino, Somalia, South Sudan, Timor-Leste, Turkmenistan and Tuvalu.
25WTO, The Uruguay Round Agreements, Annex 1C: agreement on trade-related aspects of intellectual
property rights, WTO, pp319-351 26
WHO, Parallel imports (http://www.who.int/trade/glossary/story070/en/)
28
TRIPS flexibilities also include experimental use exception: since the ability to innovate
mainly depends on existing products and former innovations and technologies, scientists can
have free access to already existing drugs for instance, for research or any other scientific
purpose.
Another TRIPS flexibility is related to compulsory licenses: according to article 31 of the
TRIPS agreement, in the case of a national emergency or other circumstances of extreme
urgency, a country can issue a compulsory license to use the rights conferred by a patent,
without any authorization from the holder and enables a pharmaceutical company to
produce a generic drug. However, the notion of “national emergency” has not been clearly
defined in the TRIPS agreement, which means that countries can get their own definition of
what a national emergency actually is.
Therefore, developing countries encountered some difficulties in making effective use of
flexibilities provided by the TRIPS agreement, mainly due to the imprecision surrounding
some provisions, hence the Doha Ministerial Declaration. In 2001, WTO members reaffirmed
that TRIPS Agreement should be implemented in a way that supports public health27, by
promoting both access to existing drugs and treatments and the creation of new ones. The
declaration also stresses the governments’ rights to use the TRIPS Agreement flexibilities.
However, as some African countries highlighted, some countries were still unable to grant
compulsory licenses, because of poor local pharmaceutical manufacturing capabilities.
Therefore, in August 2003, an amendment to the TRIPS agreement was adopted, enabling
members to import medicines under compulsory licenses, and not necessarily to produce
them locally. A country like Botswana can now issue a compulsory license and ask a firm,
established in a foreign country to produce generic drugs and export them to Botswana.
I had the chance to meet James Arkinstall (appendix 6), Head of Communications of the
MSF campaign for access to essential medicines, who explained me how MSF has tried to
encourage developing countries to use the TRIPS flexibilities, in order to guarantee a better
access to drugs and medicines for their populations. Just after MSF won the Nobel Prize in
1999, MSF Access Campaign was created, against the backdrop of the WTO Seattle round,
27
Declarartion on the TRIPS agreement and public Health, adopted on November, 14th
, 2001: “we affirm that the Agreement can and should be interpreted and implemented in a manner supportive of WTO members' right to protect public health and, in particular, to promote access to medicines for all”
29
during which protesters of an anti-globalization movement demonstrated, questioning WTO
trade policies. People started to question the design of an international framework regarding
intellectual property, applicable to every country, regardless their level of economic
development. MSF Access Campaign was therefore aimed at promoting a reliable access to
drugs and medicines and the use of the TRIPS flexibilities for the developing world to ensure
the enhancement of their population health. Therefore, MSF Access campaign is lobbying
developing countries governments that have strong IPR regimes to make them use the TRIPS
flexibilities and build advantageous national legal framework which would enable them to
use such flexibilities. And that is what they did with Thailand for instance: Thailand indeed
has a more favorable framework for action than other developing countries such as China.
Indeed, its civil society is strong and highly involved. Moreover, the legal framework in
Thailand already guaranteed public health. Finally, Thailand benefits from a local production
capacity of drugs, thanks to its public laboratory, the Government Pharmaceutical Office.
Thanks to MSF Access campaign lobbying and to the role of the civil society, Thailand was
the first country in the world to use compulsory licenses under the TRIPS agreement, and it
used it massively. In 2006, the government issued two compulsory licenses for antiretroviral
drugs: Stocrin (efavirenz) developed by the German pharmaceutical company Merck and
Kaletra (lopinavir + ritonavir) developed by the American pharmaceutical company Abbot. In
2007, a compulsory license was issued for a blood thinner, used to treat cardiovascular
diseases, Plavix (clopidrogel) developed by the French pharmaceutical company Sanofi-
Aventis. Finally, three cancer drugs compulsory licenses were issued between 2007 and 2008
for the following drugs: Taxotere (docetaxel), used to treat breast and lung cancers,
developed by Sanofi-Aventis; Tarceva (erlotinib), used to treat lung, ovarian and pancreatic
cancers, developed by the Swiss pharmaceutical company Roche; Femara (letrozole), used to
treat breast cancer and developed by the Swiss pharmaceutical company Novartis.28
The introduction of these TRIPS flexibilities and their use by countries such as Thailand or
India, has of course faced much criticism from the big pharma companies: therefore,
developing countries tend not to take full-advantage of flexibilities offered by the TRIPS
agreement. National patent offices are very cautious regarding granting of compulsory
licenses, probably because they feel threatened by potential repressions from the Western
28
RIVIERE P., “La Thaïlande ose les génériques”, Le Monde Diplomatique, February 3rd 2007
30
pharmaceutical industries: they might fear that repeated issuance of compulsory licenses
may drive away multinational pharmaceutical companies’ investments from their countries.
One example in history has significantly imprinted people’s minds: in Thailand, following the
compulsory license granting for Kaletra, the antiretroviral drug, in 2006, Abbot decided to
withdraw further versions of its drugs from Thailand’s market. One further version of the
drug did not need to be refrigerated (which represents an important feature, given that the
average temperature in Thailand is very hot and that a limited number of people has access
to a fridge), but Abbot first refused to commercialize it in Thailand before giving up under
NGOs oppression29. The drug was vital for many people living with HIV/AIDS in Thailand and
Abbot’s move therefore had severe consequences on the population health.
Moreover, developing countries might fear that the use of TRIPS flexibilities might
impact their trade relationships: developing countries may fear that the United-States would
take away trade preferences if they use TRIPS flexibilities for instance; India may fear that
repeated court cases could damage its reputation, etc. India has already been accused of
discrimination against American pharmaceutical companies by the United-States trade
representative last February30, which worsened already strained-relationships between the
two countries (the countries have already been fighting in many bilateral WTO disputes31).
India, however, decided to block the United-States investigators over its IPR regime. Both
countries have interest in maintaining good business relations. Bilateral trade in goods and
private services measured USD 93 billion in 2012, and India is the first foreign drugs supplier
of the United-States, hence the sometimes cautious approach of the Indian Department of
Industrial Policy and Promotion (DIPP) regarding compulsory licenses.
The MSF Access Campaign is therefore acting to urge developing countries governments
to adopt flexible IPR national frameworks, and to use their flexibilities, despite the United-
States and the pharmaceutical companies’ pressure. TRIPS flexibilities are legal, and
29
ACCESS CAMPAIGN, “MSF denounces Abbot’s move to withhold medicines from people in Thailand”, Access Campaign, March 15
th, 2007 (http://www.msfaccess.org/about-us/media-room/press-releases/msf-
denounces-abbott%E2%80%99s-move-withhold-medicines-people-thailand) 30
COONEY P. and KUMAR M., “US to announce trade enforcement action linked to India”, Reuters, February 10
th, 2014
31 WTO, US files dispute against India over measures relating to solar cells and solar modules, February
11th
, 2014 (http://www.wto.org/english/news_e/news14_e/ds475rfc_11feb14_e.htm). The most recent WTO dispute between India and the Unied-States is a dispute over India’s solar program.
31
governments should therefore take the opportunity to use them and to improve their
populations’ health.
Recently, the German pharmaceutical company Bayer has filed a claim against the
Controller General of Patents, Designs and Trade Marks in India, which had granted its first-
ever compulsory license in March, 2013, to NATCO, a local drug maker, to produce and sell a
generic version of patent-protected cancer drug, Nexavar. Indeed, Bayer claims it has spent
more than USD 114 billion in research to develop the drug and that the issuing of a
compulsory license by the Indian government would make it impossible for Bayer to recover
its initial investment. The Bombay High Court, however, eventually ruled in favor of the
Controller General of Patents, arguing that there were no legal obstacles to issue
compulsory license since the patented drug was not available to the public at affordable
price. This court decision has actually set a precedent for allowing the sale of generic
versions of patented drugs in developing countries, and was a major illustration of what the
Doha Declaration was aiming at: public health prevails. According to the judges, “public
interest is and should always be fundamental in deciding a legal dispute between the
parties”32. NATCO will actually be able to sell the drug for 175 USD per month, whereas the
cost of one-month treatment of Bayer’s drug is USD 5,500. In return, NATCO has to pay 7%
royalty payment on net sales to Bayer.
The TRIPS Agreement is therefore not merely governed by an unconditional protection of
IPR, but rather intends to implement a flexible protection of IPR that fits with public health
priorities. And as the Doha Declaration stresses, public health must prevail over IPR.
However, the TRIPS agreement has faced much questioning and criticism, especially among
developing countries. Can healthcare actually be considered as other “traded” goods, and
can it be regulated by the World Trade Organization? Should IPR apply in developing
countries? We will now focus on the very successful example of India, which established a
strong but flexible IPR system, which reconciled protection of innovation and public health
promotion. India indeed succeeded in both developing local technologies and
pharmaceutical industry and in significantly reducing drug prices and increasing drugs
accessibility for its own population.
32
SHIBU T. “High court’s Nexavar ruling strikes a blow for patient’s rights in India”, Times of India, July 17th
, 2014
32
C – India and China, a developing pharmaceutical industry: the
emergence of generic manufacturers
India used to have a very strong intellectual property system with patents on both
products and processes regulated by the Indian Patent Act of 1856, which was amended in
1911. The term of patents was sixteen years as from the date of the application, and it could
be extended up to twenty-six years if the inventor considered that he did not earn enough
money to cover the costs of research and development.
As a result of this strong IPR regime, following independence in 1947, India’s
pharmaceutical industry was almost nonexistent and was dominated by multinational
companies who took advantage of the legal framework to heavily patent drugs in the
country. India was therefore highly dependent on external supply for drugs. Many blamed
the strong intellectual property system for actually not being able to stimulate innovation,
industrial development and general interest. Indeed, the system was only benefiting big
multinationals, which were able to establish monopolies and to sell their products at
prohibitive prices. In 1957, multinational companies hold about 99% of the drugs patents in
India, therefore having monopolistic control of the market33. In the 1960s, the high-blood
pressure drug propranolol, developed by the British multinational company ICI
Pharmaceuticals, was not made available to Indian people, due to its very expensive price.
The members of the Indian’s Drug Manufacturer’s Association, created in 1961 to support
local pharmaceutical producers, including Yusuf Hamied (founder of Cipla), campaigned to
promote the production of an affordable local generic version of the drug, and presented
their case to Prime Minister Indira Gandhi, urging her to do something. The Association
members later declared: “we said to her that this drug is life-saving, and why should millions
be deprived of it just because the patent holder doesn't like the colour of our skin?”.
Following this episode, Indira Gandhi eventually approved a major change in the
pharmaceutical intellectual property laws34.
33
ZAMBAD S., LONDHE B., “To study the scope and importance of amended patent act on Indian pharmaceutical company with respect to innovation”, Procedia Economis and Finance, vol. 11, 2014, pp 819-828
34 JACK A., « The man who battled big pharma”, Financial Times, March 29
th, 2008
33
The pre-TRIPS period: new flexibilities in the Indian Patent Act to stimulate local
innovation and to promote access to affordable drugs within local population
Therefore, the Indian Patent Act was amended in 1970 and became more flexible:
from 1972, the new intellectual property system only regulated patents on processes.
Regarding the pharmaceutical industry, patents on processes could only be delivered for
seven years, and final drugs (products) could not be patented anymore. Since processes only
could be patented, it became possible for local Indian manufacturers to copy molecules
developed by the multinational companies in the North, by innovating in the process only.
Indian companies were therefore able to commercialize low-cost generic drugs that were
patented elsewhere. The amendment also introduced the concept of compulsory license: if
the government estimated that general interests and needs were not met, it could issue a
compulsory license and enable a local industrial pharmaceutical company to produce a copy
of the patented drug and to sell it at a more reasonable price. Finally, through the
introduction of the Drugs Price Control Order (DPCO, issued by the Government of India in
1970), drugs prices were regulated to both maximize drugs accessibility for local
populations, and cover research and development costs for the pharmaceutical industry.
Prices were fixed to ensure the manufacturing company a profit margin of 75% for essential
medicines, and a profit margin of 150% for non-essential medicines.
A flourishing local pharmaceutical industry and the emergence of a generic drugs
hub
Exhibit 6 – Evolution of Indian Pharmaceutical Sector. Source: India Brand Equity Foundation (IBEF),
Presentation on Pharmaceuticals, March 2014
34
According to Samira Guennif 35 , the Indian Patent Act flexible amendments and
institutional initiatives have given rise to a flourishing pharmaceutical industry in India and
increased the country sanitary self-sufficiency (exhibit 6). Indeed, the country’s legal and
institutional environment limited patent protection to processes, which allowed India to
produce affordable local versions of expensive patented drugs legally and to sell them, both
nationally and internationally. In the 1950s, the Indian pharmaceutical industry was
composed of 1752 companies. In 2005, 20,000 companies were part of this sector36. Drugs
production increased a lot as a result, and India is now one of the biggest producers of drugs,
and exports its production in the whole world (exhibit 7). These factors greatly influenced
the accessibility of medicines for local populations: in 2003, drugs sales in India represented
4.3 billion USD and 75% of the volume was realized by national firms37.
Exhibit 7 – Local pharmaceutical production capacity, 2004. Source: The World Medicines Situation,
published by the World Health Organization (Thailand started producing drugs locally in 2006 only, while the
map was edited in 2004)
35
GUENNIF S. and CHAISSE J. “L’économie politique du brevet au sud : variations indiennes sur le brevet pharmaceutique”, Revue internationale de droit économique, 2007, pp 185-190
36 FEDERATION OF INDIAN CHAMBERS OF COMMERCE AND INDUSTRY (FICCI), Competitiveness of the
Indian Pharmaceutical Industry in the New Patent Regime, March 2005, 16p (www.ficci.com) 37
SAMPATH P. Economic Aspects of Access to Medicines after 2005, product patent protection and
emerging firms strategies in the Indian pharmaceutical industry, Institute for New Technologies, United Nations University, 2005, 111p.
35
India pharmaceutical industry is mainly-based on generic drugs and spends very little on
high-risk research and development (exhibit 8), although this might change soon. The
industry has indeed acquired much experience and is now able to further innovate. Generic
drugs do not incur huge costs of research and development, and India can therefore offer
generic versions of patented drugs at a much lower price than the drug initial price.
Exhibit 8 – Indian Pharmaceutical Industry Overview, 2014. Source: IBEF
From the 1980s, more and more Indian generic manufacturers have emerged, producing
generic treatments and drugs, including antiretroviral drugs. In India, antiretroviral drugs
production began in 1991, with the commercialization of AZT: Cipla, the Indian
pharmaceutical firm, thanks to basic manufacturing processes was able to offer the drug on
the market at a much lower-cost than its initial price-tag, making it the cheapest
antiretroviral drug. The pharmaceutical company later engaged in the production of more
complex treatments. Other firms, such as Rambaxy, Hetero Aurodindo or Cadina followed
the same path. Market entry of Indian generic manufacturers for antiretroviral drugs
resulted in a significant fall in prices for many treatments, including AIDS treatments. In
2001, Cipla offered to sell its 3-drug combination (tri-therapy) antiretroviral treatment to
NGOs for USD 350 per year and per patient, while patented three-drug combination
antiretroviral treatments were sold for USD 931 at the same period. In March, 2001, the
patented drug combination price therefore fell to USD 727. Moreover, competition between
Indian generic manufacturers further pushed prices down. Two months after Cipla
announcement regarding its USD 350 treatment, Hetero declared selling the same treatment
36
for USD 347 and Rambaxy offered to sell the treatment for USD 295. Since then, the price for
antiretroviral treatments keeps decreasing38 (exhibit 9).
Generic drugs competition - The international market lowest price (in USD per patient and per
year) for antiretroviral tri-therapies (stavudine, lamivudine and nevirapine), from 2000 to 2006
Exhibit 9 – Generic drugs competition. Source: Untangling the Web, published by Médecins sans Frontières
and Presses de Sciences Po
Undoubtedly, the emergence of generic drugs resulted in a significant decrease in drugs
prices, and not only for antiretroviral drugs: competition from generic companies is
therefore the key to affordable drugs for the population. And paradoxically the good
performance of the Indian pharmaceutical industry in the health sector can mainly be
attributed to India patent system, and its flexibilities, according to Samira Guennif. By
introducing flexibilities in its intellectual property system, India has succeeded in stimulating
local pharmaceutical development while producing affordable generic drugs.
TRIPS and implications
India was a founder member of the General Agreement on Tariffs and Trade (GATT),
which became the WTO in 1995 and therefore had to meet WTO requirements. It benefited
from the 10-year moratorium for developing countries to adapt its legislation under the
TRIPS agreement, and took full advantage of this transition period. To comply with its
obligations, including making patents available for both products and process, India
eventually amended its Indian Patent Act in 1999, 2002 and in 200539. In 2006, India granted
its first patent for a product under the new IPR regime, to Roche, for its chronic hepatitis
treatment, Pegasys.
38
DOCTORS WITHOUT BORDERS, Untangling the web of price reductions: a pricing guide for the purchase
of ARVs for developing countries, Médecins sans Frontières (MSF), 17th
edition, July 2014 39
WIPO, India Patents (Amendment) Act, 1999 (http://www.wipo.int/wipolex/en/details.jsp?id=7622)
June, 2000 March,
2001
December,
2002
April,
2004
July, 2006
Originator drug 10,439 727 No data No data 556
Generic drug 2,767 350 201 168 132
37
However, contrary to what one could think, the post-TRIPS period has not implied a
weakened local pharmaceutical industry: indeed, India chose to maintain a wiggle room to
keep producing generic drugs. Despite pressures from the multinational companies, India
opted for a narrow interpretation of patentability: “the invention should be novel, involve an
inventive step, and be capable of industrial application”40. Patenting therefore remains
limited to “new chemical entities” and is not applicable for incremental innovations41, which
pharmaceutical companies often use as a circumvention to avoid giving up their patent
monopoly rights. Innovations such as changes on the coating of an existing drug or small
variations on existing active ingredients are not patentable under the Indian Paten Act.
Because India has been able to create such a comprehensive national legal framework and
to take full advantage of the TRIPS flexibilities, the domestic pharmaceutical industry kept
presenting strong performance and growth following changes in the IPR international regime
(exhibit 10).
Top 7 pharmaceutical companies in India by revenue
Exhibit 10 – Top 7 pharmaceutical companies in India by revenue, 2010. Source: Market Access
Opportunities in India, published by Kinapse Consulting. The seven top pharmaceutical companies are Indian,
and not foreign branches of Western pharmaceutical companies.
40
GUENNIF S., Protection du brevet et promotion de la santé publique selon les accords de libre-échange états-uniens : surenchères autour des standards minimums de l’ADPIC au Sud, Centre d’Economie de l’Université Paris Nord, 2007, 18 p
41 An incremental innovation can be defined as a minor improvement to an already existing product.
In INR billion In USD billion
Cipla 63.18 1.33
Ranbaxy 56.72 1.20
Dr. Reddy’s Laboratories 53.04 1.12
Lupin 45.09 0.95
Aurobindo Pharma 41.33 0.87
Sun Pharmaceutical 31.05 0.66
Cadila Healthcare 29.20 0.62
GlaxoSmithKline 23.74 0.50
Ipca Laboratories 18.81 0.40
Aventis Pharma 11.60 0.24
38
Indeed, India has been able to use TRIPS flexibilities to further develop its
pharmaceutical industry. The provision of compulsory licenses, for instance, acted since the
Indian Patent Act of 1970 has been internationally recognized by the TRIPS agreement, and
in March 2012, India issued its first-ever compulsory license under the TRIPS agreement, to
locally produce Nexavar (sorafenib), a kidney and liver cancer drug. China, which became a
member of the WTO on December, 11th, 2001, followed India’s move, and introduced
legislative changes to its patent law in 2012, allowing China’s State Intellectual Property
Office (SIPO) to issue compulsory licenses as well, and to export medicines to other countries
in case of emergency. Since then, India has been considering other compulsory licenses:
after India’s government considered issuing a compulsory license for Herceptin
(trastuzumab), a breast cancer treatment, on February, 2013, Roche eventually decided not
to pursue its patent application for the drug in India, therefore enabling the manufacturing
of a cheaper version by the Indian drug manufacturer Biocon. More recently, the Health
Ministry in India filled a case at the DIPP, a part of the Commerce Ministry, to grant a
compulsory license for Sprycel (desatinib). Sprycel is a leukemia (leukemia is a group of
cancers) drug, manufactured by the American Bristol Myer Squibb’s. In two previous
attempts, the DIPP rejected The Ministry of Health requests, arguing that it was not satisfied
with the Ministry arguments for granting a compulsory license: in the first attempt, for
instance, the DIPP stated that the local company did not do enough efforts to be granted a
voluntary license. Moreover, the DIPP stressed that the absence of concrete definition of
“national emergency” within TRIPS agreement, was just making things more complicated.
However, this third attempt seems likely to be approved. The patented version of the drug is
indeed out of reach for a large number of patients in India and costs around INR 160,000
(USD 2,625) for a one-month treatment: manufacturing a generic version of it can therefore
be considered as a national emergency. A generic version of the drug would only cost INR
8,000 (USD 130)42.
China, in 2013, did not address the problems of access to antiretroviral drugs and
hepatitis B treatments by issuing a compulsory license though, but by revoking the patent of
Gilead Science drug Viread (tenofovir), part of the WTO list of essential medicines, claiming
that the drug lacked novelty, and therefore enabling the pharmaceutical local companies to 42
THE PHARMA LETTER, “Indian Health Ministry seeking compulsory license for B-MS’ Sprycel”, The
Pharma Letter, August, 19th
2014
39
manufacture generic versions of it. This action was made possible by the comprehensive
legal framework China adopted to comply with the TRIPS agreement, which like India’s
national framework, reflects a narrow interpretation of the international framework.
Viread’s patent had also been declared invalid in Brazil and India43.
Thanks to these locally-produced generic versions of patented drugs in India and in
China, drugs and medicines have become more easily accessible for the local populations. In
our survey, people receiving healthcare services in India and China ranked the availability of
the drugs and medicines they needed 3.3 out of 4 on average, compared to 3 out of 4 in
other developing nations (appendix 8).
Thanks to the production of affordable drugs in India and China, an enhanced
access to medicines for local populations
The use of TRIPS flexibilities to locally produce generic-drugs in India and China has
enabled to enhance access to medicines for local populations, even though a large part of
the local production is meant for export. Indeed, there are two kinds of pharmaceutical
research and production going on in India and China:
- Many local companies are part of what is called “contract research”. This means that
you have Indian and Chinese pharmaceutical companies doing research and
producing drugs, mainly for Western markets. These companies therefore are export-
oriented, and India and China account for a large part of generic drugs global exports
(exhibit 11).
43
ELLIS S. “China revokes Viread Patent ; pricing was at issue”, Bioworld, August 7th
, 2013
40
Imports of Indian drugs and medicines
Exhibit 11 – Major importers of Indian drugs and medicines (by value), 2014. Source: Infodrive India
(http://www.infodriveindia.com/india-export-data/pharmaceutical-export-data.aspx)
- The other set of Indian and Chinese companies are the ones meant for local markets.
They mainly produce affordable generic drugs that doctors in India and China tend to
prescribe to their patients, because they are much cheaper.
In addition to the increased production of generic drugs for the local market, Indian and
Chinese governments have taken measures to ensure an access for their population to the
locally-produced efficient and affordable drugs and to prevent from irrational drug use
(counterfeit drugs, in-excess prescription of antibiotics, etc.). In 2012, Manmohan Singh, the
former prime minister of India, announced the introduction of a “free medicine for all”
program: essential drug-supplies would be free of charge for patients in public facilities
across India. The program has been modeled on already existing programs such as those of
Tamil Nadu, Rajasthan, Kerala or Bihar. The system has not been expanded yet to other
states, but will probably benefit millions of patients, by reducing the financial burden of
healthcare services and promoting greater use of generic medicines instead of costly and
irrational drug prescriptions44. The pillar of this scheme will therefore be the National List of
Essential Medicines of India (NLMEI), revised in June 2011, and including 348 medicines
covered by the DPCO (compared to 74 medicines under the 1995 DPCO).
44
SREEJA VN, “India’s generic drug healthcare policy to benefit millions of poor patients”, International
Business Times, July 7th
, 2012
41
A similar list, the National essential drug list (NEDL) has also been issued by the Chinese
government in 2009. An updated version of the list was released in April, 2013 (National
Essential Drug List 2012). The revised list contains 520 molecules (compared to 307 in the
2009 list), including 317 chemical medicines and 203 traditional Chinese medicines45.
Provinces can supplement the list, according to their specific needs. However, the 2012
NEDL introduced some restrictions to provincial supplements in order not to get distinctive
provincial essential drug lists that could contribute to greater inequities in terms of access to
healthcare. The National Development and Reform Commission is tasked with defining
market price ceilings for these essential medicines. Moreover, according to the central
government guidelines, state governments should organize public bidding for these
medicines, in order to get the lowest procurement price possible. These drugs are then
supplied to primary healthcare institutions (the scheme will probably expand to private
providers and hospitals soon), which are required to stock them and to sell them at cost
(procurement price plus a fixed distribution cost). In an article of The Lancet, Yu Fang and
colleagues analyzed the impact of the national essential medicine policy on access to drugs
and medicines for Shaanxi Province population46. They found out that between 2009 (when
the Chinese government introduced its healthcare reform) and 2011, the price of twenty-
nine generic medicines decreased by 5.2% in the public sector and by 4.7% in private
pharmacies.
Another example of initiatives to enhance locally-produced affordable drugs access is the
Jan Aushadi scheme (JAS), in India. It was launched in 2008, through a public-private
partnership (with stakeholders such as the department of pharmaceuticals, state
governments, NGOs, charities, government bodies, pharmaceutical companies, etc.). The
scheme aims at opening pharmacies in every district to provide patients with quality and
affordable generic drugs (exhibit 12). As of today, as many as 157 Aushadhi stores have
already opened across the country, enabling the local population to benefit from a strong
flourishing network of generic-drugs local manufacturers. Drugs have been made affordable
45
CHINA FOOD AND DRUG ADMINISTRATION, National Essential Medicine List (2012 edition) released, March, 19
th, 2013 (http://eng.sfda.gov.cn/WS03/CL0757/79154.html)
ZHANG M., LU J., LIU J., ZHANG S., “Exploring Impacts of the revised EDL and Associated policies”, IMS
Consulting group, April 2013 46
FANG Y., WAGNER A., YANG S., JIANG M., ZHANG F., ROSS-DEGNAN D., “Access to affordable medicines after helath reform: evidence from two cross-sectional surveys in Shaanxi Province, western China”, The
Lancet, vol 1, October, 2013, pp 227-237
42
by the emerging generic pharmaceutical industry and actually benefit the local populations,
providing them with cheaper drugs.
Average branded-drug prices comparison with Jan Audashi Scheme drug prices
Drugs category and name
of the active ingredient
Price of a pack of 10 tablets
branded drugs (in INR)
Jan Aushadhi 10 tablets
price (in INR)
Antibiotic:
Ciproflaxin
54.79 12.89
Painkiller
Diclofenac
60.40 4.20
Common cold:
Cetrizine
18.10 2.75
Fever:
Paracetamol
9.40 3.03
Pain and fever:
Nimesulide
39.67 3.16
Exhibit 12 – Jan Aushadhi drug prices, 2014. Source: Ministry of Chemicals and Fertilizers, Department of
Pharmaceuticals: Jan Aushadhi, a campaign to ensure access to medicines for all
However, in their research paper, Yu Fang and colleagues also found that the availability
of some essential medicines in China had significantly decreased between 2009 and 2011,
both in the public sector and in private pharmacies. Price reductions of drugs are essential to
ensure affordability of essential medicines for the population, but they mean little if the
cheaper drugs are actually not available. As Hans Hogerzeil and Sun Jing notice, “if maximum
prices for some medicines are imposed, local manufacturers might simply move production
capacities towards products for which the prices are not controlled”, such as non-essential
medicines, or simply focus on products for exportation. The massive production of generic
drugs in India and China might therefore not be sufficient to ensure access to healthcare for
local populations. Access to healthcare is not just about affordability of drugs. It is also about
much more factors that often do not seem to be taken into account. If hospitals keep being
financially dependent on the sales of drugs for instance (which approximately represent 40%
of the hospitals revenue in China), doctors will keep overprescribing irrational drugs, often
not included in the reimbursement list (local social insurance schemes in China are required
to provide higher coverage for listed drugs than for non-listed drugs). This would generate
43
considerable out-of-pocket expenses for the patients, therefore endangering their “right to
health”. It is essential to consider access to healthcare not only in terms of drugs
affordability, but in terms of overall health care system. As Neil Schluger, from the World
Lung Foundation stresses, “even if you have new drugs, you need the public health
infrastructure to diagnosis patients, deliver the drugs and ensure adherence to the
treatment”47.
HIV-positive activists protest against Novartis in New-Delhi, urging the company to withdraw a case against
the Indian government, 2007 (Photo: Krishnan V.)
47
WARD A., “Killer of the poor now threatens the healthy”, Financial Times, March 24th
, 2014
44
2- But lack of efficiency of health policies prevents local
population from accessing health services
The right to health for all is a fundamental right worldwide, and led to the creation of the
WHO in 1948. The WHO first conference, the International Conference on Primary Health
Care in 1978 resulted in the signing of the Alma-Alta declaration, by the 194 member-states
of the United-Nations. This declaration stresses the need for coherent action at the national
and international levels in order to protect and promote the health of people worldwide.
More recently, the WHO stressed the importance of achieving universal health coverage,
during, among other summits, Mexico International Forum on Universal Health Coverage,
held in April 2012. Universal health coverage can be defined as a mean to ensure people
access to the health services they need 48 . Therefore, several attempts to build
comprehensive healthcare systems emerged around the world.
Some systems, like the ones implemented in Great-Britain or in Sweden, offer free access
to basic health services for everyone, financed by the government. Healthcare facilities there
are public, and health personnel wages are paid by the central government or by local
communities. Although these systems have proved very successful, they often imply long
waiting lines: in 2001, 22% of British patients declared they had to wait more than three
months to get a hospital appointment. Other countries, such as France, Germany or Japan,
chose to implement a system mainly based on health insurance schemes, in which the offer
emanates from both public and private actors. Finally, some countries, among which Central
Europe countries and the United-States, decided to build systems mainly based on the
private sector, that some would call “non-systems”. In the United-States for instance,
companies co-finance health insurance contracts from private organizations for their
employees. Two out of three employees are insured this way, but employees working in
small companies have to subscribe individual health insurance policies which are often way
more expensive. Most of people who do not have full-time jobs in big companies are
therefore uncovered by insurance schemes. Pensioners of more than 65 years old are
covered by Medicare, which finances a small amount of private health insurance schemes.
48
WHO, Health financing for universal coverage (http://www.who.int/health_financing/en/)
45
The poorest people are covered by Medicaid. However, given the rising number of
unemployed people in the United-States, the system is under strain49.
We will now try to understand the healthcare systems being implemented in India
and China, and to identify their success and flaws.
A – India and China, undertaking the first step to reform their
healthcare system
China, towards universal health coverage
China’s healthcare system is just in its starting years but is already very promising,
and China will probably achieve universal health coverage quite soon.
According to the Republic of China’s first national census (the 1953 census), in the 1950s,
China’s population of 600 million people, was mainly rural (only 13.5% of the population was
living in urban areas), and poor. Sixty years later, however, the population profile is totally
different: Chinese 1.36 billion citizens are ageing (21% of the population is over 55 years old,
and only 17% below 15), half urban citizens (51% of the total population lives in urban areas)
and belong to the second largest economy in the world by gross domestic product (GDP),
with per capita GDP in purchasing power parity terms of over USD 9,800. Life expectancy has
increased from less than 40 in 1949 to over 75 years old in 201350. How has China been able
to adapt its healthcare system to such a changing population?
Back to the Mao era (1950s-1970s), China’s population had good access to basic health
services: urban population was covered by the Labor Insurance System or by the
Government Insurance system, while rural population access to health was secured through
cooperative medical schemes. Moreover, from the late 1960s, “barefoot doctors” began
providing basic medical services and health prevention campaigns in the countryside.
Although the standards of healthcare were not very high, significant health improvements
49
BULARD M., “Comment fonctionnent les systèmes de santé dans le monde ?”, Le Monde Diplomatique, February 2010
50 CENTRAL INTELLIGENCE AGENCY (CIA), The World Factbook, China, 2014
(https://www.cia.gov/library/publications/the-world-factbook/geos/ch.html)
46
occurred during that period, thanks to widespread availability of drugs (including Chinese
traditional medicines), and easy access to basic health services and healthcare facilities,
hence a sharp increase in life expectancy, from 40 in the 1940s to approximately 65 in 1980.
From the 1980s, China’s socialist economy transformed into a market-economy, at the
expense of public health which has been neglected since then. Following the dissolution of
rural cooperatives, insurance coverage indicators dropped to 7% in rural areas51. The
Chinese government therefore had to face growing public discontent, stemming from
difficulties for the population to access healthcare services. The outbreak of severe acute
respiratory syndrome in China in 2003 exposed the public health system flaws and focused
the government’s attention on health. As a consequence, on April 2009, the government
launched its healthcare reform plan (the Healthy China 2020 plan), and committed to
spending CNY 850 billion from 2009 to 2012, to provide universal health coverage for the
whole Chinese population by 2020. Public spending in healthcare is now much higher in
China than in many developing countries, and even than in some developed countries
(appendix 2). The reform plan includes five main components: expanding healthcare
coverage, establishing a national essential medicines system to meet the population needs
for affordable drugs, build a comprehensive network of health facilities especially focusing
on the primary care delivery system to provide basic health care, addressing inequities by
making public health services accessible to the whole Chinese population, and finally,
conducting public hospitals reforms. The proposed plan spans from 2009 to 2020 and is
illustrated along with its five key components, in the following chart (exhibit 13):
51
EGGLESTON K., “Health Care for 1.3 billion : an overview of China’s health system”, The Walter H.
Shorenstein Asia-Pacific Research Center, Stanford University, January 9th
, 2012
47
Exhibit 13 - Chinese healthcare reform blueprint through 2020. Source: Opportunities in China’s
pharmaceuticals market, published by Deloitte
Additionally, in its 12th Five-Year Plan (2011-2015) announcement, the Chinese government
focused on increasing medical personnel and controlling costs.
Expanding healthcare coverage
The cost of healthcare increased a lot in China in the 2000s, and China’s health reform
between 2003 and 2008 has therefore focused on extension of healthcare coverage52. The
New Rural Cooperative Medical Scheme (NRCMS) was launched, and was mainly financed by
the government. 95% of farmers were covered by the scheme in 2012. In 2007, the
government established the Urban Resident Basic Health Insurance (URBHI), to cover the
urban population that was not covered by the Urban Employee Basic Health Insurance
(UEBHI). The UEBHI, jointly funded by employers and employees, indeed only covered about
30% of the population. Finally, the government launched a Medical Financial Assistance
system (MFA) to cover the poorest citizens that currently covers medical services for more
than 68 million people. The four systems (NRCMS, UEBHI, URBHI and MFA) complement
each other and greatly expanded health care coverage for the Chinese population (exhibit
14).
52
YIP W., HSIAO WC. CHEN W. HU S., MA J., MAYNARD A., “Early appraisal of China’s huge and complex health-care reforms”, The Lancet, 2012
48
Exhibit 14 – China’s main medical insurance scheme. Source: China’s healthcare system, published by the
Swedish Agency for Growth Policy Analysis, April, 2013
As of today, about 95% of the Chinese population is covered by basic medical insurance,
which represents a huge progress compared to just ten years ago53: in 2004, 70% of the
Chinese population did not receive any formal financial protection to cover their healthcare
expenditures54. In our survey, four out of four participants receiving healthcare services in
53
LI KEQIANG, As China’s healthcare reform deepens, progress and challenges (speech) November, 16th
, 2011
54 HE JINGWEI A. “China’s Ongoing Healthcare Reform: reversing the perverse incentive scheme”, East
Asian Institute, pp 39-48, 2010
49
China are covered by a health insurance, including participants who do not have the Chinese
nationality (appendix 8). Very significant progress has therefore already occurred regarding
healthcare insurance coverage, especially in rural and less-developed areas (such as Western
and Central provinces), thanks to the launch of the NRCMS in 2003 (exhibit 15).
Health insurance coverage within the Eastern, Central and Western provinces in China
Exhibit 15 – Health insurance coverage within the Eastern, Central and Western provinces in China.
Source: Trends in access to health services and financial protection in China between 2003 and 2011, by Qun
Meng and colleagues
Establishing a national essential medicines system
The central component of the national essential medicines system is the NEDL, discussed
earlier.
The undergoing public hospital reform
Public hospitals in China, contrary to India and other developing nations (appendix 11),
play a major role in providing health care services. Indeed, health services are mainly
provided by the public system, and public hospitals beds account for 90% of the total
number of beds in hospitals in China. 75% of our survey respondents who receive healthcare
services in China declared public facilities were the healthcare facilities they trusted more
(appendix 8). Moreover, in addition to inpatient care and tertiary services, public hospitals in
50
China also deliver outpatient care services, since patients trust them more than community
health centers. Four out of four survey participants receiving healthcare in China declared
they would go to hospital or any tertiary-care facilities to receive basic healthcare services,
whereas the large majority (88%) of our survey respondents would rather go to primary
healthcare centres (appendix 8). The reform of public hospitals in China is therefore
paramount since they are responsible for a large part of health care provision. The
undergoing public hospital reform mainly aims at improving management and service
standards. To implement the reform, seventeen national and thirty-seven provincial pilot
cities have been organized. One of the facet of the reform concerns hospital financing:
government’s funding of public hospitals have experienced a big cut down since the 1980s.
The reform therefore aims at increasing local governments’ subsidies to cover the hospitals
operational costs, which may, as a consequence, allow a decrease in out-of pocket
expenditures for patients. According to official statistics, the patient out-of-pocket health
expenditure as a percentage of total health expenditure has decreased from 40.5% in 2008
to 35.5% in 2010 in the pilot cities. The reform also aims at “separating ownership and
operation” and at eradicating corruption: the idea is to make the medical staff respond to
societal needs instead of profits, in order to improve the quality and efficiency of medical
services55. Indeed, hospital directors, who are appointed by the Organization Department of
Chinese Communist Party, are often profit-seeking. The reform is therefore targeting conflict
of interests: it would also probably largely impact the public hospitals governance structure.
As of today, the governance structure in Chinese public hospitals is indeed quite archaic and
there is still some room for conflicts of interests: competing ministries for instance, may
pursue conflicting goals. If we take the example of drug prescriptions, the Ministry of Health
would probably promote medical services provision at low-costs while the Price Bureau
would tend, on the contrary, to encourage doctors to overprescribe drugs56.
Qun Meng and colleagues analyzed the improvements regarding access to healthcare for
the Chinese population, between 2008 (the year preceding the healthcare reform) and 2011.
Their findings show that availability of health services for the population increased: the use
55
KEQIANG L. “Deepening the reform of Health Care”, Qiushi Journal (organ of the Central Committee if the Communist Party of China), vol. 4, January 1
st, 2012
56 YIP W., HSIAO W., CHEN W., HU S., MA J., MAYNARD A., “Early appraisal of China’s huge and complex
health-care reforms”, The Lancet, vol. 379, March 3rd
, 2012
51
of outpatient care in primary health centres among the Chinese population slightly
increased, by 0.7% between 2008 and 2011, but the reform mainly benefited hospitals:
hospital admissions increased by 8.5% nationwide, while hospital delivery rates increased by
2%, being particularly significant in rural regions (+ 2.5%) and in Western regions (+ 4.5%)57.
The reform is successful, and has enabled an enhanced access to healthcare among the
Chinese population.
India: slow progress towards a comprehensive healthcare system
India’s healthcare system is very different from China’s healthcare system. Both
countries have chosen different paths and different methods to improve their population’s
health. While the public sector is by far the major healthcare provider in China, India
presents a dual healthcare system: on the one hand, public facilities offer almost free
healthcare services to everyone in India, but lacks funding and is of poor-quality. On the
other hand, private facilities tend to offer better quality services to people who can afford
them, but can represent a significant financial burden for patients and their families. 80% of
our survey respondents, receiving healthcare services in India, declared they would trust
private facilities rather than public facilities, but many stressed the fact that though quality
of the private sector was much better than in the public sector, the private sector was very
expensive and unaffordable for many Indians (appendix 8). Therefore, India’s healthcare
system is undermined by inequities in terms of access to health. Several initiatives have been
launched by the central and state governments to answer this issue and to significantly
improve healthcare among Indian populations. Here are some of them:
The National Rural Health Mission
The National Rural Health Mission (NRHM) was established in April 2005, in order to
improve healthcare provision to rural populations, and can be seen as a major step following
the government will to increase public spending in the health care sector. The mission
includes several key objectives:
57
MENG Q., XU L., ZHANG Y., QIAN J., CAI M., XIN Y., GAO J., XU K., BOERMA J., BARBER S., “Trends in access to health services and financial protection between 2003 and 2011: a cross-sectional study”, The Lancet, March 3
rd 2012
52
- Reinforcing the health workforce in rural areas. One of the key drivers to achieve this
goal is the involvement of community in healthcare. The mission, for instance, greatly
encourages the work of female activists, and will train 250,000 of them to provide
health prevention advice to their communities, to treat minor injuries and to send
patients to health centres when needed.
- Strengthening and modernizing public infrastructure in rural areas: the mission aims
at improving the quality of services delivered in rural state-run hospitals and at
extending the network of sub centres, primary health centres and community health
centres (exhibit 16)
- Integrating previously “vertical” health programmes and funds into horizontally-
oriented health programs: the current healthcare system in India is mainly based on
specific-diseases programs and funds (National Guinea Worm Eradication
Programme, Yaws Control Programme, National Cancer Control Programme, National
Programme for Prevention and Control of Deafness, etc.). One of NRHM key
objective is to harmonize these specific programs and to build a comprehensive
overall healthcare system.
The scheme covers the whole country, but is focused on eighteen states that have very
poor infrastructure. The introduction of NHRM has helped in significantly reduce the
incidence of infectious diseases. Following this success-story, a National Urban Health
Mission (NUHM) was launched on January, 2014, aimed at providing healthcare services, and
especially essential primary healthcare, for the urban poor. This scheme is supposed to cover
779 urban areas, representing about 50,000 inhabitants by March 201558. NRHM and NUHM
may merge in the future to form a single National Health Mission59.
58
PRESS TRUST OF INDIA, “National Urban Health Mission Launched”, Business Standard, August 4th
, 2014 59
MINISTRY OF HELATH AND FAMILY WELFARE, Framework for implementation of National Health Mission
2012-2017, New-Delhi, January, 8th
, 2014
53
Exhibit 16: rural health care system and healthcare facilities subdivisions
The Janani Suraksha Yojana
The Janani Suraksha Yojana (JSY) was introduced in 2005 to reduce maternal and
neonatal mortality by encouraging women to give birth in public health facilities or
government accredited private facilities by providing them financial incentives60. It has now
become a component of the NRHM and is complemented by public-private partnerships,
such as the Chiranjeevi Yojana, initially implemented in Gujarat and now being extended to
60
NATIONAL HELATH MISSION, Janani Suraksha Yojana background (http://nrhm.gov.in/nrhm-components/rmnch-a/maternal-health/janani-suraksha-yojana/background.html)
54
other states. Private obstetricians provide services related to delivery for below-the-poverty-
line women, and local governments bear the costs of fees paid to the doctors61.
The Rashitriya Swasthya Bima Yojana
The Rashitriya Swasthya Bima Yojana (RSBY) was established in 2008 to address the lack
of affordable health insurance for Indian population. Indeed, in our survey, 37% of people
receiving healthcare services in India were not covered by any health insurance (appendix 8).
The RSBY is a health insurance scheme funded by general public revenues: 75% of the
premium is financed by central government and 25% by state governments. Smart “health
cards” are given to families with insufficient resources (below-poverty-line families) that
enable them to access cashless inpatient health care services of up to INR 30,000
(approximately USD 670) per family and per year in over 1,000 public and 3,000 private
hospitals. As of today, more than 37 million people own a smart health card and are already
able to use this insurance scheme62. However, this only represents 3% of the Indian
population. And even if you add up their close family, which can benefit from the card as
well, the scheme has only enrolled about 10% of the Indian population so far, whereas it is
meant to enroll the entire below-poverty-line population estimated to represent 21.9% of
the total Indian population63. Moreover, the insurance scheme only covers inpatient care in
accredited hospitals (mainly private hospitals), whereas outpatient care and drug expenses
are the responsibility of the patient. This scheme therefore leads to neglected primary
health facilities. Diseases such as tuberculosis, which often requires long-term outpatient
care, therefore represent a consequent financial burden for the patients and their families.
Some federal states have also launched local similar health insurance schemes. Goa is
one of these examples: the Goa government contracted with ICICI Lombard, a private
insurer, to provide cover for primary and secondary treatment of up to INR 60,000 (around
670 USD) to anyone who has lived in Goha for more than five years64. Similar insurance
schemes have also been introduced in Kerala (Comprehensive Insurance Scheme), Tamil
61
NARENDRA MODI, Chiranjeevi Yojana: special care of mother and child, October 6th
2012, (http://www.narendramodi.in/chiranjeevi-yojana-special-care-of-mother-and-child/)
62 RSBY, “India’s poor get health cards to fund medical treatment” (http://www.rsby.gov.in/)
63 RESERVE BANK OF INDIA, Number and Percentage of Population below poverty line, September 16yh,
2013 (http://www.rbi.org.in/scripts/PublicationsView.aspx?id=15283) 64
GOPAL L., “Goha government gives all residents health insurance from ICICI Lombard”, Medindia, September 21th, 2011
55
Nadu (Kalaignar scheme), Delhi (Apka Swasthya Bima Yojana), Karnataka (Yeshasvini Health
Insurance Scheme) and Maharashtra (Rajiv Gandhi Jeevandayee Arogya Yojana). The
situation regarding health care coverage has therefore largely improved since the 2000s.
Before 2007, the only effective insurance schemes were the Employees State Insurance
Scheme (ESIS) which covers employees in the formal sector since 1952 (whereas the
informal sector represents a large part of the country’s economic activity), and the Central
Government Health Scheme (CGHS) launched in 1954, which covers the Indian central
government employees. These two schemes are funded by employees and employer.
India is therefore making some progress in building a comprehensive healthcare system.
However, India still accounts for the largest number of diphtheria and leprosy reported cases
in the world, and the life expectancy at birth of its population is lower than South-East Asia
average life expectancy (appendix 2). The country still accounts for 21% of the world’s global
burden of disease. As of today, Indian health indicators remain weak, and the country often
ranks among countries poorly performing on overall health performance. In our survey, the
average rating of the overall healthcare system in India is 2.8 out of 5 (appendix 8).
Moreover, the different initiatives launched definitely lack of coordination. The Indian
healthcare system is more like a patchwork of specific initiatives, under the impulsion of
both the central government and/or the state level, that have no real link between them,
and that sometimes overlap or conflict with other programs. There exist numerous infection
diseases programs in India, but they operate separately and are only targeting specific
diseases: the National Vector Disease Control Programme, the Revised Tuberculosis National
Control Programme, the National Leprosy Eradication Programme, etc. Unlikely, the system
created in China is horizontal-driven and multidimensional, and aims at embracing all
spheres.
B – Access to healthcare for everyone in India and China,
still a long way to go
Although both countries benefit from locally manufactured affordable drugs, India and
China have to continue their efforts regarding improvement of their healthcare systems.
56
While the system is in its starting years in China, it is almost non-existent in India, and many
flaws are still to be addressed in both countries.
Disparities jeopardize “health for all”
While figures in India and China illustrate a sharp improvement in the population
overall health these last few years, they tend to mask huge disparities within the countries.
Inequities have been simmering for years in both countries, and now need to be addressed.
India’s government has always supported the ideal of health for all: according to the
Constitution, the right to health is even a fundamental right (article 21), but it unfortunately
does not represent the current reality. China and India are both facing a major challenge:
the broadening divide between “rich” and “poor”. And both countries are subject to
decreasing government funding and increasing out-of-pocket payments. Globalization has
largely contributed to the emphasis of the divide regarding access to healthcare, especially
regarding stringent disparities between urban and rural areas. The Indian example is
probably one of the most significant regarding health inequities: on the one hand, India is
home to some cutting-edge private hospitals, such as the Escorts Heart Institute in Delhi,
which is well known for providing high-quality healthcare services to rich patients from India
and from various parts of the world65 and for employing a large number of highly-skilled
medical staff66. On the other hand, the majority of primary health centres in India does not
have any laboratory or labor room, or even any telephone connection.
65
Medical tourism is current practice in India. Patients from all over the world come to India to receive various range of medical services, such as cardiac surgery. The rationale behind medical tourism is broad: reasons include lower costs of medical services (treatments may be unaffordable for US patients, due to the lack of healthcare insurance system), higher healthcare standards and equipment (African and Middle-East patients may lack technology or medical expertise in their home-countries), and reduced waiting lists. The Indian government is being very supportive of medical tourism: it promotes tax breaks for private hospitals; it has also launched a medical visa, that enable patients to stay up to one year in India; It has launched a big marketing-campaign, Incredible India, to attract medical tourists; finally, it has given the Joint Commission International accreditation to a large number of hospitals receiving medical tourism patients. The Escorts Heart Institute even has a thumbnail “International patients” on its website (http://www.fortisescorts.in/InternationalPatients.aspx).
66 FORTIS ESCORTS HEART INSTITUTE, About us (http://www.fortisescorts.in/AboutUs.aspx). There is a
large number of medical staff in the hospital: about 200 cardio doctors and 1600 employees annually manage about 21,000 admissions.
57
There exist three levels of disparities:
The first level is the rural-urban divide. While economic growth and health infrastructure
are top-quality on the “Golden Coast” in China (the eastern coast of the country, home to
some of the largest cities in China, like Beijing, Tianjin or Shanghai), Western provinces and
rural areas are relatively underdeveloped. In India, the geographical divide is not as obvious
as in China, but likewise, cities and urban areas there represent the greatest concentrations
of wealth, whereas India’s population is 70% rural (compared to 48% for China). Mumbai,
Delhi or Kolkata are at a more advanced stage of development than rural areas in Uttar
Pradesh or Bihar. Rural areas in India only account for 10% of the hospital beds, and for 25%
of the human health personnel of the country67. The NRHM is therefore meant to correct the
imbalance between urban and rural areas populations’ access to healthcare services.
The second level of imbalances is the geographical divide. Disparities between different
states in India or between different provinces in China are striking. Although, as Qun Meng
and colleagues demonstrate, the differences in access to healthcare between regions in
China have significantly reduced since the launch of the healthcare reform and very
significant progress has already occurred regarding healthcare insurance coverage in some
underdeveloped provinces, huge disparities remain regarding physical access to health
services for instance. People from rich provinces therefore generally tend to live longer than
people from less affluent provinces (exhibit 17). Life expectancy in Beijing province, for
instance, is ten years higher than life expectancy in Yunnan province (exhibit 18). In India,
Kerala state, spends three times as much on health per capita as Bihar and has three times
as many doctors, proportionally to its population, than Odisha.
67
GILL J., TAYLOR D., Health and healthcare in India: national opportunities, global impacts, ULC School of Pharmacy, July 2013
58
Life expectancy by GDP
Exhibit 17 - Life expectancy by gross domestic product (GDP) per capita of Chinese provinces, 2000.
Source: China Statistical Yearbook (http://www.stats.gov.cn/tjsj/ndsj/2008/html/D0306e.htm)
Exhibit 18 – On the left: China life expectancy by province calculated for the year 2000. On the right:
India life expectancy by state, calculated for the year 2002. Source: Health in China and India, a cross-country
comparison in a context of rapid globalization, by Trevor Dummer and Ian Cook
59
In addition to this geographical divide, there exists a third level of disparities, with a
significant divide among individuals themselves. Factors, such as cast, class and gender are
key factors that can explain disparities, fostering contrasts in affluence among the
population. Migrant workers in China, for instance, have almost no access to healthcare, and
are at the fringe of the Chinese society. The sixth population census, conducted at the end of
2010, estimated that about 260 million people in China had lived outside their place of
residence during the last six months. Migrant workers (nongmingong in Mandarin, 农民工)
are individuals from rural areas, who decided to come to urban areas to find work. According
to Chloé Froissart, a researcher on the phenomena, they represent about 17% of the urban
population, and one third of Beijing population, and do not have residence permit (hukou in
Mandarin, 户口) for the place where they live. Indeed, in the hukou system, individuals are
identified as residents of one specific area (usually their place of birth). There are two types
of hukou: urban hukou and rural hukou. People having a rural hukou are theoretically not
meant to reside in urban areas. However, since migrant workers represent a highly flexible
and low-cost workforce, their illegal status is actually tolerated by the authorities, but they
do not have any legal citizenship. As a consequence, they do not have access to the
healthcare system and are not covered by any health insurance scheme. As a result, some
migrant workers villages emerged, everywhere in China, such as Zhejiangcun, in the South-
West of Beijing, where people have created their own health centers and schools, headed by
fellow migrants. In 2003, a public document mentioned the existence of migrant workers for
the first time and granted them some basic rights. Moreover, migrant workers went on
strike in 2010 at Honda factories to pursue fundamental rights, such as access to healthcare.
Although some minor concessions have gradually improved Chinese migrant workers’ lives,
much is still to be done regarding their access to health.
The divide between individuals and the inequities implied in terms of access to
healthcare are also further accentuated by public-private dual system in India. On one
extreme of the healthcare services spectrum, there are those who can afford the best
possible care in private facilities, implying cutting-edge technology that foreigners are
seeking as well (medical tourism is expanding in India); on the contrary, the other extreme,
people lack of basic healthcare infrastructure and basic drugs. Public healthcare facilities
(that are almost free for everyone) are often overloaded, and services are of bad quality.
60
The private sector was already the major provider of healthcare services in India at the time
of independence. And it kept growing, emphasized by the recent adoption of a liberal
market-oriented economy. One visible manifestation of this growth of the private sector in
India is the private hospitals revenues. The nationwide gross revenue of Apollo Hospitals for
instance, a network of private hospitals including thirty-eight owned hospitals and thirteen
managed hospitals across the country rose from INR 16.1 billion in 2009 to INR 37.7 billion in
201368 (approximately USD 280 million to USD 610 million). The private sector is the major
player in the healthcare field in India, whereas the public sector has been neglected despite
The Bhore Committee recommendations: The Bhore Committee report 69 indeed
recommended improvements to the Indian public health system as early as in 1946, in order
to deliver better medical services financed by the government, through which all citizens
would receive health care irrespective of their ability to pay (exhibit 19).
Share of the private sector in India’s health system
Share of the private sector
Medical graduates and post-graduates 90-95%
Undergraduate seats in medical colleges 45%
Outpatient care (in revenue) 80%
Inpatient care (in revenue) 60%
Exhibit 19 - Share of the private sector in India’s health system in revenue. Source: SENGUPTA A, Universal
health care in India, 2013.
The private sector is left unregulated and corrupted in India, which has resulted in a huge
increase in healthcare costs and in out-of-pocket expenditures (the private sector often uses
expensive inappropriate technologies and overprescribing), making it even harder for poor
population to receive care in its facilities. These out-of-pocket expenditures are indeed a
major cause of indebtedness and poverty in India. The reasons for the growth of the private
sector mainly lie in the flaws of the public system: lack of funding translates into poor-
infrastructure and low-quality services. Moreover, drug supplies in public facilities are often
interrupted. According to Mukund Uplekar, a public health researcher for The Lancet, 80% of
people in India prefer to use the private sector for basic healthcare services, and 75% for
68
APOLLO HOSPITALS, Investor Presentation, June 2013, (https://www.apollohospitals.com/apollo_pdf/Apollo_Investor_Presentation_June_2013.pdf)
69 BHORE COMMITTEE, Report of the Health Survey and Development Committee, 1959
(http://www.nhp.gov.in/directory-services-and-regulations/committees-and-commissions/bhore-committee1946)
61
major health conditions. These figures are consistent with the results of our survey, in which
80% of our survey respondents, receiving healthcare services in India, declared they would
trust private facilities rather than public facilities (appendix 8). Moreover, public health
facilities lack of skilled human resources. Indeed, graduated students largely prefer to seek
opportunities in the growing and promising private medical sector, which offer better wages
and incentives, and better working conditions70. The public system therefore often stands as
a simple safety net for people who cannot afford the private system.
An urgent need for public funding to reduce out-of-pocket payments
The fees that households are paying to access healthcare services in India and China
are constantly rising, faster than the average disposable income. In our survey, we asked
participants to react to the following statement: Drugs and medicines expenses represent a
significant financial burden for me and my family. They should answer by rating the
statement from 1 (strongly disagree) to 4 (strongly agree). People receiving healthcare
services in India and China reacted affirmatively to the statement, rating it on average 2.22
out of 4, while on average, the 135 participants rated the statement negatively (1.88 out of
4) (appendix 8). A large part of out-of-pocket payments in India and China are indeed made
on medicines, especially in India, which is, paradoxically, both the largest producer of
medicines in the developing world and home to the largest number of people who do not
have access to drugs. Indeed, as we have seen earlier, the Indian healthcare private system
is unregulated, and often overprescribes overpriced drugs to the patients. Antibiotics are
often prescribed irrationally, which increases the costs the patient has to bear, but also
expose the patient to drug resistance, which is already a major problem in India (especially
regarding malaria and tuberculosis)71. According to Amid Sengupta, over 50% of the average
household spending on medicines in India is incurred on irrational or unnecessary drugs and
diagnostic tests. The out-of-pocket expenditures associated with medicines have led to
difficulties for the population to access efficient medicines, therefore creating a growing
market of counterfeit drugs, which can cause much damage on the population’s health.
70
ANANTHAKRISHNAN G., “75% prefer the private sector”, Infochange, June 2005 71
India has the largest number of multi-drug tuberculosis resistant cases in the world, which require new treatments, often patented treatments that are much more expensive than basic treatments.
62
In 2006, out-of-pocket expenditures in China were eighteen times as much as what they
were in 1990 (exhibit 20). Government insurance schemes have therefore been introduced
partly to address the increase of out-of-pocket expenses. However, outpatient services are
still not insured for most of the Chinese and Indian population, which generates inefficiency:
patients who could be seen during an outpatient consultation are often hospitalized for
inpatient care, because the government’s insurance schemes only cover inpatient stays. And
in China, even impatient services leave patients with considerable costs to bear. The RMCS
only reimburses about 41% of the patient’s expenditure. In comparison, the French Sécurité
Sociale reimburses 80% of the patient’s expenditure for inpatient care and 70% for
outpatient care72.
Therefore, improving the health of the population also means increasing public funding,
to compensate and progressively reduce out-of-pocket expenses. The thirty member-
countries of the Organization for Economic Co-Operation and Development (OECD) with the
highest national life expectancy account for 90% of health expenses worldwide73.
Exhibit 20 - Health expenditure in China from 1978 to 2006
72
Vivinter, Base et taux de remboursement Sécurité Sociale 2014, (http://www.vivinter.fr/index.php?option=com_content&view=article&id=162&Itemid=320&lang=fr)
73 BULARD M., “Comment fonctionnent les systèmes de santé dans le monde ?”, Le Monde Diplomatique,
February 2010
63
Medical staff: a key pillar for healthcare provision
India and China are also facing medical staff shortage. If you do not have medical
teams to provide health services to your population, even if drugs are made available and if
infrastructure is of good-quality, patients’ health will not improve. It is important to
understand the reasons for medical personnel shortages. The shortage of human health
resources in India and China is mainly due to shortfalls in training, inequities in distribution,
low wages and incentives, and migration of health personnel to other countries. It may be
also due to the attractiveness of the private sector compared to the public sector: in 2012,
500,000 Chinese students graduated from 600 institutions in medical degrees. However,
many medical graduate students in China chose not to work in the medical sector, but to
pursue careers in the industrial sector for instance, hence a lack of medical staff, especially
visible in remote areas. Radical measures have to be taken in both countries to attract and
train a sufficient number of health workers to treat the local populations. Fanny Chabrol
(appendix 4), in an interview, explained me that in Botswana, where there was a severe
shortage of nurses, for all of them left to practice in Great-Britain where they were offered
better wages, the government decided to restrict international departures for nurses. A
nurse therefore explained her that, simply because the word “nurse” was written on her
identity document, they would never let her go.
India has already taken several measures to attract staff and to retain them, through
incentives for instance. Most federal states already offer high wages to public sector doctors,
especially those serving in particularly remote areas. Moreover, the Medical Council of India
and Government of India have decided to launch a mandatory one-year stint in rural areas
for freshly-graduated students from government medical colleges, after their internships, in
order to improve rural health services in remote areas74. Finally, a new Bachelor of Science
in Community Health has been launched recently75, in order to train mid-level health
professionals, who would form the medical staff in sub-centres or primary health centres
and would contribute to the treatment of common illnesses and to immunization and
prevention programmes. However, expansion of the medical tourism sector65 might impact
74
PRESS TRUST OF INDIA, “Compulsory 1 year rural posting for MBBS doctors from 2015-16”, The Times of
India, December 18th
, 2013
75 DHAR A. “Cabinet approves B.Sc. Community Health course in State universities”, The Hindu, November
14th
, 2013
64
health personnel availability: while it probably reverses the brain drain of developed
economies, it also worsens the internal brain drain and the distribution of medical staff
inequities: health personnel might be more willing to work in hospitals engaged in medical
tourism that offer higher wages and better working conditions rather than working in public
hospitals or in rural areas. An innovative solution was therefore recently launched in India
to face the lack of health personnel: telemedicine, which combines information and
telecommunications technologies with medical science for clinic records, diagnosis tests and
video consultations. Several government telemedicine networks have already been
established around India, in more than 600,000 remote villages, using the Indian Space
Research Organization satellite76.
Therefore, investment in health personnel in China and in India is vital to the future
health of their populations. Health personnel are indeed the driving force of any healthcare
reform and healthcare system improvement.
Measures have therefore been taken, both nationally (as we have just seen) but also
internationally, to address the lack of health personnel. The 2006 World Health Report,
published by the WHO, stressed the importance and the key role of health workers to meet
the Millennium Development Goals. Moreover, the Global Health Workforce Alliance was
created in 2006, gathering national governments, civil society, professional associations,
researchers, etc., to remedy health workers shortage77. 37% of the global health personnel
are estimated to work for Canada and the United-States, which only represent 10% of the
global burden of disease78. The United-States therefore have 25 physicians and 98 nurses
per 10,000 people. China only has 15 physicians and 15 nurses per 10,000 people, and India
has 7 physicians and 17 nurses (appendix 2), which is definitely not enough to meet the
population needs in terms of healthcare. Three forums on human resources have been
organized by the Global Health Workforce Alliance (2008, 2011, 2013). These global
measures underscore the global need and challenge of training health personnel.
Health concerns are therefore not limited to national borders, but are rather considered
more and more as global concerns.
76
TELEMEDINDIA, Home Page (http://www.telemedindia.org/index.html) 77
WHO, About the Alliance (http://www.who.int/workforcealliance/about/en/) 78
BOSELEY S., “Health workers shortage is a truly global crisis”, The Guardian, January 18th
2011
65
C – Access to health: global action for a global concern, the emergence
of global health
The problems India and China are facing regarding access to health for their populations
may actually be the problems all the developing countries are facing. Moreover, if the whole
developing world is facing the problem, it might eventually impact the developed world as
well. Outbreaks and pandemics are threatening the whole world. Ebola, which has already
killed more than 2,000 people in Liberia, Guinea and Sierra Leone, and which has spread to
Nigeria is not under control yet and new cases are reported every day. H7N9 bird flu was
first observed in China in 2013, and is threatening to mutate and to spread to neighbor
countries. Middle-East Respiratory Syndrome coronavirus, which has spread to the whole
world (cases have been reported in Middle-East, but also in Algeria, Tunisia Egypt, France,
Germany, Greece, Italy, the Netherlands, the United-Kingdom, Malaysia, Philippines and in
the United-States) needs to be further studied to understand its patterns of transmission.
“The novel coronavirus is a threat to the entire world”, declared Margaret Chan, Director
General of the WHO. These three viruses are transmitted by animals, but they also have
another point in common: they can cross boundaries79. Following these observations, a
public health movement has emerged in the recent years: the global health movement.
At the beginning of 2000s, only a few patients in developing countries had access to
antiretroviral drugs and treatments. However, because Western countries had realized that
they could be impacted by the HIV proliferation, and that the disease constituted a global
threat for public health, massive initiatives were taken from the international community to
answer the epidemic. In 2002, the French initiated the Global Fund to Fight AIDS,
Tuberculosis and Malaria. Additionally, PEPFAR was launched by President George W. Bush
in 2003, to fight AIDS in foreign countries through a USD 15 billion investment on the period
2003-2008. Indeed, the HIV/AIDS pandemic had become a major safety issue in the world.
The United-States therefore promoted global-health oriented policies.
Many pharmaceutical companies became involved in global health. As Fanny Chabrol
stresses in one of her article, at a time when big pharmaceutical companies face much
79
POIRET A., Epidémies, la menace invisible [TV], Arte France, 2014
66
criticism, some of them have decided to improve their image by proposing tangible actions
to help developing countries achieving a comprehensive national framework for drugs
supplies. Such initiatives have been largely encouraged by the international community. Kofi
Annan, General Secretary of the United-Nations, has largely supported the commitment of
private companies to fight AIDS through public-private partnerships. One of the very first
initiatives from the private sector is Bristol Myers Squibb financial contribution of USD 150
million since 1999, through its “Secure the Future” program80: this contribution aims at
improving healthcare system in fourteen Sub-Saharan African countries, especially through
supporting healthcare infrastructure projects and training of healthcare workforce 81 .
Novartis created Arogya Parivar (“Healthy Family” in Hindi) in Indian rural areas, to train
healthcare educators so that they can work as prevention-promoters among the
population82. Novartis, through its “Health Express” program, also works in Xinjiang, in
Western China, where life expectancy is still below 67 years old, to promote community and
physicians training and to develop healthcare systems resources83.
However, according to Fanny Chabrol, global cooperation on health is mainly dictated by
self-interest to foster political stability, to improve image, or even to secure markets for
potential future drugs development. The public private African Comprehensive HIV/AIDS
partnership (ACHAP) between the Government of Botswana, the Bill and Melinda Gates
Foundation and the Merck & Co pharmaceutical company, oriented towards promoting
healthcare among the Botswana’s population, was subject to the condition that Botswana
would not use generic drugs supply for instance (which could indeed harm Western
pharmaceutical industry).
Moreover, a key facet of global health is mutual health protection, on safety grounds:
pandemics, outbreaks of new viruses, cross-borders movements of infectious diseases are
threatening the whole world. But global health mostly focusses on diseases that might
impact developed countries. Sleeping sickness is definitely not handled at the international
80
SECURE THE FUTURE, Home Page (http://www.securethefuture.com/) 81
CHABROL F., “La santé globale : nouveau laboratoire de l’aide internationale ? Les antirétroviraux au Botswana”, Revue Tiers Monde, vol. 215, pp 17-34, July 2013
82 NOVARTIS, Social ventures (http://www.novartis.com/corporate-responsibility/access-to-
healthcare/our-key-initiatives/social-ventures.shtml) 83
JIMENEZ J., “La nouvelle frontière des soins de santé”, Le Cercle Les Echos, March, 2014
67
level, since there is no potential risk for developed countries populations to develop the
disease. And even regarding diseases such as tuberculosis, because the prevalence rate of
the disease has sharply decreased in developed countries, the investment on global research
has also dropped, despite the fact that many people keep dying of the disease in developing
countries. About 8.6 million people contract tuberculosis every year. According to the WHO,
among these people, 35% do not receive diagnosis and treatment. Moreover, efforts to fight
tuberculosis are becoming more and more complicated due to tuberculosis drug-resistance.
Global research and development is therefore particularly needed for the disease. However,
because it mostly impacts poor people (it has been almost totally eradicated in developed
countries), global research on tuberculosis has dropped by 22% in 2012.
On the contrary, when diseases threaten to affect major economic players, they tend to
attract global attention. China has had to face polio resurgence in 2011, when a polio
epidemic was imported from Pakistan to Xinjiang province84. Similarly, dengue and malaria
represent high risks for the Chinese population, and eight imported dengue cases were
reported in Chongqing in 201485. China itself has therefore emerged as a major global health
key player. China has sent medical staff to developing countries as soon as in 1963. This
south to south cooperation has now diversified into more varied projects: building hospitals,
drugs donations, training health personnel, and performing free cataract surgery under the
Brightness Action Campaign for instance86. China has therefore been an active participant on
the healthcare international scene. In 2002, it supported the creation of the Global Fund to
fight AIDS, Tuberculosis and Malaria, and contributed to up to USD 30 million to the fund
since then. China is also a large drug manufacturer, therefore playing a vital role in the
world, along with India, in supplying developing economies with affordable and efficient
drugs.
84
WHO, Controlling the polio outbreak in China, 2012 (http://www.wpro.who.int/immunization/documents/CHN_PolioOutbreakControl_ENG.pdf)
85 JUAN S., “Watch out for dengue, malaria, public told”, China Daily, April 4
th 2014
86 SUN, “Brightness Action Campaign brings light to Zimbabweans”, Crienglish.com, March 25
th, 2011. A
ten-day lasting campaign has enabled Chinese ophthalmologists to perform 500 free cataract operations in Zimbabwe in 2011. Indeed, Zimbabwe lack of medical equipment and of funds dedicated to healthcare, made it impossible for many Zimbabwean patients to receive the operation.
68
Therefore, health might gradually become a global concern that would be handled at the
global level. Traditional health institutions and actors, such as the WHO, now share their
scope of actions with actors such as pharmaceutical companies, the NGOs, the World Bank,
universities, etc. Numerous stakeholders, both public and private, sometimes working
together, have been involved in health care development, and now have a major influence
on global health policies. The phenomenon becomes particularly visible at times of
pandemics that could threaten both developing countries and developed countries. What is
happening now in West Africa is particularly significant: the NGO MSF seems to be working
on the frontline to cure patients from Ebola and to eradicate the pandemic. WHO, while
supporting MSF commitment, declared that Ebola should be considered as a public health
emergency of international concern and called for a coordinated international response87.
However, does financing of specific programs at the global level benefit the overall
health system? It seems that these global health programs, instead of promoting
comprehensive and balanced horizontal national health systems, tend to be vertical-
oriented: while illnesses such as HIV/AIDS have been largely discussed internationally, other
diseases have been totally left aside. By only focusing on specific-diseases, the programs
tend to unbalance national healthcare systems. The 11th International Congress on AIDS in
Asia and the Pacific (ICAAP) held in November 2013 is said to “have played a key role in
raising public awareness, building political commitment, strengthening advocacy networks,
and disseminating knowledge on HIV/AIDS issues among key affected populations and other
stakeholders in the regions”. But the ICAAP apparently “forgot” to discuss the prevalence of
tuberculosis in Asia, while tuberculosis disproportionally affects HIV-positive people88. The
Asia Pacific region accounts for more than half of the world’s burden of tuberculosis. India
and China alone gather 50% of all patients with drug-resistant tuberculosis89. Fanny Chabrol
is currently working on a project over joint diseases, such as the couple HIV/AIDS and
tuberculosis, or HIV/AIDS and viral hepatitis (appendix 4). She reports that some people with
87
WHO, WHO Statement on the Meeting of the International Helath Regulations Emergency Committee
regarding the 2014 Ebola outbreak in West Africa, August 8th
, 2014, (http://www.who.int/mediacentre/news/statements/2014/ebola-20140808/en/)
88 ISAAKIDIS P., GUPTA S., MENGHANEY L., “Zero tuberculosis at the latest International AIDS Congress in
Asia and the Pacific?”, The Lancet, vol. 2, April 2014 89
WHO. The global Plan to stop TB 2011-2015 : transforming the fight towards elimination of tuberculosis, 2011 (http://www.stoptb.org/assets/documents/global/plan/TB_GlobalPlanToStopTB2011-2015.pdf)
69
both hepatitis and HIV/AIDS in Cameroon, receive appropriate treatment for hepatitis, but
have never been tested for HIV/AIDS, even though the research centre for HIV/AIDS is just
across the door. The internationalization of health issues and monitoring should privilege a
horizontal approach towards health, by fighting health issues as a whole.
Chinese Tibetan family at their home in Rerdaba Grasslands, in Sichuan province, 2013 (Photo: Verdin D.)
70
71
Conclusion
The good quality manufacture and supply of drugs is paramount to ensure access to
health for local populations and to form a good-quality health care system. Intellectual
property rights critics may argue that patents prevent local population from accessing
affordable drugs. To make their cases, charities like Oxfam or Médecins sans Frontières
through its Access campaign, highlighted the important role that some generic companies
have played in producing low-cost medicines on developing countries markets’ to ensure
local populations a right to health. However, it is important not to forget that intellectual
property rights are meant to boost research and innovation, and that without such
incentives, granted by patents on effective drugs, such treatments would probably not have
been developed so fast, and the patients might still be waiting for them. Some alternative
forms of inventor’s rewarding might, however, be considered, that would not impede public
health imperatives.
The Indian and Chinese pharmaceutical industries have developed very fast during the
last decades thanks to comprehensive, flexible and favorable intellectual property rights
regimes. India is the third largest producer of drugs in the world in terms of volume. In the
1950s, only 20% of the drugs consumed in India were manufactured locally. Today, 80% of
the drugs consumed are manufactured in India, with significant contribution to access to
health for local populations, but also for population worldwide: Indian and Chinese generic-
drug manufacturers are able to deliver lower costs medicines and vaccines to the world,
including to international aid programs. It is often considered that India and China can
indeed produce medicines for about a tenth of the costs incurred in Europe and America.
The emergence of these pharmaceutical hubs has been a phenomenal revolution for the
health of the world population.
However, availability of affordable drugs is not the only measure needed for protecting
the population health. It is only part of the solution. Health programs and initiatives must go
beyond drugs price reduction, even if the latest is a major component of a comprehensive
healthcare system. Thus, overall access to health for everyone is another key component.
For example, trained medical staff as well as qualitative and accessible equipment and
72
facilities network are required to ensure provision of healthcare services. Dr. Margaret Chan,
Director General of the World Health Organization also stressed that universal coverage was
“the single most powerful concept that public health has to offer”90. Providing health
coverage for their local population should therefore be a priority in India and China.
Some progress has already been made, and both the Indian and the Chinese government
have understood that healthcare should be a central priority for their policies, in order to
sustain their economic growth and to take full-advantage of their local production of generic
drugs. Building a comprehensive healthcare system significantly depends on political will:
health should be recognized as an essential facet of human development and policies
towards the health care sector should be led with voluntarism. The election of Narendra
Modi as the Prime Minister of India, in May 2014, will probably incur major changes: he
indeed used to be Chief Minister of the state of Gujarat, where he implemented many
healthcare programs, aimed at improving the population health, such as the Mukhyamantri
Amrutam Yojana program: the program covers hospitalization and medical transportation
costs for the whole Gujarat population, up to INR 200,00091.
Healthcare reforms in India and China only are at their first stages, and the overall well-
being of our planet will probably highly depend on their success. China is going along the
right road, and will probably reach universal health coverage by 2020. Its health reform has
already proved very successful. The country has made huge progress in improving primary
health care and public health provision. However, China needs to address a fundamental
flaw in its healthcare provision: inequities, especially regarding migrant workers. Some cities
have already included migrant workers in their UEBHI or their URBHI or in separate
programs92, but the initiative should extend to China as a whole.
India still lags behind in terms of health coverage but is now focusing on healthcare as a
key priority. India’s 12th Five-Year Plan (2012-2017) proposed an almost doubling in public
financing of health, from 1.04% to 1.87% of the country GDP, a transformation of the NRHM
90
WHO, Ministerial meeting on universal health coverage (http://www.who.int/dg/speeches/2013/universal_health_coverage/en/)
91 NARENDRA MODI, Healthy Gujarat, Vibrant Gujarat! (http://www.narendramodi.in/swastha-gujarat-
ujjwal-gujarat-healthy-gujarat-vibrant-gujarat/) 92
MOU J., CHENG J., ZHANG D., JIANG H., LIN L., GRIFFITHS SM. “Health care utilisation amongst Shenzhen migrant workers: does being insured make a difference?” BMC Health Services Research, November 21th 2009, pp 9-214
73
into National Health Mission, that would extend to urban citizens, the provision of free
essential generic medicines, the expansion of RSBY and the creation of public health and
management cadres. However, availability of health care services and facilities is still
quantitatively too weak, especially regarding the number of doctors and nurses. The
shortfall is exacerbated by wide geographical disparities in terms of distribution. The lack of
extensive and adequately funded public infrastructure, and its poor quality, typical of
developing nations systems (appendix 11), especially in the tertiary care generates high out-
of-pocket expenditures for the population to access healthcare services in the private sector
infrastructures. This results in a very important financial burden for the patient’s families.
The key priority for India should therefore be the creation of an insurance scheme with
enough resources to provide healthcare for everyone. This fund could be financed by both
the private sector and the public sector. Moreover, the creation of a strong regulatory
framework, implying audits of both public and private facilities is paramount to eradicate
corruption in the healthcare sector: the Transparency International 2013 Corruption
Perceptions Index ranked India 94th out of 177 countries worldwide, with the health sector
being one of the most corrupt sectors. India therefore has to speed up reforms in the
healthcare sector, and to invest greater funds in healthcare to strengthen the public sector
network of facilities and to make quality medical services more accessible and affordable for
the Indian population93.
Indeed, although substantial improvements have already occurred in both countries,
(raising life expectancy in India and in China, drastic fall in infant mortality rates, reduction of
the infectious diseases burden, etc.), the health outcomes remain weak compared to other
similar countries at similar economic stages of development: the burden of preventable
diseases remain high; many healthcare inequities endanger the right to health; patients out-
of-pocket expenditures keep increasing; and government health expenditure is still low.
Money and investment injected in the healthcare system appear to be crucial. There is a
significant link between resources allocated to health and the overall performance of the
healthcare system (appendix 10). Resources allocated to health in India and China only
represent 4% of India GDP and 5% of China GDP, whereas the median proportion of the
93
PATEL V., KUMAR A.K. “Universal Health care in India: the time is right”, The Lancet, Vol. 377, February 5
th, 2011, pp 448-449
74
national GDP worldwide is 7%. Countries such as France, Sweden and even Brazil or South
Africa spend around 10% of their national GDP for health (appendix 2).
Healthy India and China are crucial to make the most of their demographic growth and to
sustain their economic prosperity.
This observation can also apply for other developing nations, where local populations
tend to lack access to healthcare services. In our survey analysis, we indeed found out that
people in developing countries underuse healthcare facilities, probably due to financial or
distance barriers (appendix 12). The acronym BRICS, invented in 2001, represent five key
emerging economies with extraordinary high growth rates: Brazil, Russia, India, China and
South Africa. The BRICS nations now account for about 40% of the world’s population and
for more than 25% of global gross domestic product: time has come for them to improve
their population lives. Their growing economic ambitions should indeed translate into
economic and human welfare.
Therefore, all BRICS nations have undertaken large reforms regarding healthcare, aiming
among other improvements at reaching universal health coverage. All of them declared, in a
communiqué issued at a BRICS health ministerial meeting, in 2013, that they were
“committed to work nationally, regionally and globally to ensure that universal health
coverage is achieved”94. They have all taken different paths to do so, but they all embarked
on improving access to health for their populations. Brazil and Russia took ambitious
measures more than twenty years ago. The United Health System (Sistema Único de Saúde)
in Brazil, launched in 1990 and financed by taxes, already embraces the whole population,
and provides free healthcare services to everyone in Brazil. In Russia, the Mandatory Medical
Insurance, launched in 1996 and funded by payroll taxes as well as general taxes, grants
Russian citizens with a right to access health services for free. China’s and India’s reforms
are quite recent compared to Brazil and Russia, and their emerging healthcare systems are
just in their starting years. The National Health Act in South Africa, aiming at building a
comprehensive healthcare system, was promulgated in 2004, but concrete measures were
94
MINISTRY OF HEALTH AND FAMAILY WELFARE, BRICS Health Ministers Delhi Communiqué, January 11th
2013 (http://pib.nic.in/newsite/erelease.aspx?relid=91533)
75
unveiled very recently. The five countries, by taking such measures, are therefore showing a
growing political will to improve populations’ health.
And although governments’ spending on health as a proportion of gross domestic
product is still low and despite the long way to go to meet populations’ expectations and
needs in terms of healthcare provision and healthcare services, the five countries will
probably succeed in key achievements in the years to come, that will significantly improve
their populations’ health and lives.
76
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84
Table of appendices
Appendix 1 – India and China maps ................................................................................................................................. 85
Appendix 2 – Indicators tables ........................................................................................................................................... 86
Appendix 3 – The World Trade Organization: overview ........................................................................................ 88
Appendix 4 – Fanny CHABROL interview (03/07/2014) ......................................................................................... 93
Appendix 5 – James ARKINSTALL interview (15/08/2014).................................................................................... 96
Appendix 6 – Survey .............................................................................................................................................................. 109
Appendix 7 – Respondents’ answers ............................................................................................................................. 114
Appendix 8 – General overview of the respondents’ answers ......................................................................... 121
Appendix 9 – Survey analysis 1 ........................................................................................................................................ 126
Appendix 10 – Survey analysis 2...................................................................................................................................... 128
Appendix 11 – Survey analysis 3...................................................................................................................................... 129
85
Appendix 1 – India and China maps
Source: Health in China and India, a cross-country comparison in a context of rapid globalization, by
Trevor Dummer and Ian Cook
86
Appendix 2 – Indicators tables
Life expectancy at birth (2012)
Diphteria (number of reported cases in 2012)
Leprosy (number of reported cases in 2012)
Malaria (number of reported cases in 2012)
India (d) 66 2 525 134 752 1 067 824
China (d) 75 0 1 210 2 718
Brazil 74 0 33 303 242 758
South Africa 62 0 15 6846
Minimum 46 0 0 0
Median 74 0 41 46 819
Maximum 84 2 525 134 752 10 338 093
WHO South-East Asia Region 67 3953 166 445 3 760 367
WHO Western Pacific Region 76 142 5 371 888 438
WHO African Region 58 0 20 599 77 079 733
WHO Region of the Americas 76 0 36 178 468 469
WHO European Region 76 32 0 0
WHO Eastern Mediterranean Region
68 334 4 235 6 997 006
Low income group 62 247 27 200 58 957 355
Lower middle income 66 3 981 167 501 28 139 207
Upper middle income 74 234 37 869 2 078 743
High income 79 28 0 0
Selected infectious diseases table. Source: World Health Statistics 2014
General government expenditure on health as % of total expenditure on health (2011)
General government expenditure on health as % of total government expenditure (2011)
Total expenditure on health as % of gross domestic product (2011)
Per capita government expenditure on health in USD (2011)
India (d) 31% 8% 4% 19
China (d) 56% 13% 5% 153
Brazil 54% 9% 9% 512
South Africa 48% 13% 9% 319
Minimum 16% 2% 2% 3
Median 62% 11% 7% 191
Maximum 100% 28% 18% 8 436
WHO South-East Asia Region 37% 9% 4% 26
WHO Western Pacific Region 65% 15% 7% 472
WHO African Region 48% 10% 6% 49
WHO Region of the Americas 50% 18% 14% 1 726
WHO European Region 74% 15% 9% 1 782
WHO Eastern Mediterranean Region
51% 7% 4% 107
Low income group 39% 9% 5% 11
Lower middle income 37% 8% 4% 31
Upper middle income 56% 12% 6% 226
High income 17% 12% 2 875
Health expenditure Table. Source: World Health Statistics 2014
87
Hospital beds per 10 000 population (2006-2012)
Physicians per 10 000 population (2006-2013)
Nursing and midwifery personnel per 10 000 population (2006-2013)
India (d) 7 7 17
China (d) 38 15 15
Brazil 23 19 76
South Africa … 8 49
Minimum 1 0 1
Median 26 13 28
Maximum 138 77 174
WHO South-East Asia Region 10 6 15
WHO Western Pacific Region 43 15 25
WHO African Region … 3 12
WHO Region of the Americas 23 21 46
WHO European Region 53 33 81
WHO Eastern Mediterranean Region
8 15 16
Low income group 21 2 5
Lower middle income 10 8 18
Upper middle income 32 16 25
High income 54 29 87
Density of health workforce and infrastructure table. Source: World Health Statistics 2014
Median availability of selected generic medicines (2001-2009) (a)
Median consumer price ratio of selected generic medicines (2001-2009) (b)
Public Private Public Private
India (d) 22% 77% … (c) 1.9
China (d) 16% 13% 1.6 1.4
Brazil 0% 77% … (C) 11.3
South Africa … 72% … 6.5
Minimum 0% 0% 0.9 1.1
Median 46% 70% 2.4 4.4
Maximum 100% 100% 6.5 28.3
Essential medicines table. Source: World Health Statistics 2014
(a) Availability is reported as the percentage of medicine outlets in which a medicine was found on the day of data
collection. As baskets of medicines differ by individual country, results are not exactly comparable across countries.
(b) Consumer price ratio = ratio of median local unit price to the Management Sciences for Health (MSH) international
reference price of selected generic medicines. A ratio of 1 therefore correspond to the international reference price. In
some low- and middle-income countries where patients have to pay for medicines in the public sector, prices of selected
lowest priced generics can be more than twice international reference prices
(c) Medicines are provided free to patients in the public sector
(d) India is part of the WHO South-East Asia region, and of the lower middle income income groupings. China is part of
the WHO Western Pacific Region and of the upper middle income income groupings.
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Appendix 3 – The World Trade Organization: overview
A brief historic
At the end of World War II, the world became interconnected and integrated, hence a trade
liberalization and economic cooperation. The Bretton Woods System instituted a multilateral
institutional framework of rules, through several organizations: the International Monetary Fund
(IMF), the International Bank of Reconstruction (IBRD), and the International Trade Organization
(ITO). However, ITO was never approved by fear that it would harm the United-States foreign trade
relations.
Protectionism, though, has often been considered as a leading cause to the Great Depression in the
United-States and had proved unsuccessful. If the United-States (steel consuming nation) restricts the
import of foreign-made steel to protect domestic steel producers, it will add to the cost of materials
for domestic automakers that use steel to produce finished products (which is commonly described
as the double-side sword of protectionism). Therefore, the General Agreement on Tariffs and Trade
(GATT) was signed in 1947, promoting free-trade. Contracting states committed to negotiate
reductions in custom tariffs and other impediments to international trade in goods and GATT 1947
progressively came to govern all of the world's trade.
The original agreement (GATT 1947) only covered trade in goods. The WTO current rules (the
agreements), are the result of negotiations between the members. Indeed, to update GATT 1947,
eight completed rounds of multinational negotiations have been held so far.
The World Trade Organization (WTO)
The WTO was founded under the GATT 1994 agreement, under the Uruguay Round (1986-1994). It is
an intergovernmental organization responsible for:
Implementing the WTO Agreement
Acting as a forum for ongoing Multilateral Trade Negotiations
Serving as a tribunal for resolving disputes
Reviewing the trade policies of WTO members.
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The WTO is overseen by the Ministerial Conference, made up of representatives from all WTO
member-countries. They meet at least once every two years. The Ministerial Conference appoints the
WTO Director-General for a four-year term. Roberto Azevedo holding the position, since September
1st 2013. Beneath the Ministerial Conference is the WTO General Council, made up of representatives
of each nation and responsible for overall supervision of the WTO’s activities. The WTO Trade Policy
Review Body periodically reviews the Trade policies and practices of member countries, to ensure
that member nations adhere to the rules and commitments of GATT.
Structure of the World Trade Organization
Decision making by the WTO is by consensus (general agreement in the absence of any voiced
objection). If a consensus is not reached, majority vote rules, with each member having one vote.
WTO Membership: GATT 1947 member-states and the European members were original members.
Any new member must negotiate entry into the WTO and be approved by 2/3 of the members.
Members can withdraw (6-month notice). In 2012, the Russian Federation entered the WTO, which
therefore has 157 members.
Trade in goods
Since 1947, GATT has been promoting lower custom duty rates and other trade barriers, under three
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main principles:
Nondiscrimination: all nations should be treated equally, and without discrimination. Nations
should not « play favorites » with each other's goods or services.
Most favored nation status: when a GATT member nation sets a favorable tariff rate on a
particular type of goods imported from one GATT member, the same tariff rate must be set
on those goods for other GATT nations. This principle bears some exceptions though (lower
importation tariffs rates for developing countries; higher tariffs rates for human rights
violating countries; use of measures to counter dumping and subsidization; lower tariffs rates
for goods traded in free-trade areas or custom unions, etc)
National Treatment Principle: once goods are legally imported, they should be treated as
domestic products. It implies that imported products may not be regulated or taxed
differently from domestic goods.
Trade in services
Trade in services can now enjoy the same principles of freer and fairer trade that originally only
applied to trade in goods. These principles appear in the new General Agreement on Trade in
Services (GATS), implemented during the Uruguay Round (1986-1994).
Intellectual property
The WTO’s intellectual property agreement (TRIPS) gathers rules for trade in ideas and creativity. The
rules state how copyrights, patents, trademarks, geographical names used to identify products,
industrial designs, etc (intellectual property) should be protected when trade is involved. The
agreement was achieved during the Uruguay round.
The first international property treaty was the International Convention for the Protection of
Industrial Property, known as the Paris convention. It guaranteed that in each signatory country,
foreign trademark and patent applications from other signatory countries receive the same
treatment and priority as those from domestic applicants. Applications could be filed on a standard
form with the World Intellectual Property Organization (WIPO). The WIPO, a United-Nations agency,
processed the common application and forwarded it to the countries designated by the applicant.
However, the Paris Convention did not harmonize patent laws and lacked an enforcement
mechanism.
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To harmonize intellectual property rights worldwide, the TRIPS was ratified in 1994, at the end of the
Uruguay Round, and took effect in most countries in 2001. Therefore, intellectual property policies
were no longer dictated by the WIPO but became part of the WTO. TRIPS agreement requires its
signatories to enact minimum standards of protection and to create a viable enforcement
mechanism. TRIPS has therefore caused developing countries to adopt intellectual property laws that
approximate those of Europe and North America. All WTO members must recognize the patent
holders’ patents protection for at least twenty years. Patent protection is also now available for any
new inventions whether products or processes, provided that they are new, involve an inventive step
and are capable of industrial application. If one nation believes that another is out of compliance, it
can initiate a dispute before a WTO panel. Finally, some flexibility were acted as provisions of the
TRIPS agreement among which:
Parallel imports: These are products marketed by the patent owner in one country and imported
into another country without the approval of the patent owner. For example, suppose company A
has a drug patented in the Republic of Belladonna and the Kingdom of Calamine, which it sells at a
lower price in Calamine. If a second company buys the drug in Calamine and imports it into
Belladonna at a price that is lower than company A’s price, that would be a parallel import. Parallel
import are allowed under the TRIPS agreement.
Compulsory licensing: Compulsory licensing is when a government allows someone else to produce
the patented product or process without the consent of the patent owner. The TRIPS agreement
allows compulsory licensing for pharmaceuticals, but only under a certain number of conditions. For
instance, the person or company applying for a compulsory license must have first attempted,
unsuccessfully, to obtain a voluntary license from the right holder on reasonable commercial terms
(a voluntary license is an authorization emanating from the patents’ holder to use his rights).
Moreover, royalties still have to be paid to the patent’s holder under compulsory license. However,
for “national emergencies”, “other circumstances of extreme urgency” or “public non-commercial
use”, there is no obligation to try for a voluntary license.
Research exception: it allows researchers to use a patented invention for research, in order to
understand the invention more fully.
However, these flexibilities were very unclear, and a large number of countries pushed for
clarification, to make sure to use them legally. The Doha Ministerial Declaration, approved in 2001
during the Doha round (2001-ongoing) made it clear that the TRIPS agreement should be
implemented and interpreted in a way that supports public health, and underscored countries ability
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to use the TRIPS flexibilities. Moreover, developing countries were given ten years from the effective
date of TRIPS to become compliant. The least-developed countries were given twenty years.
In August 2003, the TRIPS Council decided to provide additional flexibility under the TRIPS
agreement, by allowing any WTO member to export pharmaceuticals made under compulsory.
Sources: World Trade Organization (http://www.wto.org/) ; SCHAFFER R., FILIBERTO A., DHOOGE L.,
EARLE B., International Business Law and its Environment, South-Western Cengage Learning, 8th
edition, 715 p, 2012
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Appendix 4 – Fanny CHABROL interview (03/07/2014)
Interview with Fanny Chabrol, research fellow at the International and Strategic
Relationships Institute (IRIS) in Paris, specialized on global health
: il faut s’intéresser à ce que ça nous dit sur les politiques de santé Concept de santé globale
actuelles. Il s’agit d’un concept promu par les Etats-Unis, puisque la santé globale devenait un
problème de sécurité pour eux (notamment avec l’explosion du VIH/Sida). La politique de santé
globale naît donc aux Etats-Unis, avec la promotion des investissements du secteur privé dans la
recherche. Cela s’apparente à une politique du containment par l’innovation technologique.
L’exemple le plus flagrant est celui de la fondation Bill et Melinda Gates, qui est devenu un acteur
majeur des politiques de santé. La santé globale consiste donc à rassembler des acteurs de la
philanthropie et de l’humanisme autour de maladies où il y a matière à innover (VIH/Sida
notamment). Ces acteurs privés sont très actifs dans les institutions internationales : la fondation
Gates par exemple, est le premier financeur de l’OMS. Ce concept a promu un traitement vertical des
maladies, plutôt d’une véritable politique de santé horizontale. La politique de santé est donc
conditionnée par la possibilité d’innover des laboratoires pharmaceutiques sur certaines maladies.
La question de la polio est assez intéressante : cette maladie est devenue le cheval de bataille de Bill
Gates. Il est rare d’éradiquer totalement une maladie (ça arrive tous les deux siècles), et Bill Gates
souhaiterait avoir l’honneur d’éradiquer la polio, via sa fondation. Or, la maladie persiste au Nigeria,
au Pakistan et en Afghanistan. On a donc vu, ces dernières années, un acharnement de la fondation
Gates pour l’éradication de la polio, notamment au Cameroun (où elle est réapparue de par la
proximité du Nigeria) alors qu’elle avait été éradiquée. Un tel acharnement devient presque ridicule.
Il s’agit encore une fois d’une politique de santé verticale.
Avec la santé globale, on alloue des ressources disponibles à des enjeux très spécifiques, plutôt
commerciaux. La santé globale semble donc davantage répondre à des intérêts propres qu’à un
impératif de santé publique. Il serait d’ailleurs intéressant de se demander si l’Inde et la Chine
n’appliquent pas justement cette politique de santé globale, en produisant une énorme quantité de
médicaments, uniquement dans le but de satisfaire leur balance commerciale.
: il peut être intéressant de regarder de plus près les flux des médicaments Production de génériques
indiens et chinois, et éventuellement de se pencher sur les types de médicaments, de s’intéresser à
l’évolution de la production dans le temps, et à la part de la production pharmaceutique locale sur la
consommation nationale. A quels pays les médicaments produits en Inde et en Chine sont-ils
destinés ? L’Inde est un grand fournisseur de l’Afrique, avec d’importantes plateformes d’échange,
comme le Nigeria, la Tanzanie, le Kenya, l’Afrique de l’Est, etc. Il ne faut pas avoir une vision ethno
centrée des choses, souvent, la production de médicaments pour l’Afrique ne transite pas par
l’Europe, mais passe plutôt davantage des Suds vers les Suds. L’utilisation des flexibilités des ADPIC
par l’Inde et la Chine pour développer leur industrie pharmaceutique locale répondait-elle à un
besoin de développement économique, ou à une volonté de l’état de favoriser l’accès aux soins des
populations ? Dans le cas de l’Inde, il s’agirait plutôt d’une volonté d’améliorer la situation sanitaire
de la population, dans le cas de la Chine, il faudrait y regarder de plus près. Le Nigeria est aussi un
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producteur de médicaments, mais certaines réglementations monopolistiques l’ont probablement
empêché de monter en puissance.
Les profils de l’Inde ou de la Chine sont assez parlants : Un paradoxe propre aux pays émergents ?
dans les deux cas, nous sommes face à de gros succès économiques, mais le développement ne
semble pas profiter aux populations : les richesses nationales ne viennent pas réinjecter le système
de santé (c’est également le cas en Afrique du Sud). Le développement d’un pays nécessite le soutien
et le développement de secteurs spécifiques. Si ces secteurs sont majoritairement centrés autour de
l’économie, la santé sera peut-être laissée de côté.
: le brevetage des médicaments fait que l’on a des médicaments très Brevetage des médicaments
chers (environ 150 euros l’injection pour soigner l’hépatite C, à raison d’une injection par semaine,
sur parfois plus de 70 semaines …). Mais le problème n’est pas tant le brevetage en lui-même (qui est
utile pour financer la recherche, etc.), mais plutôt l’incapacité des états et de la communauté
internationale à se mobiliser et à aller vers les laboratoires pour négocier les prix ou les faire baisser
durablement. La question du brevetage ne se pose que pour les médicaments issus d’innovations
récentes. On est actuellement à un stade des politiques internationales de santé où l’accès aux soins
équivaut à l’accès aux médicaments. Pourtant, l’accès aux soins, c’est aussi des infrastructures, un
personnel médical, de la prévention et du dépistage, etc.
: de nombreuses mobilisations ont lieu en Inde, où se trouve une société civile hyper-Société civile
développée. De ce point de vue, la Chine est très différente, même si l’on voit progressivement
émerger des ONG en Chine contre l’exclusion des travailleurs migrants par exemple, pour défendre
leur accès au système de santé et au système éducatif.
: le Botswana a acquis son indépendance en 1966. L’Etat indépendant était L’exemple du Botswana
un état développementaliste. Il a ainsi développé l’économie du diamant, mais au lieu de
s’approprier les revenus générés par le secteur, a choisi d’utiliser les revenus du diamant pour
développer des politiques sectorielles, dans le logement, l’éducation, la santé, etc. Pour cette raison,
le Botswana est souvent considéré comme un modèle. De plus, grâce à ses revenus nationaux, il a
été épargné par les plans structurels du FMI des années 1980, qui imposaient de réduire
drastiquement les dépenses publiques et les budgets, à un moment où il aurait au contraire fallu les
développer : le Botswana, lui, a pu continuer d’investir dans ses politiques sectorielles, contrairement
à d’autres pays d’Afrique, soumis à l’austérité. D’autres pays, comme le Gabon ou l’Ile Maurice ont
suivi le même schéma. Les politiques publiques en matière de santé au Botswana consistent en la
quasi-gratuité des soins de santé pour les citoyens (on peut se présenter à l’hôpital avec sa carte
d’identité et n’avoir rien à régler). De plus, l’Etat indépendant a récupéré une bonne partie des
hôpitaux des missionnaires et les a développés. Il a également développé des politiques de
vaccination dans les années 1980. Le VIH/Sida, cependant, a touché le Botswana de plein fouet, et
celui-ci a été ravagé par l’épidémie. Il a alors reçu de l’aide de bailleurs de fonds pour le financement
de la lutte contre le Sida.
: le financement de la lutte Grand débat actuel : programmes verticaux versus système horizontal
contre le VIH profite-t-il à la lutte contre les autres maladies également ? Il s’agit là d’un programme
vertical, et non d’un développement horizontal du système de santé. En se focalisant sur le VIH/Sida,
on tend à en oublier le reste. C’est notamment ce qui ressort du projet de Fanny Chabrol au
Cameroun, où elle travaille sur les maladies conjointes (VIH-Sida, tuberculose, hépatites virales). En
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agissant via des programmes verticaux, on laisse à l’abandon tous les autres problèmes de santé et
toutes les autres maladies. Certaines personnes atteintes de l’hépatite C au Cameroun, et traitées
pour l’hépatite C, sont à un stade très avancé du VIH/Sida, mais n’ont pas été dépistées pour cette
maladie, alors que le centre de recherche sur le Sida se trouve juste à côté (problème d’une gestion
verticale des problématiques de santé).
: il est important de comprendre pourquoi on a une pénurie de personnel Formation des médecins
médical dans les pays en développement : s’agit-il d’une fuite des cerveaux, d’un manque de
formation ? En Inde, le personnel est attiré par les conditions avantageuses du secteur privé. Au
Botswana, et en Afrique en général, il s’agit plutôt d’un problème de fuite des cerveaux, lié au
manque de reconnaissance du statut de médecin. Aujourd’hui ont été mis en place des incitations,
pour que les médecins restent, parfois avec des politiques quelque peu autoritaires. Au Botswana par
exemple, de nombreuses infirmières partent travailler en Grande-Bretagne, où le salaire est plus
attrayant, ce qui pose un véritable problème en termes de santé publique. Le Botswana avait donc
imaginé restreindre les départs à l’étranger. De telles mesures ont effectivement été mises en place
dans certains pays d’Afrique, comme au Cameroun : lorsque Fanny Chabrol se trouvait au Cameroun,
une infirmière lui a expliqué que rien que parce qu’il y avait écrit « infirmière » sur sa carte, on ne la
laisserait jamais partir à l’étranger. Concernant la fuite du personnel médical, il en va aussi de la
responsabilité des pays européens (termes de citoyenneté) : est-ce que l’on peut accepter que du
personnel des pays du Sud vienne travailler en Europe alors qu’il y a une véritable pénurie de
travailleurs de santé là-bas et que l’urgence est grande ?
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Appendix 5 – James ARKINSTALL interview (15/08/2014)
Interview with James Arkinstall, Head of Communications of the Médecins Sans Frontières
Access Campaign
La campagne Access
Médecins Sans Frontières a reçu le Prix Nobel en 1999, ce qui lui a permis de susciter l’attention
médiatique. MSF a donc décidé, en 1999, de lancer une nouvelle campagne, la campagne d’Accès aux
Médicaments essentiels (‘Access’). La création d’Access, coïncide, à l’international, avec Seattle, ce
gros forum de l’OMC pendant lequel se sont déroulées des manifestations violentes à la marge, puis
avec le procès de Pretoria où les compagnies pharmaceutiques ont tenté d’empêcher Mandela
d’importer des génériques indiens. Etant donné le cadre de l’époque, les gens commençaient
effectivement à prendre conscience des impacts des négociations internationales sur la propriété
intellectuelle sur l’accès aux traitements. Le fait de vouloir harmoniser la propriété intellectuelle au
niveau international, sous-entendait que tout le monde devait appliquer les mêmes droits de
propriété intellectuelle, la même protection, et ce, quel que soit le niveau de développement de leur
pays. Alors qu’avant 1995, il y avait zéro brevetage des produits pharmaceutiques dans de nombreux
pays : aucun brevet en Inde par exemple. Même dans des pays comme l’Espagne, jusqu’à assez
récemment, il n’y avait pas de brevets, idem pour la Grèce.
Le point de départ de la prise de conscience et de la mobilisation internationale, c’est l’arrivée du
VIH. Le VIH était la première maladie extrêmement visible, et qui affectait à la fois une population
Sud mais aussi une population Nord (à l’inverse de la maladie du sommeil par exemple, dont
personne ne se souciait vraiment). On retrouve ces préoccupations aujourd’hui avec Ebola : Ebola, si
tout le monde en parle, si tout le monde en a peur, c’est parce que la maladie peut prendre l’avion …
et impacter les pays du Nord. C’est exactement la même chose en 1999 avec le VIH, mais de façon
bien plus importante, car il s’agit dans le cas du VIH d’une réelle crise sanitaire pour les pays du Nord,
et pas d’une simple menace potentielle. Des populations dans le Nord se sont battues pour obtenir
un traitement pour le VIH, que ce soit un traitement expérimental (on en a l’exemple dans le film
Dallas Buyer’s Club), ou, plus tard, un traitement abordable, et ont, en quelque sorte, obtenu gain de
cause. Ces populations se sont alors posé la question suivante : « C’est très bien, j’ai accès au
traitement, mais qu’en est-il des X millions de personnes atteintes de la maladie, en Afrique ou en
Asie, qui elles, n’ont pas accès au traitement ? ». A ce moment-là, on a assisté à une très forte
mobilisation sur la scène internationale, puisqu’il était impossible, pour les groupes de patients et les
ONG, qui s’étaient battues pour la disponibilité du traitement dans les pays du Nord, d’ignorer le fait
que dans d’autres pays, les traitements n’étaient pas accessibles.
L’idée du programme Access de MSF, c’est donc d’assurer un accès fiable aux médicaments pour les
populations pour que les programmes MSF sur le terrain puissent donner des soins de qualité avec
des médicaments appropriés. Cependant, la campagne ne vise pas uniquement les médicaments,
mais également des diagnostics, des vaccins, etc. C’est un problème qui perdure, car pour certaines
pathologies, les médicaments, diagnostics ou vaccins ne sont pas accessibles, soit parce qu’ils
n’existent tout simplement pas, soit parce qu’ils sont trop chers, soit parce qu’ils sont de mauvaise
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qualité. La mauvaise qualité ne veut pas nécessairement dire qu’ils sont d’une qualité déplorable,
mais peut également vouloir dire qu’ils ne sont seulement pas adaptés à la population, par exemple
parce qu’il s’agit d’un médicament qui n’agit pas sur la bonne souche de la maladie qui touche une
région donnée.
Prenons ces cas d’inaccessibilité des traitements un à un. Premièrement, certains médicaments
n’existent pas. Il n’existe par exemple aucun traitement pour soigner certaines maladies négligées
comme la maladie du sommeil. Pourquoi ? Parce qu’il n’y a pas de marché. Les laboratoires ne vont
pas investir dans une maladie tropicale, à perte. Pourquoi ? Parce que ce ne sont pas des ONG, et
qu’ils sont à but lucratif. De plus, on ne peut pas non plus compter sur le secteur public pour produire
ces médicaments, puisque celui-ci manque de financements : la priorité de la recherche dans les pays
développés, ce n’est pas de trouver un vaccin contre une maladie négligée … Même dans les
universités, les financements pérennes ne sont pas dirigés vers les Suds et vers les maladies qui
touchent peu de personnes. Les médicaments peuvent aussi ne pas exister en raison de la prise de
risque que représente leur développement. Lorsque la recherche n’est pas du tout avancée, il y a
d’autant plus de risques – cercle vicieux.
Deuxièmement, certains médicaments sont inadaptés. Nous avons déjà parlé des différentes
souches. Il se peut également que le médicament soit simplement trop compliqué à utiliser. Il y a des
diagnostics pour certaines maladies par exemple, qui nécessitent une ponction lombaire. Vous vous
imaginez, vous, faire une ponction lombaire en République Démocratique du Congo ? D’autres
traitements nécessitent la mise en place de nombreuses intraveineuses, c’est pareil, le traitement
existe, il n’est pas impossible, mais la prise en charge est au-delà des compétences et des capacités
locales dans un pays comme la Guinée. Forcément, avec ce type de diagnostics, aucune mise à
l’échelle n’est possible. Inadapté, ça peut aussi se voir dans le prix d’un médicament ou d’un
diagnostic, dans le sens où le processus de production est intrinsèquement coûteux, et donc même
l’arrivée de génériques ou de la compétition ne parviendra jamais à baisser les prix suffisamment : le
nombre de patients qui pourrait en bénéficier resterait forcément limité. Un produit inadapté peut
aussi être un produit conçu pour être conservé au frigidaire, ce qui rend son utilisation difficile dans
les pays les plus pauvres. Pour résumer, ces médicaments inadaptés, souvent, sont des produits qui
ont été développés pour un marché au Nord : en France, par exemple, pour amortir le coût de ces
diagnostics, nous avons la Sécurité Sociale et la Carte Vitale, donc un coût de production
intrinsèquement élevé, ce n’est pas une barrière. Pour une ponction lombaire, nous avons des
médecins éduqués, et s’il faut consulter six fois de suite, ce n’est a priori pas un problème majeur. De
même, si l’on doit être hospitalisé pendant une vingtaine de jours, ce n’est a priori pas un drame.
Pour des pathologies qui sont à cheval entre le Nord et le Sud, on a donc sur le marché des produits
qui sont précisément adaptés aux besoins du Nord et pas aux patients du Sud. Et l’industrie
pharmaceutique ne se démènera probablement pas pour créer des produits adaptés aux besoins du
Sud : elle appartient au secteur privé, et ce qui l’intéresse, c’est d’obtenir une marge, pas
nécessairement que son produit soit le plus facilement utilisable dans les pays pauvres.
Troisièmement, un produit peut être inaccessible parce qu’il est trop cher (les antirétroviraux par
exemple) : c’est là où la question des brevets intervient.
A partir du constat de ces problèmes qui empêchait MSF d’assurer des soins de qualité dans les
terrains, l’ONG a donc choisi en 1999 de créer une structure multidisciplinaire, réunissant à la fois
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des médecins, des spécialistes en laboratoires, des spécialistes en vaccins, des juristes (pour tout ce
qui concerne les questions de propriété intellectuelle), des économistes de la santé, ainsi que des
équipes de communication et des équipes de lobbying. Pathologie par pathologie, en fonction de la
barrière identifiée, Access fait du lobbying : la barrière identifiée peut être que le gouvernement ne
fait pas assez pour donner à sa population le meilleur traitement possible, que la compagnie
pharmaceutique a une politique de licence jugée trop restrictive et qui empêche l’accès aux
médicaments d’un grand nombre de patients, que le savoir d’une université, ayant breveté une
découverte grâce à du financement public soit pourtant bloqué quelque part dans un laboratoire
privé et ne soit donc pas utilisable par d’autres chercheurs, que le gouvernement d’un pays n’ait
aucun cadre règlementaire précis concernant la propriété intellectuelle et ses flexibilités, et attribue
donc des brevets à des entreprises trop facilement, etc.
La campagne Access s’est donc assez naturellement focalisée sur les produits, plutôt que systèmes de
santé au sens large. MSF se considère davantage comme un acteur humanitaire et non pas comme
un acteur de développement, les systèmes de santé ne sont donc pas une priorité partagée par tout
le mouvement MSF. Il existe toutefois une unité qui s’occupe de l’accès aux soins de manière plus
générale chez MSF. Il s’agit de l’Analysis and Advocacy Unit.
En ce qui concerne l’industrie du médicament dans les pays en développement : le lobbying, auprès
de gouvernements qui ont des lois de propriété intellectuelle un peu trop « laxistes » (accordent des
brevets trop facilement), consiste en grande partie à leur faire utiliser les flexibilités offertes par les
ADPIC (TRIPS en anglais). La plupart des pays dotés d’une industrie pharmaceutique sont membres
de l’OMC (l’Iran étant une exception). Nous avons vu que l’ADPIC propose d’harmoniser la protection
de la propriété intellectuelle dans les pays membres de l’OMC, d’instaurer des standards minimaux
pour le brevetage des médicaments. Or, au sein des ADPIC, suite au forum de Seattle, à l’épidémie de
VIH, à la déclaration de Doha, etc, il existe en effet de nombreuses flexibilités. La Déclaration de
Doha a clairement énoncé le principe selon lequel les impératifs de santé publique devaient prévaloir
sur les intérêts commerciaux : s’il y a concurrence entre les deux, c’est le droit à la santé qui prévaut.
Le lobbying auprès des gouvernements consiste donc à rappeler aux pays toute la gamme de
possibilités contenue dans les ADPIC : des flexibilités, autorisées par la régulation, comme les
exceptions pour la recherche, les licences obligatoires, les importations parallèles, etc. Il s’agit donc
de montrer aux pays qu’avec un petit peu de volonté politique pour la mise en œuvre de ces
flexibilités, et la création d’un cadre juridique qui leur était favorable, il est possible d’agir pour
améliorer la santé de leurs populations.
Un exemple : dans chaque pays, il y a un organe gouvernemental chargé de la mise sur le marché des
médicaments (une sorte d’instance des médicaments, la Commission d’Autorisation de Mise sur le
Marché des Médicaments en France par exemple), et une autorité chargée des brevets (L’Institut
National de la Propriété Intellectuelle (INPI) en France, l’Office Européen des Brevets (OEB) en
Europe, Department of Industrial Policy and Promotion (DIPP) en Inde, State Intellectual Property
Office (SIPO) en Chine, etc.). Dans certains pays, l’instance des médicaments est totalement soumise
à l’aval de l’autorité des brevets, ce qui revient, en quelque sorte, pour l’instance gouvernementale
des médicaments, à faire la police des brevets : « Vous ne pouvez pas autoriser une mise sur le
marché de ce médicament, parce qu’il est brevetable ou breveté. » Rééquilibrer les pouvoirs de
chacune de ces deux institutions est un exemple de politiques que les gouvernements pourraient
mettre en place. Ils pourraient même aller encore plus loin, en inversant la balance des pouvoirs, et
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en donnant une plus grande importance à l’instance des médicaments (en la finançant massivement
par exemple) pour faire en sorte que celle-ci puisse influencer l’office des brevets : « Ce médicament
m’intéresse, mais coûtera une fortune s’il est breveté ; n’accordez donc pas de brevet à ce
médicament : une version générique permettrait en effet de faire baisser les coûts de la Sécurité
Sociale de X milliards ». Il existe donc des moyens légaux d’inverser la donne : il suffit d’instaurer un
cadre juridique national sécurisé, qui permettrait d’agir en toute légalité, et de se protéger contre les
procès.
La campagne Access a choisi de focaliser ses actions de lobbying sur les pays ayant développé une
industrie pharmaceutique locale (ce qui facilite grandement les choses), comme la Thaïlande, l’Inde,
l’Afrique du Sud, ou le Brésil. La Chine possède également une industrie pharmaceutique locale, mais
il est très difficile d’agir là-bas. Ces différents pays ont des politiques et approches industrielles très
différenciées, et il peut donc être intéressant pour nous de les parcourir un à un.
La Thaïlande
En Thaïlande, la société civile est extrêmement présente et prononcée, et le cadre légal national
garantit l’accès à la santé. Il est donc relativement aisé pour faire du lobbying ‘access’ dans ce pays.
Les Thaïlandais – alors sous junte militaire - ont été les premiers à utiliser les licences obligatoires, et
ce, de façon massive, d’abord pour deux antirétroviraux en 2006 et 2007, puis pour un anticoagulant
en 2007, et enfin, pour trois anti-cancéreux en 2008. La Thaïlande a, de plus, une capacité de
développement des médicaments qui lui est propre, puisqu’elle possède un laboratoire
pharmaceutique national, le Government Pharmaceutical Office, ce qui lui facilite énormément les
choses : la seule chose que le pays a à faire pour produire des génériques de médicaments brevetés
est de déposer une licence obligatoire. Tandis que dans des pays où il n’existe aucune capacité de
production locale de médicaments, le gouvernement doit d’abord trouver un pays capable de
fabriquer des génériques et ayant l’autorisation de les exporter, c’est autrement plus difficile.
Les licences obligatoires ont provoqué une vive réaction. Abbott, qui détenait l’un des brevets des
antirétroviraux concernés, a répondu en suspendant tous les enregistrements de ses nouveaux
médicaments en Thaïlande. Ce qui équivalait à priver la population thaïlandaise du progrès médical.
La licence obligatoire portait sur un antirétroviral qui devait être mis au réfrigérateur pour être
conservé. Une nouvelle version du médicament, développée par Abbott, permettait de conserver le
produit en dehors du réfrigérateur. Abbott a donc refusé de mettre ce nouveau médicament sur le
marché thaïlandais. MSF a réagi, en lançant une importante campagne anti-Abbott, donc le message
était en quelques mots : « Vous êtes en train de condamner les populations à utiliser un sous-
produit, qui n’est absolument pas adapté, et qu’elles ne peuvent donc utiliser ». On utilisait, pour
sensibiliser les gens, des photos de médecins MSF, sortant les capsules molles d’une boîte, où toutes
étaient collées entre elles. Il était très facile de faire passer le message suivant : « Merci Abbott de
rendre la situation impossible ». Finalement, Abbott s’est donc rétracté.
Les Thaïlandais ont aussi reçu des menaces de la Commission Européenne, via Peter Mandelson, le
Britannique, qui à l’époque était Commissaire Européen au Commerce Extérieur. De plus, les
Américains ont inscrit la Thaïlande sur la liste 301 (The Special 301 Report). Il s’agit d’une liste, éditée
annuellement par le Trade Representative américain, sur laquelle sont répertoriés les pays qui, selon
les autorités américaines, érigent des barrières commerciales qui menacent les intérêts des Etats-
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Unis. Faire partie de cette liste induit nécessairement de sévères conséquences, avec des menaces
commerciales assez violentes.
Les Thaïlandais ont publié un livre blanc sur toute cette expérience des licences obligatoires (le
Thailand White Paper), afin de justifier leur point de vue. Il s’agit d’un superbe outil de propagande,
dans lequel ils répertorient notamment les lettres de menaces qu’ils ont reçues. Les Thaïlandais ont
donc, en quelque sorte, ouvert la voie pour l’utilisation des licences obligatoires. Par la suite, de
nombreux pays de la même zone géographique ont ainsi eu recours aux licences obligatoires, comme
l’Indonésie, qui a utilisé sept licences obligatoires pour des médicaments pour le VIH et l’hépatite B
en 2013.
Ce qui était assez spectaculaire avec le cas de la Thaïlande, c’est qu’ils les utilisent à la fois pour les
antirétroviraux et pour les anti-cancéreux : malgré la réaction d’Abbott, de l’Europe et des Etats-Unis,
il y a néanmoins une sorte de tolérance internationale pour les antirétroviraux (le VIH/Sida constitue
une véritable pandémie aux yeux du monde), de la même manière qu’il y aurait une tolérance pour
les licences obligatoires sur des médicaments permettant de soigner Ebola, si ces médicaments
existaient et si le Liberia, par exemple, décidait d’en émettre. Les anti-cancéreux, en revanche,
aujourd’hui, ne sont pas considérés comme des médicaments permettant de faire face à une urgence
nationale par la communauté internationale. Donc l’Indonésie, ou la Malaisie, ont elles aussi émis
des licences obligatoires, mais ce n’était pas aussi sensible que dans l’exemple de la Thaïlande, sans
doute parce que les médicaments concernés, n’étaient pas aussi sensibles que les médicaments de
l’exemple thaïlandais (anti-cancéreux, anticoagulants, etc).
Le Brésil
Le Brésil a une politique totalement différente, pour le meilleur comme pour le pire. Pour le meilleur,
parce qu’ils traitent le problème en amont, avec des politiques de brevetage assez restrictives (où les
demandes de brevets par exemple passent d’abord par le Ministère de la Santé qui juge en amont de
l’utilité d’un médicament sur le plan thérapeutique avant d’en considérer la brevetabilité). De plus, le
Brésil possède une énorme masse critique : lorsque le Brésil prend une décision en matière
commerciale ou en termes de prix des médicaments, cela a une valeur de ‘benchmark’ pour le reste
du sous-continent américain, voire au-delà. Avec une importante population sous antirétroviraux, le
Brésil présente une demande suffisamment intéressante pour que les laboratoires pharmaceutiques
y prêtent attention. Pour le pire en raison de l’influence d’une politique industrielle : le curseur est
placé sur la politique industrielle plutôt que sur les impératifs de santé publique. En d’autres termes,
le Brésil tente de réconcilier le développement de sa capacité de production pharmaceutique locale à
moyen terme avec les objectifs visant à améliorer la santé de sa population.
Le Brésil a bénéficié du précédent thaïlandais : à tout instant, il peut brandir, auprès des laboratoires
pharmaceutiques, la menace du « regardez, moi aussi je peux utiliser des licences obligatoires,
comme en Thaïlande ». Il s’agit surtout d’une menace de dissuasion : le Brésil n’a finalement jamais
émis de licences obligatoires, mais les a massivement utilisées en tant que menaces, afin d’obtenir
des prix satisfaisants sur des médicaments brevetés lors des négociations avec les compagnies
pharmaceutiques. Cela débouche toujours sur un accord avec les laboratoires, soit uniquement sur
les prix (ce médicament coûtera X au Brésil pendant 20 ans), soit sur les prix et le transfert de
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technologies (cela coûtera un peu plus que X pendant 15 ans, mais au bout de 15 ans, nous
opérerons un transfert de technologie, et le Brésil produira lui-même le médicament).
Cette politique industrielle est vulnérable en ce qu’elle est variable d’un gouvernement à l’autre. Elle
dépend fortement de l’appétit ou de l’agressivité du gouvernement. Cet appétit et cette agressivité
ont énormément diminué depuis la fin du gouvernement Lula, avec une réorientation des stratégies.
Elle a aussi pour méfait que le Brésil se retrouve parfois à payer beaucoup plus cher pour un
médicament que n’importe quel autre pays (alors qu’il était en position de force), seulement parce
qu’il cherche à développer son industrie locale : s’il priorisait le développement de l’industrie locale
dans une moindre mesure, sans doute aurait-il pu importer un générique, certes produit à l’étranger,
mais bien moins cher, et accessible immédiatement.
Autre élément dans l’arsenal du pays, la diplomatie brésilienne est très importante. Le Brésil joue un
rôle stratégique à l’Organisation Mondiale de la Santé (OMS), et semble ne craindre personne et ne
pas plier sous les menaces américaines, ce qui est très intéressant. C’est également de cas de l’Inde
ou de l’Afrique du Sud, à l’opposé de la Chine d’ailleurs. Les Chinois ne parlent pratiquement pas du
tout à l’OMS …
L’Afrique du Sud
Les Sud-Africains sont en retard concernant l’utilisation des flexibilités, ce qui est assez étrange, étant
donné qu’ils étaient à l’épicentre des questions d’accès aux médicaments, avec notamment le procès
de Pretoria de 2001 ! MSF a d’ailleurs joué un rôle très important durant le procès, en Afrique du
Sud, important de façon illégale des médicaments dans les valises, etc. Ils ont d’ailleurs fini par
rendre publiques leurs actions : « nous agissons illégalement, arrêtez nous, venez nous faire un
procès ! ». Ce qui donne une possibilité d’action à MSF, c’est cette puissante image de marque, à
laquelle les laboratoires pharmaceutiques hésitent tout de même à s’attaquer.
Le dénouement du procès de Pretoria a conforté les Sud-Africains dans leur capacité à importer des
génériques. Pourtant, ils ne s’en sont pas massivement servis. Ils ont été grandement impactés par
le VIH/Sida, mais l’environnement politique n’était pas très propice à faire changer les choses
pendant longtemps. Les choses commencent tout juste, depuis très récemment, à bouger.
Un problème fondamental avec l’Afrique du Sud, c’est leur système de brevetage des médicaments
très laxiste. Il n’y a aucun examen des brevets, aucune opposition possible au brevet, que ce soit
avant la demande ou après. Dans certains pays, comme en Inde, il existe un système procédurier où
l’office des brevets examine la validité des brevets et peut même inviter des experts à donner leur
analyse : « vous avez un délai de 6 semaines pour me dire que ce brevet n’est pas mérité, et je
tiendrai compte de vos arguments ; passé ce délai, je rendrai ma décision, sur le brevetage ou non
dudit médicament ». On peut donc lancer une pre-grant opposition, faire une opposition à une
demande de brevet avant son examen. Les post-grant oppositions, sont souvent beaucoup plus
compliquées : il s’agit de démontrer qu’un brevet en place n’est en réalité pas valable. Seulement, le
brevet a déjà été accordé, et toute une machinerie commerciale (marketing, etc) est déjà en place :
certains groupes de patients s’opposent aux post-grant oppositions parce qu’ils ont déjà été cooptés
pour obtenir le médicament gratuitement, etc. Ce qui est intéressant, c’est de savoir qui peut faire
une opposition. Ce peut-être un compétiteur, une ONG, un patient. En Inde par exemple, tout le
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monde peut s’opposer avant l’examen d’un brevet. Ceci dit, il faut avoir certaines connaissances en
procédés chimiques et en systèmes légaux, ce qui n’est pas à la portée de tous. A cet égard en 2012,
MSF a lancé la Patent Opposition Database (http://patentoppositions.org/), afin d’aider les groupes
de patients et autres acteurs à se concerter, à proposer des arguments, et à s’opposer à l’octroi de
certains brevets (pre-grant opposition et post-grant opposition). L’Afrique du Sud par exemple, en
consultant cette base de données, pourrait comprendre grâce à quels arguments la Thaïlande a
réussi à s’affranchir des brevets de certains médicaments. Il s’agit bel et bien de mettre en commun
les politiques utilisées par les pays pour contrer les brevets au moyen de pre-grant oppositions,
comme de post-grant oppositions.
Certains pays ont donc un système légal qui permet aussi bien les pre-grant opositions que les post-
grant oppositions, d’autres n’ont ni l’un ni l’autre, comme l’Afrique du Sud. C’est d’ailleurs
particulièrement d’actualité, puisque les Sud-Africains sont en ce moment même en train de
réformer leur politique de brevetage. Treatment Action Campaign (TAC), l’un des groupes phares du
procès de Pretoria, est en train de mener une large campagne (Fix The Patent Law, en coopération
avec la campagne Access), afin que le gouvernement sud-africain introduise dans sa réforme de lois
des brevets des clauses pour les pre et post-grant oppositions, pour les licences obligatoires, pour les
importations parallèles etc. En d’autres termes, TAC incite l’Afrique du Sud à se doter de l’arsenal
juridique à sa disposition, qui permettrait une forte baisse du prix des médicaments. En effet,
aujourd’hui, l’Afrique du Sud, malgré son faible niveau de développement, et un gros fardeau de
maladies comme la tuberculose, le VIH/Sida, etc, paye souvent ses médicaments plus chers que le
Brésil, ce qui est relativement choquant. Une étude de l’Université de Pretoria a montré que 80% des
brevets octroyés par le bureau des brevets en Afrique du Sud ne l’auraient jamais été s’il y avait un
examen plus rigoureux des demandes de brevets.
De plus, l’Afrique du Sud possède une industrie pharmaceutique locale, mais qui est plutôt cooptée :
il s’agit de génériqueurs, mais en partenariat très étroit avec les laboratoires pharmaceutiques
occidentaux. Les Sud-Africains ont une capacité locale de production, mais leur ambition n’est pas de
faire baisser les prix des médicaments et de construire un marché avec des marges plus faibles, mais
de produire en collaboration étroite avec les grands laboratoires.
L’Inde
L’Inde est membre de l’OMC depuis 1995. Elle a toutefois bénéficié d’une période de transition,
jusqu’en 2005 pour adapter sa législation aux ADPIC, et a attendu la dernière minute pour adapter sa
réglementation nationale. Il y a donc eu, fin 2005, une intense campagne d’Access auprès des
parlementaires indiens. En 2005, lorsque l’Inde est contrainte d’adapter sa législation nationale à la
législation internationale (ADPIC), on craint que le monde en développement ne voie sa source de
médicaments abordables se tarir. La menace qui pèse du fait du changement de législation indienne
à l’époque, c’est effectivement que les médicaments pré-2005 soient accessibles, mais que les
médicaments post-2005 ne soient jamais accessibles pour les pays en développement, puisque l’Inde
ne pourra désormais plus refuser de breveter des produits. La capacité d’action de l’industrie
pharmaceutique indienne semble en péril avec le changement de lois : cette industrie avait
effectivement permis, en 2003, de passer de 12 000 dollars à 365 par an, pour le coût des
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trithérapies. La question fondamentale qui se posait était de savoir si l’on pourrait faire pareil avec
les nouveaux médicaments, une fois l’Inde membre à part entière des ADPIC.
Au final, la nouvelle réglementation nationale s’est avérée très flexible et favorable à l’accès aux
médicaments pour les populations, avec l’introduction, notamment, de la section 3(d), très
restrictive sur la brevetabilité des médicaments : un médicament ne peut être breveté que s’il
apporte une efficacité thérapeutique avérée supplémentaire. En conséquence, énormément de
produits ne sont pas brevetables : en Europe pour schématiser, si l’on découvre qu’un médicament,
connu pour traiter le cancer, peut aussi traiter le diabète, il est possible de breveter cette
‘découverte’. De même, lorsqu’un médicament est sous forme de poudre, et qu’on le produit
désormais sous forme de sel, il est possible de le breveter à nouveau en Europe. Ces possibilités et
toutes les innovations incrémentales, ne sont pas admises, sous la réglementation nationale des
brevets en Inde. De plus, le Indian Patent Act a légalisé les pre-grant et post-grant oppositions. La
résultante de cette loi, c’est que l’Inde a pu continuer à jouer son rôle de ‘pharmacie du monde en
développement’. Elle fournit 80% à 90% des antirétroviraux achetés par les programmes d’aide au
développement (Fonds mondial, MSF, etc).
Cette législation des brevets a conduit au procès de Novartis. Novartis avait enregistré, sur le marché
indien, une première version du Glivec, un anti-cancéreux, dans les années 1990. Une deuxième
version du Glivec avait été mise sur le marché après 1995, mais avant le changement de
réglementation de 2005. Brevetable ou pas brevetable ? Une clause rétroactive, dans la nouvelle
réglementation, impliquait que tous les médicaments entrés sur le marché après 1995 soient
réexaminés, en vue de leur octroyer d’éventuels brevets, au cas par cas (la ‘mailbox’). Il s’agissait
d’examiner les médicaments pour savoir si leur brevetage avait validité rétroactive ou non. Novartis
a donc fait une demande de brevet rétroactif pour sa deuxième version du Glivec. Cependant, lors du
nouvel examen de la demande de brevetage, le bureau des brevets indiens déclare que la seconde
version du Glivec n’est pas brevetable, en raison de la section 3(d) de la réglementation indienne,
puisque trop similaire à la première version.
Novartis reproche alors à l’Inde sa section 3(d), que la compagnie pharmaceutique juge
anticonstitutionnelle, et intente un premier recours juridictionnel devant la Haute Cour de Madras.
En 2007, la Haute Cour statue que la section 3(d) de la réglementation indienne est bien
constitutionnelle. En 2009, la justice rejette également l’appel de Novartis. A la suite de ce premier
procès, Novartis lance une nouvelle procédure, devant la Cour Suprême de l’Inde, afin de prouver
que la section 3(d), bien que constitutionnelle, ne s’applique pas dans le cas du Glivec, que
l’interprétation qu’en fait le bureau des brevets indiens n’est pas correcte (notamment son
interprétation du concept d’efficacité thérapeutique supplémentaire). Seulement, en 2013, la Cour
Suprême indienne statue que l’interprétation faite par le bureau des brevets indien du concept
d’efficacité thérapeutique était correcte. Cette décision de justice est très importante, puisqu’elle
constitue un précédent sur le procédé d’evergreening, utilisé à outrance par les compagnies
pharmaceutiques pour prolonger la durée de leurs brevets, en apportant des modifications mineures
à des produits déjà existants.
Mais que faire pour garantir un accès abordable aux nouveaux médicaments qui arrivent sur le
marché et dont l’efficacité thérapeutique supplémentaire est avérée ? Certaines flexibilités de la loi
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indienne comme les pre-grant ou post grant oppositions peuvent permettre de ne pas octroyer de
brevets (parce que quelqu’un a déjà soumis un brevet tout à fait similaire sur une molécule similaire,
parce qu’il s’agit d’une innovation évidente que n’importe qui d’autre aurait pu trouver, etc.). En
appliquant à la lettre la loi des brevets indienne, certains médicaments révolutionnaires sur le plan
thérapeutique peuvent donc ne pas être brevetés en Inde, ce qui est parfois difficile à comprendre,
mais il s’agit là de la règle du jeu … La nouvelle bataille qui va se jouer ces prochaines années
concernera sans doute le brevetage du Sovaldi (sofosbuvir), le nouveau médicament pour contrer
l’hépatite C. Effectivement, techniquement parlant, ce nouveau médicament, pourtant
révolutionnaire, pourrait ne pas être brevetable en Inde. En effet, une molécule extrêmement
similaire avait déjà été déposée sur le marché indien auparavant, et il n’était pas très difficile de
transformer cette ancienne molécule en cette nouvelle. Gilead, qui a développé ce nouveau
médicament contre l’hépatite C, aura peut-être à se livrer à une véritable bataille judiciaire dans les
années à venir.
Si l’opposition au brevetage échoue, restent les licences obligatoires, qui sont aujourd’hui la seule
solution possible. Lorsque l’on arrive au stade, ou, malgré les flexibilités qu’offre le Indian Patent Act,
le brevet d’un médicament est approuvé, mais que celui-ci reste inaccessible, on essaie d’abord de
faire pression sur la compagnie pharmaceutique, afin d’obtenir des licences - des termes d’accès au
brevet ou au produit - qui soient les plus favorables possibles. Il existe alors deux types de licences :
la licence volontaire (s’il y a accord avec la compagnie pharmaceutique, pour une production de
versions génériques en échange de royalties), ou la licence obligatoire comme on a vu avec la
Thaïlande (sans accord de la compagnie pharmaceutique). Aujourd’hui, les licences volontaires
mènent souvent à des situations où l’accès aux médicaments des populations n’est que faiblement
amélioré car l’industrie détient le pouvoir – c’est une sorte de compétition arrangée. (Quelqu’un de
l’industrie pharmaceutique vous dirait bien sûr le contraire puisque les compagnies pharmaceutiques
ont parfois accepté de considérablement réduire leurs marges. Cependant, même lorsque la
compagnie pharmaceutique réduit sa marge de 96% par rapport à la marge du produit sur le marché
américain, un produit qui se vend 85 000 dollars par exemple, le médicament reste toujours trop
cher. Chez Access, ce n’est pas l’amplitude de la réduction consentie par un laboratoire qui devrait
déterminer le prix, mais le coût de production.)
Les pays en développement présentent de gros potentiels de marché pour les compagnies
pharmaceutiques. Le marché pharmaceutique est en effet saturé en Europe, et les systèmes de santé
sont endettés : on ne nous fera pas consommer davantage de médicaments. Il en va de même pour
les marchés pharmaceutiques américains et japonais. La croissance de la demande se fait désormais
de plus en plus dans les pays en développement, où l’on voit émerger une classe moyenne, où le
pouvoir d’achat ne cesse d’augmenter, où des maladies qui étaient réservées aux marchés du Nord
font désormais leur apparition (diabète, maladies cardio-vasculaires, tabagisme, etc). Des pays
comme le Mexique font face à de graves problèmes de santé publique, avec une très forte
augmentation de l’obésité. Les marchés des pays en développement vont devenir de plus en plus
intéressants pour l’industrie pharmaceutique.
Comment les laboratoires vont-ils réagir à ces nouveaux marchés ? S’ils accordent des licences
volontaires, ce sera dans le but de préserver leurs parts de marché sur ces marchés émergents.
105
L’industrie pharmaceutique accorde donc seulement des licences volontaires qui préservent cet
intérêt.
L’autre alternative, ce sont les licences obligatoires, dont la menace plane sur les compagnies
pharmaceutiques depuis le précédent de la Thaïlande. Les licences obligatoires sur les anciens
antirétroviraux sont aujourd’hui plus facilement acceptées, mais le défi à venir consiste à faire
accepter des licences obligatoires sur des médicaments comme les anticancéreux, ou les
médicaments cardio-vasculaires. La première licence obligatoire indienne portait sur le médicament
Nexavar, un anti-cancéreux. Elle est révélatrice de ce shift, des antirétroviraux, vers les anti-
cancéreux. De plus, cette licence obligatoire est révélatrice du fait que des dispositions, même
légales, sont régulièrement attaquées en justice, et donc révélatrice de la pression que les pays en
développement subissent : Bayer, qui a initialement développé le Nexavar a intenté un procès, qui
est en cours de décision. Le bémol de cette licence obligatoire sur le Nexavar, c’est que la licence
obligatoire a été accordée uniquement pour la production locale : l’exportation est spécifiquement
exclue. Natco (la compagnie pharmaceutique locale autorisée à produire une version générique du
Nexavar) ne pourrait donc pas inonder le marché international, et notamment le marché africain de
cette version générique du médicament. (Vu le médicament en question, ce ne serait de toute façon
pas un objectif prioritaire, car le Nexavar ne permet de rallonger la vie de quelqu’un que de quelques
mois seulement, ce n’est donc pas un médicament révolutionnaire dont le monde en développement
a urgemment besoin ; mais il s’agit d’un cas d’école pour de futures licences obligatoires sur les anti-
cancéreux, et à ce titre, on peut donc regretter cette restriction à l’exportation). La question n’est
donc pas vraiment résolue, mais il s’agit tout de même déjà d’une véritable avancée.
En décembre dernier, le PDG de Bayer a d’ailleurs fait une annonce qui a eu l’effet d’une bombe : il a
déclaré ouvertement, à Londres, qu’il fallait tout de même comprendre la position de Bayer, qui
n’avait pas non plus développé Nexavar pour les Indiens qui ne pouvaient pas le payer : « Nous avons
développé ce produit pour les patients occidentaux qui peuvent se le permettre, en toute
honnêteté ». Bloomberg l’a cité, puis, MSF a largement utilisé la citation sur les réseaux sociaux pour
faire réagir. Bayer a donc été obligé de s’expliquer. Cela illustre bien la différence de perspective
entre MSF et les laboratoires pharmaceutiques … Certains laboratoires, comme Bayer, se moquent
typiquement de l’image qu’ils renvoient. Au contraire, d’autres laboratoires cherchent davantage à
préserver leur image et leur réputation, comme GlaxoSmithKline, Gilead, etc. Les stratégies de ces
laboratoires-là sont beaucoup plus intelligentes, et donc plus difficiles à combattre : ils accordent
régulièrement des licences volontaires par exemple, afin de se préserver d’éventuelles attaques des
ONG et des gouvernements, tout en contrôlant le marché.
La Chine
La Chine, c’est très compliqué. Lancer une campagne de sensibilisation publique en Chine par
exemple, est totalement impossible. Lorsque l’on critique les politiques indiennes ouvertement, sur
un plateau télévisé ou dans un communiqué de presse, le gouvernement est mécontent, mais cela en
reste là. Si l’on critique les politiques chinoises, en revanche, on risque l’expulsion. Le relationnel
avec le gouvernement chinois est très sensible. Il est très difficile également de rencontrer les bons
interlocuteurs en Chine.
106
La politique chinoise ne cherche pas à émuler la volonté de l’Inde de se placer sur un créneau de
compétition à bas prix, alors qu’elle pourrait très bien le faire, comme elle l’a fait avec les I-Pods ! La
Chine tend plutôt à vouloir attirer les investissements étrangers en recherche et à se focaliser
uniquement sur certains segments des produits pharmaceutiques qui lui sont favorables : les Chinois
sont par exemple très importants sur le marché des vaccins ou dans la production des API (active
pharmaceutical ingredients). Il est difficile de connaître leur angle d’attaque.
Mais ce qui est très clair, c’est qu’ils ont très peu de pression interne pour favoriser l’accès aux soins
des populations locales. Les choses commencent aujourd’hui à changer, lentement, mais il n’y a pas
de droit constitutionnel aux soins en Chine, pas de lobbies pour l’accès aux soins, à l’inverse des
questions environnementales où les choses ont bougé. Certains scandales à grande échelle ont
raisonné, comme le lait contaminé, mais il n’y a eu qu’une très faible mobilisation pour l’accès aux
antirétroviraux pour les populations par exemple. C’est peut-être dû à la persistance de la honte
attachée au fait d’être malade. Et tandis qu’en Inde, il existe des associations de prostituées, de
transsexuels, de toxicomanes, qui se battent, il n’existe rien de tel en Chine ou alors de façon
beaucoup moins visible et vocale. Les laboratoires ont tendance à jouer un peu l’Inde contre la Chine.
A la suite du procès de Novartis en Inde par exemple, Novartis a décidé de fermer ses centres de
recherche en Inde pour réinvestir en Chine. Et même si six mois plus tard, le laboratoire est à
nouveau sur le marché indien, cette décision n’était pas anodine.
Concernant les licences obligatoires, pour illustrer à quel point les Chinois sont éloignés de l’exemple
indien, les Chinois sont aujourd’hui en train de débattre de la possibilité de débattre de la loi. C’est la
petite avancée que nous avons des organes de décision chinois : avoir un débat pour savoir si oui ou
non, la Chine devrait considérer les licences obligatoires comme un arsenal juridique intéressant
pour leurs populations …
Quel modèle pour le futur ?
Il y a un tel gaspillage aujourd’hui, car la recherche est contenue dans un système totalement
hermétique, où il n’existe aucun partage des connaissances : tout est fait en parallèle, d’où un
véritable gâchis. De nouveaux business-model sont actuellement en train d’être étudiés, ce sont des
questions depuis longtemps posées par les experts (mais qui à ce jour n’ont pas bénéficié d’une
communication à grande échelle).
Dans le modèle actuel, la quasi-totalité de la recherche de base est réalisée par des instituts
gouvernementaux (Institut Pasteur, facultés de biologies, université d’Oxford, etc.). Un mouvement
émerge qui consiste à remettre en cause le fait que l’on paye pour la recherche fondamentale
(concrètement, ce sont nos impôts qui payent les instituts gouvernementaux), mais que cette
recherche soit ensuite commercialisée par le privé … Ce sont les instituts gouvernementaux qui
devraient contrôler la manière dont leur savoir est utilisé. UAEM (Universities Allied for Essential
Medicines) est un mouvement extrêmement actif autour de cette thématique.
Aujourd’hui, les deniers publics financent la recherche fondamentale. Puis les universités
commercialisent cette recherche aux laboratoires, qui réalisent alors les essais cliniques à grande
échelle. Les essais cliniques à grande échelle sont effectivement le savoir propre des laboratoires, et
coûtent effectivement relativement cher. Il faut bien évidemment que quelqu’un paye pour la
107
recherche et ces essais (MSF n’est pas naïf au point d’affirmer que les brevets ne devraient pas
exister), mais n’existerait-il pas un moyen alternatif de pérenniser la recherche ? De nombreux
systèmes alternatifs s’organisent aujourd’hui, mais il est souvent assez difficile de communiquer
dessus sans passer pour des idéalistes.
Aujourd’hui, le brevet consiste à donner l’exclusivité à l’inventeur en échange de l’accès à son
invention. En d’autres termes, le contrat moral à la base du brevet, c’est « j’accepte de surpayer si
en échange, vous me donnez accès à ce que vous avez découvert ». Est-ce que l’on ne pourrait pas, à
la place d’un système fondé sur l’exclusivité, imaginer un système fondé sur le partage des
connaissances dès le départ ? Un système dans lequel on donnerait un prix absolument fantastique à
l’inventeur dès le départ, une énorme somme d’argent immédiate par exemple, et où, en
contrepartie de cette énorme somme, l’invention tomberait dans le domaine public, dès le départ. La
somme immédiate viendrait des deniers publics. Aujourd’hui déjà, ce sont les deniers publics qui
financent l’inventeur, en amont parce que l’on finance la recherche effectuée dans les instituts
gouvernementaux, en aval, parce que nous, les Occidentaux, payons des médicaments très chers
(même si l’on ne s’en rend pas forcément compte, grâce à la Sécurité Sociale, mais nous cotisons
également pour celle-ci). Ce système permettrait de payer moins in fine, puisqu’il éviterait de
nombreux gaspillages, et donnerait l’accessibilité immédiate à la recherche, plutôt qu’au bout de 20
ans.
Les brevets s’appliquent parfaitement aux automobiles, aux capsules Nespresso, etc, mais est-ce qu’il
ne vaudrait pas mieux repenser le modèle et réfléchir à un modèle alternatif en ce qui concerne la
santé publique ? Nous n’avons pas tous le luxe de pouvoir attendre 20 ans pour se faire soigner … Ne
devrions-nous pas réfléchir à des modèles d’innovation quelque peu différents qui pourraient
s’appliquer à la santé publique ? Ceci dit, ces nouveaux modèles ont du mal à percer.
La question de l’accès aux médicaments reste fondamentale … Il faudra nécessairement changer les
règles du jeu au bout d’un moment, parce qu’un combat pays par pays, médicament par
médicament, est épuisant. On n’est plus dans les années 90 et 2000, avec l’épidémie du VIH, le
procès de Pretoria, Doha, et tout ce bruit autour de la question. La conscience publique est en train
de s’épuiser, et donc de s’affaiblir aujourd’hui. La recherche pour des maladies des pays en
développement ne cesse de diminuer (stagnation totale sur la tuberculose par exemple, alors que la
menace ne cesse de croître).
Il faut repenser le modèle, tout en pérennisant la recherche. Aujourd’hui, les compagnies
pharmaceutiques cessent toute innovation sur certaines pathologies, se retirent de toute recherche,
et développent uniquement des produits susceptibles de leur rapporter davantage d’argent. C’est ce
qui est en train de se passer, comme on le voit avec la tuberculose. Certains laboratoires, comme
Roche, se mettent sur des créneaux plus intéressants, et évitent les secteurs où pourraient se poser
des problèmes d’image si l’accès à leurs produits devenait une question difficile. Cela pose la
question de savoir comment l’innovation doit être structurée : l’innovation doit-elle répondre à des
impératifs commerciaux ou à des impératifs médicaux ?
Le secteur public seul devrait pouvoir déterminer les priorités de santé publique. Nous parlions tout à
l’heure d’un prix immédiat, pour récompenser les inventeurs. Ce prix devrait être proportionnel à
108
l’apport que l’inventeur fait pour la santé publique. Un inventeur qui développe un médicament
contre l’hépatite C devrait recevoir un énorme prix, tandis qu’un inventeur qui développerait un
médicament contre la chute des cheveux (et qui aujourd’hui, dans le système actuel, toucherait une
somme considérable, parce que les gens achèteraient son médicament), devrait recevoir un prix
beaucoup plus faible : son innovation n’est pas essentielle au bien-être de la société. Le
gouvernement a donc un rôle important à jouer, en termes de définition des objectifs de santé
publique et d’orientation de la recherche. Aujourd’hui, ces décisions sont laissées au marché, créant
une sorte de système vicieux où personne ne travaille sur les antibiotiques par exemple, alors que la
résistance aux antibiotiques est devenue un problème de santé publique colossal. En effet, un
antibiotique est un médicament qui n’est pas disponible en libre-service et qui doit être prescrit par
un médecin. De plus, un antibiotique est, par essence, un produit que l’on consomme pendant une
durée limitée (une semaine ou deux, pas plus). Au contraire, les médicaments permettant de traiter
les troubles psychiatriques ou les problèmes cardio-vasculaires se prennent à vie, et génèrent en
conséquence des revenus bien supérieurs à ceux des antibiotiques. Ce qui est intéressant avec les
antibiotiques, c’est que leur délaissement par les laboratoires pharmaceutiques impacte aussi bien
les pays du Sud que les pays du Nord. Ils illustrent bien un défaut fondamental dans la manière dont
la recherche est aujourd’hui structurée : on ne cherche pas à pallier les manquements du marché. Un
angle d’attaque à suivre, pour l’introduction d’éventuels modèles alternatifs, est donc bel et bien
celui des antibiotiques.
109
Appendix 6 – Survey
We decided to conduct a survey regarding access to healthcare among populations from
various countries. 135 participants took part in the survey, and I am grateful to all of them,
for taking some time to participate in the survey, and for helping us conducting our research
question.
We designed a questionnaire on Google Forms and on Survey Monkey to collect data from a
sampling group of people from all around the world. In addition to making the questionnaire
public, we posted it on universities, international students and health actors groups’ pages
on Facebook, assuming that member-people would be more likely to answer our
questionnaire. International Federation of Medical Students’ Association (IFMSA) network
members were particularly active participants.
However, I am fully conscious that the survey answers are biased: the sample mainly
includes young people (less than 35) from the upper middle class. Indeed, answering the
survey supposed, for most of the respondents, having the Internet, using Facebook and
speaking English. One can easily assume that people having the Internet, using Facebook and
speaking English may not face much problems regarding access to healthcare. On the other
hand, people facing problems to access healthcare services might not be able to answer the
survey. It was especially difficult to get respondents from China. Indeed, because of the
censorship, Facebook and Google Forms cannot be easily accessed in China. Moreover,
disease and healthcare related topics are often considered as a taboo in Chinese society and
culture.
Despite these biases, the sample was large enough (135 respondents) for the data to be
representative: following the Central Limit Theorem, we collected data from more than 30
people to ensure sampling distribution nearly follows normal distribution. The survey
therefore gives us an overall insight on how health care systems work in various countries in
the world. The open question in the questionnaire about what individuals think about the
healthcare system in their country has enabled me to collect precious information regarding
potential key success factors and flaws of national healthcare systems.
Access to healthcare
Thank you for participating in this survey. Your participation is anonymous and your answers will remain strictly confidential.
As part of my master thesis, I am currently working on access to healthcare in developing countries, especially in India and China. However, participants may take part in the survey regardless of their country of origin.
Thank you,
Doriane Verdin, Master in International Business student, Grenoble Graduate School of Business ([email protected])
*Obligatoire
What is your nationality? *
If applicable, please precise if the country where you usually receive healthcare services isdifferent than your country of nationality
In which state / province / county do you live?
Where do you live? *
In a urban area
In a rural area
Are you a male or a female? *
M
F
How old are you? *
Less than 18
Between 18 and 35
Between 35 and 50
More than 50
In general, how would you rate your overall health? *
1 2 3 4 5
Modifier ce formulaire
Poor Excellent
How long has it been since your most recent visit with an health provider? *
(Excluding medical visits outside of your country of nationality)
Less than 6 months
6 months to 1 year
1 year to 2 years
2 years or more
Where was it? *
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Public hospital
Private hospital
Autre :
Who examined you during your last visit? *
(Excluding medical visits outside of your country of nationality) Multiple answers possible
General practionner
Nurse
Medical specialist (cardiologist, dermatologist, psychologist ...)
Hospital personnel (doctor, midwife, specialist)
Autre :
How well do health providers usually explain you how to take your medicines? *
0 1 2 3 4
Do not explain Very well
Which healthcare facilities do you trust more?
Public facilities
Private facilities
Where would you usually go to receive basic healthcare services? *
Doctor's office or any other healthcare centre
Hospital or any other tertiary-care facility
Autre :
How much money do you spend on helthcare in a typical year? *
Please specify the currency. Count all healthcare-related costs, including health insurance premiumsand any other out-of-pocket expenses for medical services and medicines
Do you currently have health insurance? *
Yes
No
If applicable, who pays for your health insurance?
Multiple answers possible
Your employer
National government
State government
Self-funded
Autre :
How would you rate the overall healthcare system in your country? *
1 2 3 4 5
Poor Excellent
For what reasons?
Please justify your previous answer
In the last 5 years, has a lack of money kept you or your siblings from going to the doctor? *
Yes
No
In the last 5 years, has the price of a medicine kept you or your siblings from following aprescribed treatment? *
Yes
No
Drugs and medicines expenses represent a significant financial burden for me and myfamily *
1 2 3 4
Strongly disagree Strongly agree
I usually take generic drugs rather than patented drugs *
1 2 3 4
Strongly disagree Strongly agree
Fourni par
For the same active ingredient, I would buy a generic drug rather than a patented drug *
1 2 3 4
Strongly disagree Strongly agree
The medicines I need are made easily available *
1 2 3 4
Strongly disagree Strongly agree
Any further detail, comment or suggestion?
If you wish to receive a copy of the survey findings and conclusions, please indicate you e-mail adress
You will receive an electronic copy of the thesis by December, 2014
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NationalityHealthcare
country
Healthcare country development class
(UNDP)
Place of residence
Place of residence: rural/urban
AgeOverall health
condition
Last visit with an health
provider?
In which facility? With whom?
How well do health providers usually explain you how to take your medicines?
Currency
Healthcare out-of-pocket
expenses per year
Counter value in USD
Health insurance?
Payer of health
insurance
In the last 5 years, has a lack of
money kept you or your
siblings from going
to the doctor?
In the last 5 years, has the price of a medicine kept you or
your siblings
from following a prescribed treatment?
Drugs and medicines expenses
represent a significant financial
burden for me and my
family
I usually take
generic drugs rather than
patented drugs
The medicines I
need are made easily
available
Which healthcare
facilities do you trust more?
How would you rate the overall
healthcare system in your country?
For what reasons?
Where would you usually go to receive
basic healthcare services?
For the same active ingredient, I would buy a generic drug
rather than a patented drug
Gender
French FranceMajor developed economies (G7)
Paris In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
2 EUR 80 $ 106 YesNational government
No No 1 1 4 Public facilities 5Doctor's office or any other healthcare centre
4 M
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 EUR 500 $ 660 YesYour employer, Self-funded
No No 1 3 4 Public facilities 5Doctor's office or any other healthcare centre
3 M
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 EUR 50 $ 66 Yes Self-funded No No 1 4 4 Public facilities 4Doctor's office or any other healthcare centre
4 F
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
4Less than 6 months
Private hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 EUR 30 $ 40 YesNational government
No No 1 4 3 Public facilities 5The overall healthcare system is almost free and takes care of your health. Everyone can have a good doctor and treatment.
Doctor's office or any other healthcare centre
4 F
German GermanyMajor developed economies (G7)
In a urban areaBetween 18 and 35
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 EUR 250 $ 330 Yes
Your employer, National government, State government, Self-funded
No No 1 3 4 Public facilities 3Generally, very high standards. However the system and doctors cannot handle all patients. It is a little bit overloaded.
Doctor's office or any other healthcare centre
3 M
Irish IrelandDeveloped economies
London In a urban areaBetween 18 and 35
3Less than 6 months
Public hospital Nurse 2 EUR 150 $ 198 YesYour employer, Self-funded
No No 2 4 3 Private facilities 3 Its overstretched with long waiting periods for access to routine GP appointments at my registered GP office.Doctor's office or any other healthcare centre
4 F
Canadian CanadaDeveloped economies
Ontario In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 USD - $ - Yes
National government, State government
No No 1 1 4 Private facilities 5Well educated doctors / Easy access to health care facilities / Clean and well-maintained health care facilities / Health care covered by government (provincial and federal) / Prescription drugs are readily available if needed
Doctor's office or any other healthcare centre
2 F
Venezuelan VenezuelaDeveloping economies
Shanghai In a urban areaBetween 18 and 35
46 months to 1 year
Private hospitalGeneral practionner
2 USD 300 $ 300 Yes Your employer No No 2 3 4 Private facilities 1
Lack of infrastructure, doctor might be really good but the government does not provide public hospitals with the necessary equipment or basic resources. In Venezuela for example, people have to buy their medicine and sometimes if they need an operation, they have to bring the materials, from gauze pads to suture thread and needles.
Doctor's office or any other healthcare centre
3 M
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 22 $ 29 Yes Self-funded No No 1 3 4 Public facilities 4Doctor's office or any other healthcare centre
4 M
French FranceMajor developed economies (G7)
Bouches-du-Rhône
In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 EUR 100 $ 132 Yes Parents No No 1 4 3 Public facilities 4Doctor's office or any other healthcare centre
4 F
French FranceMajor developed economies (G7)
Ile-de-France In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
2 EUR 400 $ 528 Yes Parents No No 1 3 4 Public facilities 5Doctor's office or any other healthcare centre
4 F
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 500 $ 660 Yes Self-funded No No 3 2 3 Public facilities 4 Subventions from the state. the problem is, that it costs a lot to the governmentDoctor's office or any other healthcare centre
2 F
French FranceMajor developed economies (G7)
Paris In a urban areaBetween 18 and 35
31 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
1 EUR 30 $ 40 YesYour employer, State government
No Yes 3 3 3 Public facilities 4 French healthcare system is really good and efficientDoctor's office or any other healthcare centre
3 M
French FranceMajor developed economies (G7)
Ile de France In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR 200 $ 264 YesNational government
No No 1 3 4 Public facilities 4
Because France is one of the few countries to benefit from universal healthcare coverage. This coverage is, of course, not perfect (funding problems for instance, extra billing and user fees to be examined by the best doctors, which generates inequalities regarding healthcare treatments), but still, it exists, and guarantees to everyone access to healthcare.
Doctor's office or any other healthcare centre
3 F
French FranceMajor developed economies (G7)
Ile de France, Val de Marne
In a urban areaBetween 18 and 35
3Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
2 EUR 200 $ 264 YesSelf-funded, Cotisation
No Yes 2 4 4 Public facilities 4Doctor's office or any other healthcare centre
4 F
Indian India BRICS Rhone Alpes In a urban areaBetween 18 and 35
31 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 INR 5 000 $ 82 Yes Self-funded No No 2 4 3 Private facilities 3 Quality of private is much better than public but private comes at a huge premium though.Doctor's office or any other healthcare centre
3 M
Swedish SwedenDeveloped economies
Jönköpings Län
In a urban areaBetween 18 and 35
51 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 50 $ 66 Yes
Your employer, National government, State government, Self-funded
No No 1 1 4 Private facilities 4Doctor's office or any other healthcare centre
1 F
French FranceMajor developed economies (G7)
Isère In a rural areaBetween 35 and 50
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 1 000 $1 320 YesYour employer, Self-funded
No No 1 4 4 Public facilities 5 Total coverage, whatever happensDoctor's office or any other healthcare centre
4 M
Colombian ColombiaDeveloping economies
London In a urban areaBetween 35 and 50
41 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 GBP 500 $ 830 Yes Self-funded Yes Yes 2 3 4 Private facilities 4 Coverage, drugs diversity, government services and funding, loads of hospitals ranked 4.Doctor's office or any other healthcare centre
3 M
Brazilian Brazil BRICS Bahia In a urban areaBetween 18 and 35
4Less than 6 months
Private hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
1 BRL 2 000 $ 895 Yes Self-funded No No 1 4 3 Private facilities 2
We have a public health care system that we pay high taxes to maintain, but we still need to pay for a private health insurance because our public system is too limited to provide a decent service for everyone. And that might make you think the private health insurance is good, right? But is almost just as bad, to make an appointment to see a doctor usually I have to wait for almost a month, the only place I can get to see a doctor immediately is if I go to a hospital's emergency room.
Doctor's office or any other healthcare centre
4 F
Appendix 7 - Respondents' answers
NationalityHealthcare
country
Healthcare country development class
(UNDP)
Place of residence
Place of residence: rural/urban
AgeOverall health
condition
Last visit with an health
provider?
In which facility? With whom?
How well do health providers usually explain you how to take your medicines?
Currency
Healthcare out-of-pocket
expenses per year
Counter value in USD
Health insurance?
Payer of health
insurance
In the last 5 years, has a lack of
money kept you or your
siblings from going
to the doctor?
In the last 5 years, has the price of a medicine kept you or
your siblings
from following a prescribed treatment?
Drugs and medicines expenses
represent a significant financial
burden for me and my
family
I usually take
generic drugs rather than
patented drugs
The medicines I
need are made easily
available
Which healthcare
facilities do you trust more?
How would you rate the overall
healthcare system in your country?
For what reasons?
Where would you usually go to receive
basic healthcare services?
For the same active ingredient, I would buy a generic drug
rather than a patented drug
Gender
French FranceMajor developed economies (G7)
Beijing In a urban areaBetween 18 and 35
5Less than 6 months
Private hospital
General practionner, Medical specialist (cardiologist, dermatologist, psychologist ...)
1 EUR - $ - YesYour employer, National government
No No 1 4 4 Public facilities 5 AffordableDoctor's office or any other healthcare centre
4 M
German GermanyMajor developed economies (G7)
In a urban areaBetween 18 and 35
42 years or more
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 EUR Yes Parents No No 1 1 4 Private facilities 4I guess we do have a system that works really well for private patients, but for public it is less perfect. Still, we have access to everything we need, whenever we need it.
Doctor's office or any other healthcare centre
2 F
French FranceMajor developed economies (G7)
Ile de France In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 EUR 1 000 $1 320 Yes
Your employer, National government, Self-funded
No Yes 2 3 4 Public facilities 5
Excellent reimbursement rates. Accessible health facilities. Available drugs. Good medical staff. Risk-pooling for healthcare exceptionnal costs. Most employers provide you with a complementary private helath-insurance to cover your overall helath-care expenses (further than the ceiling of the Sécurité Sociale). Many additional systems to cover the poor. Excellent system.
Doctor's office or any other healthcare centre
3 F
French FranceMajor developed economies (G7)
Ile-de-France In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 EUR 80 $ 106 YesYour employer, National government
Yes Yes 2 4 4 Public facilities 4Basically, in France we have the chance to have a National healthcare assurance paid by our country, which give us the chance to be well protected in case of illness, compared to many foreign countries as United States for example.
Doctor's office or any other healthcare centre
4 M
Chinese China BRICS In a urban areaBetween 18 and 35
42 years or more
Public hospital
Hospital personnel (doctor, midwife, specialist)
3 CNY 200 $ 32 Yes University No No 3 3 3 Public facilities 3Hospital or any other tertiary-care facility
2 F
Russian Russia BRICS In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 USD 1 300 $1 300 Yes Your employer Yes No 2 3 4 Private facilities 3Due to there is huge difference between urban and rural areas. Moreover, to have free expert help, especially rare and costly diseases (cancer, leukemia, heart disease ..), some segments of the population are waiting for help in a very large queues, which can last for several months.
Doctor's office or any other healthcare centre
2 F
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR 100 $ 132 YesState government, Self-funded
No No 3 3 3 Public facilities 3Doctor's office or any other healthcare centre
4 M
French FranceMajor developed economies (G7)
Yvelines In a rural areaBetween 18 and 35
41 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR - $ - Yes Family No No 1 2 3 Private facilities 4Doctor's office or any other healthcare centre
3 M
Chinese FranceMajor developed economies (G7)
Paris In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 100 $ 132 Yes Your employer No No 3 3 4 Private facilities 4 Access to basic healthcare is guaranteed to anyone including foreignersDoctor's office or any other healthcare centre
3 F
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 EUR 40 $ 53 Yes No Yes 2 2 3 Public facilities 4Doctor's office or any other healthcare centre
2 M
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner, Medical specialist (cardiologist, dermatologist, psychologist ...)
3 EUR 250 $ 330 YesNational government, Self-funded
No No 2 4 3 Public facilities 3 ViabilityDoctor's office or any other healthcare centre
4 F
French FranceMajor developed economies (G7)
Paris In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 EUR 200 $ 264 YesNational government
No No 4 3 4 Public facilities 4 As for me the problem is that some people can not have access to health care...Doctor's office or any other healthcare centre
3 F
French FranceMajor developed economies (G7)
Alsace In a urban areaBetween 18 and 35
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
2 EUR 600 $ 792 Yes Parents No No 3 1 3 Private facilities 4Healthcare and medecines are easily affordable. There are many public hospitals for poor people but also some private hospitals for those who have good incomes or insurance.
Doctor's office or any other healthcare centre
1 M
French FranceMajor developed economies (G7)
Paris In a urban areaBetween 18 and 35
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
1 EUR 390 $ 515 YesState government
Yes No 4 3 3 Public facilities 4Excellent coverage and quality, but missing the digital health revolution on the contrary to private health countries
Doctor's office or any other healthcare centre
3 M
Nepalese China BRICS Shanghai In a urban areaBetween 18 and 35
52 years or more
Public hospital
Hospital personnel (doctor, midwife, specialist)
3 USD 100 $ 100 Yes Your employer No No 2 3 4 Public facilities 3
In China, for the foreigners, going to hospital (public) can be more challenging, language being the issue. For me personally I don't like their system. You have to waste the whole day going from one place to other for the check, payment, etc. I do speak their language but the procedure is breath taking for me. But the treatment is still good / About Nepal : My country being among the underdeveloped/developing countries we lack equipments, but in terms of expertise, we have the expertise but especially in the urban part
Hospital or any other tertiary-care facility
2 M
French FranceMajor developed economies (G7)
Paris In a urban areaBetween 18 and 35
52 years or more
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 200 $ 264 Yes Self-funded No No 2 3 3 Public facilities 4 Good universal healthcare coverageDoctor's office or any other healthcare centre
4 M
French FranceMajor developed economies (G7)
Bas-Rhin In a rural areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 EUR 120 $ 158 Yes No No 1 3 2 Public facilities 5Our healthcare system is known for being extremely skilled, especially because we have good doctors and good support.
Doctor's office or any other healthcare centre
4 F
Italian ItalyMajor developed economies (G7)
Isère In a urban areaBetween 18 and 35
4Less than 6 months
Public hospital
Nurse, Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR 150 $ 198 YesYour employer, Self-funded
No No 1 1 4 Private facilities 5Doctor's office or any other healthcare centre
2 M
Indian India BRICS Rhone Alpes In a urban areaBetween 18 and 35
31 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 EUR 100 $ 132 Yes Self-funded Yes Yes 3 3 2 Private facilities 3 Ease of Access / Low Price of Services / Unorganized / Rising Prices / Diminishing Interaction with PatientDoctor's office or any other healthcare centre
3 M
Australian AustraliaDeveloped economies
New South Wales
In a urban areaMore than 50
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 AUD No No No 4 3 3 Public facilities 3 Got to wait too long for hospital proceduresDoctor's office or any other healthcare centre
3 M
NationalityHealthcare
country
Healthcare country development class
(UNDP)
Place of residence
Place of residence: rural/urban
AgeOverall health
condition
Last visit with an health
provider?
In which facility? With whom?
How well do health providers usually explain you how to take your medicines?
Currency
Healthcare out-of-pocket
expenses per year
Counter value in USD
Health insurance?
Payer of health
insurance
In the last 5 years, has a lack of
money kept you or your
siblings from going
to the doctor?
In the last 5 years, has the price of a medicine kept you or
your siblings
from following a prescribed treatment?
Drugs and medicines expenses
represent a significant financial
burden for me and my
family
I usually take
generic drugs rather than
patented drugs
The medicines I
need are made easily
available
Which healthcare
facilities do you trust more?
How would you rate the overall
healthcare system in your country?
For what reasons?
Where would you usually go to receive
basic healthcare services?
For the same active ingredient, I would buy a generic drug
rather than a patented drug
Gender
French FranceMajor developed economies (G7)
Paris In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
2 EUR 300 $ 396 Yes Self-funded No No 2 3 4 Public facilities 4Doctor's office or any other healthcare centre
4 F
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR 500 $ 660 Yes Parents No No 1 4 4 Public facilities 4French system is not perfect, but I think it's one of the best in the world: it offers good reimbursement rates, in particular if you have to go to the hospital. But without personnal health insurance it can be complicated for glasses, orthodontics…
Doctor's office or any other healthcare centre
4 F
French FranceMajor developed economies (G7)
Paris In a urban areaBetween 18 and 35
46 months to 1 year
Laboratory Nurse 4 EUR 50 $ 66 YesState government
Yes No 3 3 4 Public facilities 4
It's easy to have access to medicines / Many of them are repayed (well at least for the "small" sicknesses) / Health providers (particularly hospital and pharmacy) are honest and don't try to make us buy the most expensive medicine/care to make more money / Health providers explain us how to use the medicines they give (and it's also written in the medication label)Nevertheless, it's not perfect : seeing a doctor is expensive / we have to wait a really long time for an appointment with specialists (dentist, physiotherapist, ophthalmologist, etc) / there is a lack of nurses in hospitals / the State tends to forget that health must not be money-making and many hospitals etc have to shut for not making enough money, or loosing money
Doctor's office or any other healthcare centre
4 F
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 EUR 200 $ 264 Yes Family No No 2 3 2 Private facilities 4 Because the state helps people to access healthcare services, etc.Doctor's office or any other healthcare centre
4 F
Dutch NetherlandsDeveloped economies
In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 EUR 1 500 $1 980 Yes Self-funded No No 1 2 4 Public facilities 3We have an insurance in the Netherlands that is mandatory but does not cover the first 360 euro's. It also does not cover teeth care and eye care. On the other hand, 24/7 we have doctors available. So that is really good. In general the doctors are well-trained too.
Doctor's office or any other healthcare centre
2 F
French SpainDeveloped economies
In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 EUR 300 $ 396 YesYour employer, Self-funded
No No 1 3 3 Private facilities 3Doctor's office or any other healthcare centre
4 F
Egyptian EgyptDeveloping economies
In a urban areaBetween 18 and 35
56 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
2 EGP 200 $ 28 No Yes Yes 4 3 2 Private facilities 2Insurance doesn't cover everyone and most people don't visit the doctor unless it's Emergency due to unmet costs
Doctor's office or any other healthcare centre
2 F
Chilean ChileDeveloping economies
Santiago In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 CLP 60 000 $ 102 YesState government
No Yes 1 3 4 Private facilities 2
Doctors are capable and well-trained to do their job. But there's no real "system". Private health is the only option if you don't want to wait a gazillion years for an appointment or surgery in the public hospitals; and when we're talking about cancer you don't have a gazillion years. Patented medicine is usually way more expensive, there're generics who do practically the same and are more affordable.
There're many stories about doctors working double or triple time and attending more people per person than they're capable.
Doctor's office or any other healthcare centre
3 M
Australian AustraliaDeveloped economies
New South Wales
In a urban areaBetween 18 and 35
5Less than 6 months
Public hospital
General practionner, Nurse, Medical specialist (cardiologist, dermatologist, psychologist ...), Hospital personnel (doctor, midwife, specialist)
4 AUD 100 $ 93 NoNational government
No No 1 3 4 Public facilities 5
Low healthcare costs are available to all citizens of Australia, and even lower costs for those who are poorer. This means that everyone has the choice of receiving absolutely free health check ups and surgery and discounted antibiotics, making the country healthier and stopping the more serious illnesses occurring because people do not have to worry that they will be in debt or that the service will be bad.
Doctor's office or any other healthcare centre
4 F
Russian Russia BRICS Moscow In a urban areaBetween 18 and 35
3Less than 6 months
Private hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 NOK 40 000 $6 454 No No No 3 4 4 Private facilities 4Doctor's office or any other healthcare centre
4 F
French FranceMajor developed economies (G7)
France Aquitaine
In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR 200 $ 264 YesNational government
No No 1 2 4 Public facilities 5 Excellent coverage, no charge for the patientDoctor's office or any other healthcare centre
1 M
American United-StatesMajor developed economies (G7)
Alabama In a urban areaBetween 18 and 35
16 months to 1 year
private doctor's office
General practionner
2 USD 9 000 $9 000 Yes Self-funded Yes Yes 4 4 2 2
I have a genetic autoimmune disorder. The treatment is very costly. I haven't had an infusion of the treatment in several years. When I last got sick in the United-States I could not afford a half dose of broad spectrum antibiotics (98 USD) after having paid the health insurance premium (~450 USD). The student health insurance did not cover antibiotics. The healthcare system is great. If you can afford it. I can't. I had to move to Norway to afford to have some minor surgery done
Doctor's office or any other healthcare centre
4 M
German GermanyMajor developed economies (G7)
In a urban areaBetween 18 and 35
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner, Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR 1 200 $1 584 YesNational government, Self-funded
No No 1 2 4 Public facilities 4
It's better than somewhere else but still there are many problems, for example that you usually get a better service when you have a private insurance. But on the other hand you get many things you don't need when your insurance is private because the hospital/doctors get more money if they work with persons who have a private insurance.
Doctor's office or any other healthcare centre
2 M
Czech Czech RepublicDeveloped economies
Paris In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 CZK 1 000 $ 47 YesNational government
No No 1 1 4 Public facilities 5 Easily accesible healthcare for everybody.Doctor's office or any other healthcare centre
1 F
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
46 months to 1 year
Public hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR 200 $ 264 YesNational government
No No 1 3 3 Public facilities 4
In France, you can basically have everything for free if you have no money. And the National Healthcare covers practically everything needed. But you have to wait quite a long time if you need appointments with specialist in public hospital. However, it's still possible to see them without paying like 200€ for a 20 minutes consultations as they can do when they work in their private office.
Doctor's office or any other healthcare centre
4 M
Ugandan UgandaLeast developed countries
In a rural areaBetween 18 and 35
36 months to 1 year
Public hospital Nurse 3 USD 4 $ 4 No Yes Yes 3 2 2 Private facilities 3 Iit is does not provide quality services and it is very expensiveHospital or any other tertiary-care facility
3 M
Pakistani PakistanDeveloping economies
Pakistan/Sindh
In a rural areaBetween 18 and 35
32 years or more
Private hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
2 PKR 5 000 $ 49 NoYour employer, Self-funded
No No 3 3 3 Private facilities 2In my country there are no basic health care policy from government sector for the citizens of Pakistan. Lack of implication of government polices from government institutions. Also governments have no health policy on national level.
Hospital or any other tertiary-care facility
3 M
Indian India BRICS In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 INR 8 000 $ 132 YesNational government
No No 1 4 4 Private facilities 5Doctor's office or any other healthcare centre
4 M
NationalityHealthcare
country
Healthcare country development class
(UNDP)
Place of residence
Place of residence: rural/urban
AgeOverall health
condition
Last visit with an health
provider?
In which facility? With whom?
How well do health providers usually explain you how to take your medicines?
Currency
Healthcare out-of-pocket
expenses per year
Counter value in USD
Health insurance?
Payer of health
insurance
In the last 5 years, has a lack of
money kept you or your
siblings from going
to the doctor?
In the last 5 years, has the price of a medicine kept you or
your siblings
from following a prescribed treatment?
Drugs and medicines expenses
represent a significant financial
burden for me and my
family
I usually take
generic drugs rather than
patented drugs
The medicines I
need are made easily
available
Which healthcare
facilities do you trust more?
How would you rate the overall
healthcare system in your country?
For what reasons?
Where would you usually go to receive
basic healthcare services?
For the same active ingredient, I would buy a generic drug
rather than a patented drug
Gender
Greek GreeceDeveloped economies
Oslo, Norway In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
2 EUR 100 $ 132 Yes Self-funded No No 2 2 4 Private facilities 1 Economic crisis in Greece makes the healthcare system worse every yearDoctor's office or any other healthcare centre
2 F
Greek GreeceDeveloped economies
Northern Greece, Xanthi
In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Hospital personnel (doctor, midwife, specialist)
2 EUR 700 $ 924 Yes Self-funded Yes No 2 2 2 Private facilities 2 Lack of health materials , lack of facilities and lack of personnel (doctors, nurses etc)Hospital or any other tertiary-care facility
1 M
Panamanian China BRICS Beijing/China In a urban areaBetween 18 and 35
36 months to 1 year
Public hospitalGeneral practionner, Nurse
2 CNY 500 $ 81 Yes University No No 4 3 4 Private facilities 4 Doctors are really thoughtful with the patientsHospital or any other tertiary-care facility
4 F
French FranceMajor developed economies (G7)
Paris In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 75 $ 99 YesNational government
No No 2 4 4 Public facilities 5 We are in a country where the doctor takes care of you before asking you to payDoctor's office or any other healthcare centre
4 F
Canadian CanadaMajor developed economies (G7)
Ontario In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 USD - $ - Yes
Your employer, National government, State government
No No 1 1 3 Private facilities 4 Everything that I need is taken care of but it could be faster.Doctor's office or any other healthcare centre
1 F
Iranian TurkeyDeveloping economies
Istanbul/ Turkey
In a urban areaBetween 18 and 35
4Less than 6 months
Private hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 TRY 200 $ 93 No Self-funded No No 2 3 2 Private facilities 3Hospital or any other tertiary-care facility
3 F
Indian India BRICS In a urban areaBetween 18 and 35
3Less than 6 months
Private hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
2 INR 10 000 $ 165 No No No 1 1 4 Private facilities 3We surely have some of the best medical doctors , but disparitries are there in delivery to all spheres of society- the rich and affleunt can afford the best , while though state run hospitals offer free services to the poor , there is reverance to some major treatments
Fathers clinic 1 F
French FranceMajor developed economies (G7)
Saint Germain en Laye, Yvelines
In a urban areaBetween 18 and 35
3Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
2 EUR 250 $ 330 Yes
Your employer, State government, Self-funded
Yes Yes 2 2 2 Private facilities 5Doctor's office or any other healthcare centre
4 F
Indian India BRICS In a urban areaBetween 18 and 35
3Less than 6 months
Private hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 INR 2 000 $ 33 Yes No No 2 2 4 Private facilities 3 Due to patient overload, doctors take their patient for granted in government hospitalsDoctor's office or any other healthcare centre
2 M
British Great-BritainMajor developed economies (G7)
Hertfordshire In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Nurse 4 GBP - $ - NoState government
No No 1 1 4 Public facilities 5 It is free for allDoctor's office or any other healthcare centre
1 F
Sudanese SudanLeast developed countries
Khartoum state
In a urban areaBetween 18 and 35
41 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 SDG 500 $ 88 No No No 3 3 3 Private facilities 2Health care services are usually concentrated within the capital, and also not in all areas. It is usually the fortunate that benefit mostly, rural and less urban areas are disadvantaged. Usually when a case is serious or unknown people from other cities travel to the capital to receive their health care.
Doctor's office or any other healthcare centre
3 M
Indian India BRICS Maharashtra In a urban areaBetween 18 and 35
1Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
0 INR 200 000 $3 300 No Self-funded No No 4 1 3 Private facilities 1 Way too expensiveDoctor's office or any other healthcare centre
4 M
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
1 EUR 2 000 $2 640 Yes Your employer No No 3 1 2 Public facilities 4 French healthcare system is reliable and efficient. Provide high quality services.Doctor's office or any other healthcare centre
1 M
Tunisian TunisiaDeveloping economies
In a urban areaBetween 18 and 35
3Less than 6 months
Public hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 USD 100 $ 100 Yes Your employer No No 2 1 3 Public facilities 3Hospital or any other tertiary-care facility
1 F
French FranceMajor developed economies (G7)
Brittany In a urban areaBetween 18 and 35
41 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 22 $ 29 Yes
One part is me / One part is free cuz i have a scholarship
No No 2 4 4 Public facilities 4Healthcare in France seems pretty good, doesn't seem too expensive to me so I think most people got at least 70% of fees covered if not 100%.
Doctor's office or any other healthcare centre
4 M
Tunisian TunisiaDeveloping economies
In a urban areaBetween 18 and 35
31 year to 2 years
Private hospitalGeneral practionner
2 EUR 40 $ 53 No Self-funded Yes Yes 3 4 4 Private facilities 3 Corruption and weak public sectorDoctor's office or any other healthcare centre
3 M
French FranceMajor developed economies (G7)
Val-De-Marne In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR - $ - NoNational government
No No 1 4 4 Public facilities 5 Free for all. Skilled technicians, in both technical and client-relationship fields.Doctor's office or any other healthcare centre
4 M
Indian India BRICS In a urban areaBetween 18 and 35
46 months to 1 year
Public hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 INR 20 000 $ 330 Yes Self-funded No No 2 3 3 Private facilities 2Due to excessive population in India general health care services are not as good but private hospitals provide better health care but at a steeper cost
Doctor's office or any other healthcare centre
3 M
Danish DenmarkDeveloped economies
Copenhagen In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 USD 75 $ 75 YesNational government
No No 1 1 4 Public facilities 4 It's paid by the goverment and covers everything except beauty operations and some of your medication billDoctor's office or any other healthcare centre
3 M
French FranceMajor developed economies (G7)
Norway - Trondheim
In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 200 $ 264 Yes Self-funded No No 2 3 3 Private facilities 5Doctor's office or any other healthcare centre
3 M
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
2 EUR 50 $ 66 YesNational government, Self-funded
No No 2 4 4 Public facilities 4Doctor's office or any other healthcare centre
4 F
NationalityHealthcare
country
Healthcare country development class
(UNDP)
Place of residence
Place of residence: rural/urban
AgeOverall health
condition
Last visit with an health
provider?
In which facility? With whom?
How well do health providers usually explain you how to take your medicines?
Currency
Healthcare out-of-pocket
expenses per year
Counter value in USD
Health insurance?
Payer of health
insurance
In the last 5 years, has a lack of
money kept you or your
siblings from going
to the doctor?
In the last 5 years, has the price of a medicine kept you or
your siblings
from following a prescribed treatment?
Drugs and medicines expenses
represent a significant financial
burden for me and my
family
I usually take
generic drugs rather than
patented drugs
The medicines I
need are made easily
available
Which healthcare
facilities do you trust more?
How would you rate the overall
healthcare system in your country?
For what reasons?
Where would you usually go to receive
basic healthcare services?
For the same active ingredient, I would buy a generic drug
rather than a patented drug
Gender
Polish PolandDeveloped economies
Mazowsze In a urban areaBetween 18 and 35
51 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 10 $ 13 Yes Self-funded No No 1 2 3 Private facilities 2 Too many people, too long time of waiting to get an appointmentDoctor's office or any other healthcare centre
2 F
Norwegian NorwayDeveloped economies
sør-Trøndelag In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 1 000 $1 320 Yes Self-funded No No 1 2 4 Public facilities 5Doctor's office or any other healthcare centre
2 F
German GermanyMajor developed economies (G7)
Baden-Württemberg
In a rural areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner, Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR 700 $ 924 Yes Self-funded No No 1 1 4 Public facilities 5You get good conditions for the money you are paying. Even if You don't have enough money for paying the insurance it will be paid by the state.
Doctor's office or any other healthcare centre
1 F
German GermanyMajor developed economies (G7)
North Rhine Westphalia
In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 EUR 800 $1 056 Yes Self-funded No No 1 1 4 Private facilities 4 Germany is a high developed country.Doctor's office or any other healthcare centre
1 M
Norwegian NorwayDeveloped economies
Trondheim/Sør-Trøndelag
In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 NOK 2 000 $ 323 YesNational government, Self-funded
No No 1 2 2 Public facilities 4 Good treatment methods and a low percentage of fatalities, but long queues to have surgery etc.Doctor's office or any other healthcare centre
2 M
French FranceMajor developed economies (G7)
In a urban areaBetween 18 and 35
4Less than 6 months
Private hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR - $ - YesYour employer, State government
No No 2 4 4 Private facilities 5Doctor's office or any other healthcare centre
4 F
Norwegian NorwayDeveloped economies
Sør-Trøndelag
In a urban areaBetween 18 and 35
41 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 NOK 400 $ 65 NoState government
No No 1 2 3 Public facilities 4Doctor's office or any other healthcare centre
2 F
Chinese China BRICS Beijing In a urban areaBetween 18 and 35
4Less than 6 months
Public hospital
Hospital personnel (doctor, midwife, specialist)
1 CNY 7 000 $1 137 Yes
Your employer, Self-funded, both from myself and my employer
No No 2 2 3 Public facilities 2
Actually I know there exist lots of problems in China's national healthcare system. It could not cover everyone in China: it is not fair. I think it is an interesting as well as daunting task to conduct a thorough research about China's national healthcare system concerning the following reasons: first, it is just in its starting years now; second, it is different from the Western ones.
Hospital or any other tertiary-care facility
3 F
Dutch NetherlandsDeveloped economies
Noord-Brabant
In a rural areaBetween 18 and 35
51 year to 2 years
Public hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 EUR 1 200 $1 584 Yes Self-funded No No 1 2 4 Public facilities 4 Everybody will get treatment and there are many modern hospitalsDoctor's office or any other healthcare centre
2 F
Indian India BRICSMaharashtra India
In a urban areaBetween 35 and 50
4Less than 6 months
Private hospitalGeneral practionner
3 NOK 1 200 $ 194 Yes Your employer No No 3 3 3 Private facilities 3Pros: Availability of services / Flexibility of choosing doctors and multiple consultations still you are satisfied.Cons: Hygiene is poor / There are some dishonest doctors with poor regulations to govern them
Doctor's office or any other healthcare centre
3 M
Spanish SpainDeveloped economies
Castilla- La Mancha
In a urban areaBetween 18 and 35
4Less than 6 months
Public hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR YesNational government
No No 1 4 4 Public facilities 4On the one hand it's public and accesible for every Spanish citizen but it doesn't provide the quality required sometimes. Long waiting, non specialized personal for each illness
Hospital or any other tertiary-care facility
4 F
Greek GreeceDeveloped economies
In a urban areaBetween 18 and 35
5Less than 6 months
Dentistry
Hospital personnel (doctor, midwife, specialist)
4 EUR 100 $ 132 YesNational government
Yes Yes 3 2 3 Private facilities 1 Bad hospitals. No health care system, or at least, it doesn't work properlyDoctor's office or any other healthcare centre
3 F
Italian ItalyMajor developed economies (G7)
Puglia In a urban areaBetween 18 and 35
41 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner, Hospital personnel (doctor, midwife, specialist)
3 EUR 50 $ 66 No No No 2 3 4 Private facilities 3Doctor's office or any other healthcare centre
4 M
Russian Russia BRICS Moscow In a urban areaBetween 18 and 35
4Less than 6 months
Public hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
1 EUR 200 $ 264 YesNational government
No No 2 1 2 Private facilities 3Doctor's office or any other healthcare centre
1 F
Dutch NetherlandsDeveloped economies
Noord-Holland In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 1 400 $1 848 Yes Self-funded No No 1 3 4 Private facilities 5Everyone has health care insurance, it is easy to switch, there are multiple for different target groups (students, wealthier people), most doctors etc. have good contacts with the insurance companies.
Doctor's office or any other healthcare centre
3 F
Polish PolandDeveloped economies
Mazowieckie In a urban areaBetween 18 and 35
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Hospital personnel (doctor, midwife, specialist)
3 PLN 750 $ 234 Yes my mother No No 2 4 4 Private facilities 1 Long lines (few months for the appointment), bad clinicsDoctor's office or any other healthcare centre
3 F
German GermnayMajor developed economies (G7)
Bavaria In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 EUR - $ - Yes Family No No 1 3 4 Public facilities 4Doctor's office or any other healthcare centre
4 F
Indian India BRICS Bihar In a urban areaBetween 18 and 35
52 years or more
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 INR 5 000 $ 82 Yes Self-funded No No 1 3 4 Private facilities 2
Public Health care system is totally bad... There is lack of infrastructure ,doctors ,trained nurses etc... The government spends very less on it... Public health care hospitals and private hospitals in small township areas in India are totally unhigenic: if you visit there for treatment you will get infected by some other virus and get sick..
Doctor's office or any other healthcare centre
4 M
Romanian BelgiumDeveloped economies
Brussels In a urban areaBetween 18 and 35
4Less than 6 months
Public hospital Dentist 2 EUR 100 $ 132 Yes
Your employer, National government, Self-funded
No No 1 4 4 Public facilities 5Hospital or any other tertiary-care facility
4 F
British South AfricaDeveloping economies
In a urban areaBetween 18 and 35
51 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 ZAR 14 400 $1 351 Yes Self-funded No No 1 4 4 Public facilities 3Public health system has the best doctors but the systems are lacking and there are many areas for improvement. At least public system has access to everything. Big private health service which contains some bad/dodgy doctors and is not well controlled.
Doctor's office or any other healthcare centre
4 F
NationalityHealthcare
country
Healthcare country development class
(UNDP)
Place of residence
Place of residence: rural/urban
AgeOverall health
condition
Last visit with an health
provider?
In which facility? With whom?
How well do health providers usually explain you how to take your medicines?
Currency
Healthcare out-of-pocket
expenses per year
Counter value in USD
Health insurance?
Payer of health
insurance
In the last 5 years, has a lack of
money kept you or your
siblings from going
to the doctor?
In the last 5 years, has the price of a medicine kept you or
your siblings
from following a prescribed treatment?
Drugs and medicines expenses
represent a significant financial
burden for me and my
family
I usually take
generic drugs rather than
patented drugs
The medicines I
need are made easily
available
Which healthcare
facilities do you trust more?
How would you rate the overall
healthcare system in your country?
For what reasons?
Where would you usually go to receive
basic healthcare services?
For the same active ingredient, I would buy a generic drug
rather than a patented drug
Gender
Austrian AustriaDeveloped economies
In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 EUR 200 $ 264 Yesas student insured with parents
No No 1 2 4 Private facilities 4 Free access to all citizens, high quality treatmentDoctor's office or any other healthcare centre
2 F
Venezuelan VenezuelaDeveloping economies
Caracas, DC. In a urban areaBetween 18 and 35
3Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 VEF 8 000 $1 272 YesYour employer, Self-funded
No No 3 1 1 Private facilities 3Healthcare system in Venezuela is now going through a bad moment since we do not have enough resources, supplies, etcetera, in neither public nor private facilities, and it translates into more expenses for the patients (since public healthcare is supposed to be completely free).
Doctor's office or any other healthcare centre
1 M
British Great-BritainMajor developed economies (G7)
In a rural areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 GBP - $ - NoNational government
No No 1 2 4 Public facilities 5
The maximum amount any person has to pay for medication in the U.K. is £7.25 and this is exempt entirely for those on benefits or the elderly. It means that each person has an equal chance to be healthy and well looked after regardless of their financial situation or status. I have also found public health care to be more trustworthy as the practitioners involved seem to be in it for the right reasons, not for financial gain and so they show more care and understanding for their patients.
Doctor's office or any other healthcare centre
3 F
German GermanyMajor developed economies (G7)
hessen (Germany)
In a rural areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR 450 $ 594 Yes
My parents: it's an insurance for the whole family
No No 3 3 3 Private facilities 4
You can get help if you need it and it does not cost much because of the good insurances. The only thing that is not good about it is that the insurances do not support alternative medicines such as homeopathy. So you have to pay much more and have some problems in getting your medicine if you are intending to choose more natural ways of healing as your treat. What my family does. Natural medicines such as homeopathy are not that easy to get, other medicines you can get really easily.
Doctor's office or any other healthcare centre
2 F
Indian India BRICS Punjab In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Hospital personnel (doctor, midwife, specialist)
4 INR 2 000 $ 33 Yes Your employer No No 1 3 4 Private facilities 4Doctor's office or any other healthcare centre
4 F
British Great-BritainMajor developed economies (G7)
Redding, California, USA
In a urban areaBetween 35 and 50
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
2 GBP - $ - YesNational government
No No 1 4 3 4Haven't used it much over the years. On the whole it seems okay but friends and family have had varied experiences.
Doctor's office or any other healthcare centre
4 M
German GermanyMajor developed economies (G7)
In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR YesNational government, Self-funded
No No 2 2 4 Private facilities 4Basic healthcare for everyone, but differences between private and national health insurance. Problems, because there are too few doctors and nurses
Doctor's office or any other healthcare centre
3 F
Swedish SwedenDeveloped economies
Malmö city In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Nurse 4 EUR 100 $ 132 YesNational government
No No 1 4 4 Public facilities 5Open to everyone / Treatment given when needed regarless of patients income with no demands for payment now or later / Good treatments, including follow ups / Medical expenses and maximum drug expenses per year and person is about 200€
Doctor's office or any other healthcare centre
4 F
French FranceMajor developed economies (G7)
Ile de France In a urban areaMore than 50
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 1 700 $2 244 Yes
Your employer, National government, Self-funded
No No 1 4 4 Public facilities 4
Because we have access to a large panel of medicines and healthcare services. However, I think general private practitionners are profit-driven and tend to prescribe you medicines they have interest in (specific drugs, large vaccination campaigns promoted by pharmaceutical corp, do not want to rescribe homeopathy, etc). High-technology medicines, drugs and diagnosisis are so expensive that the Sécurité Sociale is endebted: therefore, some health policies are encouraging doctors and medical staff to reduce medical check-ups, and to prescribe low-cost drugs that are not necessarly efficient. The risk is to get low-cost and sometimes less efficient drugs and services, just because Sécurité Sociale might not be able to afford more expensive products. Prevention is probably harmed by costs reductions. Because we often do not have out-of-pocket payments, people may tend to overuse drugs that they do not actually need, and are not aare of the costs of the medicines they are buying. Another problem is that some people who cannot affort out-of-pocket payments at general practitionners officies, go to the hospital for minor illness, therefore making tertiray-care facilities overcrowded. I think that we could improve packaging efficiency: sometimes, the doctor prescribes you with a 5 days treatment, but the only packaging you can get at the pharmacy is a 10-days one = waste of drugs ...
Doctor's office or any other healthcare centre
2 F
South African South Africa BRICS Kwazulu Natal In a urban areaBetween 18 and 35
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
2 ZAR 1 500 $ 141 Nomyself and government
No Yes 3 4 3 Private facilities 2Poor access to health care services in rural areas. Extremely long waiting times for public hospital patients. Poor upkeep of patient rights, especially right to information and education re their own health care.
Doctor's office or any other healthcare centre
4 F
French FranceMajor developed economies (G7)
Ile de France In a urban areaMore than 50
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 EUR 1 200 $1 584 YesYour employer, Self-funded
No No 1 3 4 Public facilities 4
The system offers good helathcare coverage to everyone. Moreover, healthcare services are made easily available (and quite fast!). Since our system is very attractive, a lot of people come to receive healthcare services in France, which represents significant financial costs for the Sécurité Sociale, which is already facing funding trouble. A lot of people, through health insurance coverage have reimbursement rates of 100%: therefore, they are not aware of the real cost of their helatcare services or drugs, and tend to overuse helatcare services and drugs, even when it's not necessary. No sufficient controls : some doctors and patients may abuse the system (doctors are profit-driven, some hospitals may keep the patients longer than what is needed when the occupancy rate is low for instance). People who do not afford an health insurance can get a universal health coverage system: it's a good system beause everyone can benefit from healthcare services, but there also are some abuse.
Doctor's office or any other healthcare centre
3 M
TurkishUnited Arab Emirates
Developing economies
Abu Dhabi In a urban areaBetween 18 and 35
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner, Medical specialist (cardiologist, dermatologist, psychologist ...)
3 AED 500 $ 136 Yes Self-funded No No 4 2 3 Private facilities 4Hospital or any other tertiary-care facility
2 M
Canadian CanadaMajor developed economies (G7)
Ontario In a urban areaLess than 18
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
2 CAD 500 $ 460 Yes Your employer No No 2 3 3 Public facilities 4 Free healthcare is unavailable in most countries.Doctor's office or any other healthcare centre
2 M
Canadian CanadaMajor developed economies (G7)
Ontario In a urban areaBetween 18 and 35
31 year to 2 years
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Hospital personnel (doctor, midwife, specialist)
1 CAD 100 $ 92 Yes Father No No 1 1 4 Public facilities 5 It's free and it's very accessible to everyoneDoctor's office or any other healthcare centre
1 F
Korean South KoreaDeveloping economies
Ontario In a urban areaBetween 18 and 35
52 years or more
Private hospital
Nurse, Hospital personnel (doctor, midwife, specialist)
4 CAD 30 $ 28 Yes
National government, State government
No No 2 2 3 Private facilities 5Health care in South Korea does not offer free coverage for certain illnesses such as cancer. Although you are not required by law to apply for one, commercials for insurance coverages that are aired on TV are common. You are held responsible for finding an insurance company to assist you with the fees.
Doctor's office or any other healthcare centre
2 M
Canadian CanadaMajor developed economies (G7)
Ontario In a urban areaBetween 18 and 35
36 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 CAD 3 000 $2 759 Yes Your employer No No 1 1 4 Public facilities 4Doctor's office or any other healthcare centre
1 M
Sri Lankan Sri LankaDeveloping economies
In a urban areaBetween 18 and 35
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
2 USD 100 $ 100 No No No 3 2 3 Private facilities 3Doctor's office or any other healthcare centre
2 F
NationalityHealthcare
country
Healthcare country development class
(UNDP)
Place of residence
Place of residence: rural/urban
AgeOverall health
condition
Last visit with an health
provider?
In which facility? With whom?
How well do health providers usually explain you how to take your medicines?
Currency
Healthcare out-of-pocket
expenses per year
Counter value in USD
Health insurance?
Payer of health
insurance
In the last 5 years, has a lack of
money kept you or your
siblings from going
to the doctor?
In the last 5 years, has the price of a medicine kept you or
your siblings
from following a prescribed treatment?
Drugs and medicines expenses
represent a significant financial
burden for me and my
family
I usually take
generic drugs rather than
patented drugs
The medicines I
need are made easily
available
Which healthcare
facilities do you trust more?
How would you rate the overall
healthcare system in your country?
For what reasons?
Where would you usually go to receive
basic healthcare services?
For the same active ingredient, I would buy a generic drug
rather than a patented drug
Gender
Indian CanadaDeveloping economies
Ontario In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Hospital personnel (doctor, midwife, specialist)
2 CAD 200 $ 184 No No No 2 2 2 Private facilities 3Doctor's office or any other healthcare centre
2 M
Canadian CanadaMajor developed economies (G7)
Ontario In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Hospital personnel (doctor, midwife, specialist)
1 CAD 50 $ 46 YesParent's insurance by their employer
No No 1 1 4 Private facilities 4
Just pretty slow, seems like doctors do not really care for patients and sometimes no mediciness are prescribed and you are told to just take an over-the-counter drug. For access of healthcare in India I can say that if you have money, you have a way better access than if you don't. It's as simple as that. Access to healthcare can never be equal in a country where everything runs under corruption.
Doctor's office or any other healthcare centre
2 F
American United-StatesMajor developed economies (G7)
California In a urban areaMore than 50
3Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Physician's Assistant
3 USD 500 $ 500 YesNational government
Yes Yes 3 4 3 Private facilities 3It is good, adequate actually, and could be better. I wish naturopathic medicine was more readily accessible (affordable).
Doctor's office or any other healthcare centre
1 F
Canadian CanadaMajor developed economies (G7)
Ontario In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 CAD 500 $ 460 Yes Parents No No 1 3 4 Private facilities 5Doctor's office or any other healthcare centre
3 F
Canadian CanadaMajor developed economies (G7)
Ontario, Canada
In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 CAD - $ - YesParent's employer
No No 1 2 4 Public facilities 4Overall good service and practices everywhere you go however there may be long waits for some services that are in high demand (eg. Specialists and the emergency room)
Doctor's office or any other healthcare centre
3 F
Indian CanadaMajor developed economies (G7)
Ontario In a urban areaBetween 18 and 35
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 CAD 75 $ 69 YesState government
No No 1 3 3 Public facilities 4
Public healthcare is great since most health problems are treated for free. This also means longer waiting periods for patients, whose conditions may worsen in the process. Problems such as cysts, for example, require the typical patient to wait six months to a year before receiving treatment from a specialist (from the experience of a family member).
Doctor's office or any other healthcare centre
3 F
Indonesian IndonesiaDeveloping economies
Bali In a urban areaBetween 18 and 35
3Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 IDR 750 000 $ 64 No Self-funded No No 4 3 3 Private facilities 2Because the good healthcare system has not covered the rural areas yet, there's much difference between rural areas and urban areas. Moreover, our national health insurance doesn't cover all of iIndonesian people yet.
Doctor's office or any other healthcare centre
4 F
Indian India BRICS Bihar In a rural areaBetween 18 and 35
56 months to 1 year
Public and Private (Both)
General practionner
3 INR 9 000 $ 148 NoState government, Self-funded
No No 2 1 3 Public facilities 4There are good doctors in our country to take care of our health. There are plenty of government schemes which are made available to us through the Department of Health. I am an Indian and I have full faith in Indian doctors, they also keep good care of our health. Thank You and best of luck
Hospital or any other tertiary-care facility
2 M
Pakistani PakistanDeveloping economies
Punjab In a urban areaBetween 18 and 35
4Less than 6 months
Private hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
4 PKR 25 000 $ 246 No Yes Yes 3 1 3 Private facilities 2Very few doctors for a lot of patients. Polio is not eradicated. Hospitals have poor hygiene. There is a lack of funds. Funds allocated to health sector are very low.
Hospital or any other tertiary-care facility
1 F
Indian SwitzerlandDeveloped economies
In a urban areaBetween 18 and 35
3Less than 6 months
Public hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
2 CHF 2 500 $2 672 YesYour employer, Self-funded
Yes No 2 3 4 Private facilities 5 Paranoia and subsequent and over insuring of everythingDoctor's office or any other healthcare centre
3 F
Egyptian EgyptDeveloping economies
Cairo In a urban areaBetween 18 and 35
5Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
4 EUR 500 $ 660 No No No 3 3 3 Private facilities 3 The private health care system is expensive , while the public one is less efficient and slower.Doctor's office or any other healthcare centre
3 M
Indian India BRICS Paris In a urban areaBetween 18 and 35
42 years or more
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 INR - YesYour employer, Self-funded
No No 3 2 2 Private facilities 2Public hospitals are overburdened and insufficiently resourced. Access to quality treatment with latest techniques is available only in private hospitals and they are extremely expensive.
Doctor's office or any other healthcare centre
2 M
Indian India BRICSAndhra Pradesh
In a urban areaBetween 18 and 35
51 year to 2 years
Private hospitalGeneral practionner
2 INR 2 000 $ 33 No Self-funded Yes No 3 1 4 Private facilities 2Doctors are not taking responsibility, staff are very negligible, government surveillance is not there, etc. Doctor's office or any
other healthcare centre1 M
Indian India BRICSHimachal Pradesh
In a rural areaBetween 35 and 50
4Less than 6 months
Public hospital
Medical specialist (cardiologist, dermatologist, psychologist ...)
2 INR 10 000 $ 165 YesState government
No No 3 4 4 Public facilities 3Even though the health care facilities in hospitals are good, a lot needs to be done, especially in rural and tribal areas, where health care providers are few and patients have to travel large distances for a consultation
Hospital or any other tertiary-care facility
4 M
Indian India BRICS bihar In a urban areaBetween 18 and 35
4Less than 6 months
Private hospitalGeneral practionner
4 INR 1 000 $ 16 No No Yes 2 1 4 Private facilities 2Public infrastructure is very weak. Moreover, in India, it is impossible to get generic medicine. Only in some hospitals you can get some, otherwise any one can get any medicine without having a prescription.
Doctor's office or any other healthcare centre
4 M
Indian India BRICSHimachal Pradesh
In a rural areaBetween 35 and 50
46 months to 1 year
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Hospital personnel (doctor, midwife, specialist)
3 INR 5 000 $ 82 Yes Your employer No No 2 4 4 Public facilities 3Lot has been achieved considering what conditions we were in as a society but there still is a lot that needs to be done.
Doctor's office or any other healthcare centre
4 M
Indian India BRICS New Delhi In a urban areaBetween 18 and 35
4Less than 6 months
CGHS DispensaryGeneral practionner
3 INR 1 500 $ 25 No No No 1 3 2 Public facilities 3Private health sector makes money and their treatment is not upto the mark. Public health sector is flooded with patients due to which physicians many times don't take care of the patients carefuly and the quality of medicines received from government health hospitals, dispensaries is not effective.
Doctor's office or any other healthcare centre
2 F
Indian India BRICS Maharashtra In a urban areaBetween 18 and 35
32 years or more
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
Medical specialist (cardiologist, dermatologist, psychologist ...)
3 INR 1 000 $ 16 No No No 1 3 3 Private facilities 3The state where I stay has a good public health infrastructure as well as many tertiary private healthcare facilities. But, the cost of healthcare is somewhat higher espcially the cost of tertiary healthcare.
Doctor's office or any other healthcare centre
4 M
Indian India BRICS Maharashtra In a urban areaBetween 18 and 35
4Less than 6 months
Health care centre (including doctor's offices, clinics, ambulatory surgery centres)
General practionner
3 INR 5 000 $ 82 YesInstitution where I study
No Yes 3 2 2 Private facilities 2 Human resources and infrastructure issues in the public health care systemDoctor's office or any other healthcare centre
3 F
121
Appendix 8 – General overview of the respondents’ answers
122
123
124
125
In which country do you receive healthcare services?
126
Appendix 9 – Survey analysis 1: Countries' development groupings/ Healthcare system rating
Our concern is to find out a potential relationship between your country development grouping and
your rating (perception) of the overall healthcare system in your country. Technically, likert scales
(rating of the overall healthcare system in your country, from poor to very well) are ordinal, but they
are, most of the time, treated as interval variables. We will therefore consider the rating of the
overall healthcare system in your country as an interval variable. We will be comparing 5 means: the
healthcare system rating of major developed economies (part of the G7) (1), the healthcare system
rating of developed economies (2), the healthcare system rating of the BRICS (3), the healthcare
UNDP development groupings
1 - Major developed economies
2 - Developed economies
3 - BRICS 4 - Developing economies
5 - Least developed countries
Ratings of the overall healtcare system
5 5 3 3 1 3
5 2 5 2 4 2
4 4 4 3 3
5 4 3 3 2
3 5 3 3 2
4 4 3 4 2
4 5 5 5 4
5 5 5 3 3
4 4 1 3 3
4 4 2 1 3
4 5 4 2 2
4 5 2 3 3
5 4 5 3 3
5 5 4 2 4
4 4 4 4 5
5 5 4 2 3
4 3 4 4 3
3 4 1 2 2
4 5 5 2 2
4 4 1 3 3
4 4 5 2
3 4 4 3
4 4 5 3
4 4 5 3
4 4 2
4 5
5 4
5 4
4 3
4 5
4 4
4 4
Mean 4,203125 3,625 2,85 2,85 2,5
Minimum rating
2 1 1 1 2
Maximum rating
5 5 5 5 3
Median 4 4 3 3 2,5
Standard deviation
0,646840612 1,377221526 0,8660254 0,933302004 0,707106781
127
system rating of developing economies (4) and the healthcare system rating of the least developed
countries (5). We are using an Anova test because we are testing simultaneously several groups
means to see if there is an overall difference.
We are fully aware that the rating of the overall healthcare system in your country is dependent of
the referential you take. People do not usually know how the healthcare systems in other countries
than theirs work. Therefore, the perception of the quality of your healthcare system is probably
biased by the referential which may vary for every individual.
Hypothesis
H0: µ (Major developed economies)= µ (Developed eonomies) = µ (BRICS)= µ (Developing
economies)= µ (Least developed countries)
H1: µ (Major developed economies) ≠ µ (Developed economies) ≠ µ (Developing economies) ≠ µ
(Least developed countries)
Level of significance: 0.05%
Anova: single factor
Groups Sample size Sum Mean Variance
1 - Major developed
economies
64 269 4,203125 0,418403
2 - Developed
economies
24 87 3,625 1,896739
3 - BRICS 25 70 2,8 0,75
4 - Developing
economies
20 57 2,85 0,871053
5 - Least developed
countries
2 5 2,5 0,5
Source of variations SS df MS F P-value F crit
Between groups 52,93599537 4 13,23399884 16,37959 6,8661E-11 2,441350263
Within groups 105,034375 130 0,807956731
Total 157,9703704 134
Conclusion
On average, people receiving healthcare in developed economies seem more satisfied of the
national healthcare system than people receiving healthcare in developing economies. The
difference between the different means is significant. Indeed, F is bigger than its critical value (F
crit) and the probability (P-value) is smaller than the level of significance (0.05).
Consequently, we can reject H0 and accept H1: there is a significant relationship between your
country development grouping and its overall healthcare system quality. People leaving in
developed countries usually benefit from a better healthcare system than people leaving in
developing countries, probably because healthcare systems in developing countries are at their
beginning stages or sometimes nonexistent, because of a lack of public funding.
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Appendix 10 – Survey analysis 2: Countries development groupings / Most trusted healthcare sector
Our concern is to find out a potential relationship between your country development grouping and
the healthcare sector you trust more. We are using Chi-square to observe if the distribution of
frequencies is what we would expect to occur by chance. Otherwise, there may be a dependence
between the two variables.
Hypothesis
H0: Independence between the country development grouping and the most trusted healthcare
sector
H1: Dependence between the country development grouping and the most trusted healthcare sector
Level of significance: 0.05%
Observed frequency
UNDP development
groupings
1 - Major
developed
economies
2 -
Developed
economies
3 - BRICS 4 -
Developing
economies
5 - Least
developed
countries
TOTAL
Private hospitals 17 12 20 16 2 67
Public hospitals 45 12 5 4 0 66
TOTAL 62 24 25 20 2 133
Expected frequency
UNDP development
groupings
1 - Major
developed
economies
2 -
Developed
economies
3 - BRICS 4 -
Developing
economies
5 - Least
developed
countries
TOTAL
Private hospitals 31,2330827 12,0902256 12,593985 10,075188 1,0075188 67
Public hospitals 30,7669173 11,9097744 12,406015 9,92481203 0,9924812 66
TOTAL 62 24 25 20 2 133
P-Value = 0,00062365Chi-square test:
Conclusion
When comparing observed frequency to expected frequency, we can see that people in developed
economies seem to trust public facilities more than public facilities, while it is the opposite for
people in developing countries. The difference between the frequencies is significant. Indeed, the
P-value is smaller than the level of significance (0.05).
Consequently, we can reject H0 and accept H1: there is a significant relationship between your
country development grouping and its most trusted healthcare sector. Indeed, apparently, people
in developed economies trust more public facilities, while people in developing economies seem to
trust more private facilities. This trend may be explained by a lack of healthcare public funding in
developing economies that might generate a lack of quality regarding public facilities.
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Appendix 11 – Survey analysis 3: Countries’ development grouping / Most recent visit to an healthcare provider
Our concern is to find out a potential relationship between your country development grouping and
your most recent visit with an healthcare provider. Indeed, one can assume that people living in
developing countries or in least developed countries might face difficulties to access healthcare
services, such as financial difficulties, distance or lack of healthcare personnel. We will therefore
compare 5 means: average time in months since the most recent visit to an healthcare provider for
people in major developed economies (part of the G7) (1), average time in months since the most
UNDP development groupings
1 - Major developed economies
2 - Developed economies
3 - BRICS 4 - Developing economies
5 - Least developed countries
Last visit with an healthcare provider (in
months)
3 9 3 18 9 9
3 9 3 3 18 18
3 9 18 24 24
3 3 3 3 9
9 3 3 18 3
9 3 3 3 24
3 3 3 3 9
3 3 3 3 3
3 18 3 3 3
18 3 3 3 18
3 3 3 9 3
3 3 18 3 18
3 3 3 3 3
3 3 3 24 9
24 3 18 3 24
3 18 18 9 9
3 3 3 9 3
9 3 3 24 3
18 3 3 18 3
3 3 9 3 3
3 3 3 3
3 3 3 9
3 3 3 3
9 3 3 24
9 18 3
24 9
3 3
3 3
3 3
3 3
9 9
3 3
Sample (number of participants)
64 24 25 20 2
Mean 5,859375 5,75 9,12 9,9 13,5
Minimum rating 3 3 3 3 9
Maximum rating 24 18 24 24 18
Median 3 3 3 9 13,5
Standard deviation 5,46233042 5,72750799 8,28311536 8,03217215 6,36396103
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recent visit to an healthcare provider for people in developed economies (2), average time in months
since the most recent visit to an healthcare provider for people in BRICS (3), average time in months
since the most recent visit to an healthcare provider for people in developing economies (4) and
average time in months since the most recent visit to an healthcare provider for people in the least
developed countries (5). We are using an Anova test because we are testing simultaneously several
groups’ means to see if there is an overall difference.
Hypothesis
H0: µ (Major developed economies)= µ (Developed economies) = µ (BRICS)= µ (Developing
economies)= µ (Least developed countries)
H1: µ (Major developed economies) ≠ µ (Developed economies) ≠ µ (Developing economies) ≠ µ
(Least developed countries)
Anova: single factor
Groups Sample
size
Sum Mean Variance
1 - Major developed
economies
64 375 5,859375 29,8370536
2 - Developed economies 24 138 5,75 32,8043478
3 - BRICS 25 228 9,12 68,61
4 - Developing economies 20 198 9,9 64,5157895
5 - Least developed countries 2 27 13,5 40,5
Source of
variations
SS df MF F P-value F-crit
Between groups 482,558958 4 120,63974 2,82723511 0,02740433 2,44135026
Within groups 5547,17438 130 42,6705721
Total 6029,73333 134
Conclusion
The difference between the different means is significant. Indeed, F is bigger than its critical value
(F crit) and the probability (P-value) is smaller than the level of significance (0.05).
Consequently, we can reject H0 and accept H1: there is a significant relationship between your
country development grouping and the average duration since your most recent visit to a
healthcare provider.
Therefore, one can assume that the more developed you country is, the more recent your last visit
to an healthcare provider will be, which might mean that people in developed countries often go
to visit healthcare providers, while people in developing countries seldom use healthcare facilities.
This is probably due to financial and distance barriers to access healthcare facilities in developing
countries.
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