Examination of Witnesses (Questions 1040
- 1059)
TUESDAY 20 MAY 2008
Dr Iain Gillespie and Dr Benedicte Callan
Q1040 Lord Avebury:
This is where the robust analysis comes in?
Dr Gillespie: This is where the robust analysis
comes in, exactly.
Q1041 Lord Avebury:
Who is going to undertake that then?
Dr Gillespie: I do not know who will undertake
the analysis, but certainly in our view if one comes back to the
point raised by the Chairman of asking what works and what does
not, where does the value for money lie, at the moment, as far
as we can see, we do not have in place globally, internationally,
a system for developing robust analysis of the different interventions
and asking what works where. Who should do such analysis is for
our governments to decide. I am not suggesting it should be us.
Q1042 Lord Avebury:
But in your paper you say this is necessary, so why should the
OECD not undertake it?
Dr Callan: I think there is some analysis of
these different mechanisms. It is done for the most part by academic
think-tanks and researchers, so there are people who are pro-AMCs,
there are people who are against AMCs, people who will say that
they are all very well and good when you have a bunch of leads
already well-advanced and some will say it is going to be completely
useless when you do not know what kind of vaccine you want to
develop—it will be completely useless for AIDS, for example.
What we do not have, and I think this is where the more robust
analysis comes in, is any sense of, if governments are going to
be funding these, what are the pros and cons of different options
that they have before them. They have Advance Market Commitments
before them, they have ideas of patent extensions, they have ideas
of patent buy-outs, they have these ideas of the Global Fund,
which is a "push" mechanism really, just to increase
the amount of funding that goes into R&D more generally. There
are pros and cons to these. They do address problems at different
points in the innovation cycle. They are more or less systemic,
and what I mean by "systemic" is that one of the major
problems with AMCs is that one would have to create a series of
AMCs for a series of different diseases and they would have to
be done over time.
Q1043 Lord Avebury:
Yes.
Dr Callan: There is an analysis of what the
pros and cons of these different mechanisms are, but there is
not really a good analysis of what choices governments themselves
have and what some of the pros and cons of investing in these
different mechanisms are going to be and where the gaps are going
to be if we do go down the route of AMCs. Does that mean that
we are foregoing research into riskier research ventures whose
outcome is less well-known. That is the place where there is definitely
a need for a better sense of what options are available to governments.
There is a certain amount of academic literature that exists on
these different mechanisms, they all come out of academia as ideas,
but now the question is who is going to fund them and what is
the best way for governments to spend their limited resources
in this area.
Q1044 Lord Desai:
I am going to slightly reverse the order of my question because
what we are discussing about the knowledge base for deciding what
is and what is not effective is very important. One of the things
you said is that the Noordwijk Agenda identifies the need for
further action on "facilitating the development ... of a
sustainable architecture for the sharing and exchange of knowledge,
data and research tools necessary for the discovery of medicines.."
What are the problems here? Are the problems technical data sharing
or practical, technical, legal, political? We know in the Indonesian
case they refused to do any virus sharing. Is that the sort of
problem you face in constructing a proper knowledge base?
Dr Gillespie: You ask what are the problems
and I would say that all of the issues you have listed are problems.
I would probably add one to them, which is financial. If one steps
back from this and thinks in general terms of what is going wrong
here, I think our experience from Indonesia and from a number
of other countries, often the subject of looking at the sharing
of information is who are the winners and who are the losers in
sharing of such information. It seems to us it is the practitioners,
those who are generating and using information, who are the ones
who are best placed to reach a judgment on what they win and what
they lose, what do they gain by networking. A top-down approach
of saying, "You will network, you will share", is all
well and good provided there is also the bottom-up approach of,
"and here is what you will benefit from it. Here are some
of the checks and balances in place. Here is the financing for
delivery". At the moment we see a desire to network, a desire
to look at knowledge and information exchange. We see a number
of models in other fields that seem to be interesting, seem to
be being developed by practitioners and maybe working, but understanding
the transaction and costing them is complex. Essentially, in many
cases we are not seeing these two initiatives, the bottom-up and
the top-down, come together. If I was to say there was one fundamental
issue over the Indonesian case, I would say it was perhaps the
lack of mutual understanding of the bottom-up and the top-down.
Q1045 Lord Desai:
Is that because the people do not want to share information because
there are economic consequences of revealing, so it is sort of
a financial problem, not lack of finance but fear of loss of business?
Dr Gillespie: I think that is one of the issues.
One of the issues is the notion of the inherent value of intellectual
assets, whether it be a genome sequence or know-how. If you share
that information and share that information openly, will you get
a return on that investment? I was saying what are the checks
and balances that allow you some recourse to having a return on
the intellectual asset that you have put in. Here, the patent
pool model is a rather interesting one, where the sharing of intellectual
assets, in this case patents, allows anyone essentially to negotiate
access to that body of information and there is a return, whether
it is a monetary return or non-monetary return, and it is a clear
and understood return to each individual who has put an asset
into the pool. That notion, that understanding and buy-in—that
there is a return on that investment to the individual putting
into the pool in that model—is the key critical factor here.
Q1046 Lord Desai:
The Agenda calls for "the use of existing flexibilities of
multilateral agreements to foster innovation and access".
There the question arises whether the flexibility afforded by
TRIPS is being undermined by bilateral FTAs. Is there a lot of
co-operation between you and WHO, WTO, WIPO and organisations
like that?
Dr Gillespie: As an organisation, the approach
that the OECD has taken on multilateral trade agreements is that
it is for WTO and WIPO to negotiate them to make them work. Our
focus is, firstly, on what are the economic impacts of these regimes
and, secondly, as far as patents are concerned, it is around downstream
licensing behaviour to try and encourage access and shift knowledge
around. So it is to look at the patent system as a sustainable
regime which has two purposes: one is rewarding investment; the
other is the dissemination of knowledge. Our focus is more on
the dissemination of knowledge in this field. As far as whether
the individual trade agreements have stymied flexibilities or
not, that is not something we have focused on or done any analysis
of, so I could not really shed any light on that. Instead, what
we have focused on is, as I say, the downstream behaviour; you
have a patent or you have a trademark, how do you try and encourage
access to that so you get a social benefit from that system.
Q1047 Lord Desai:
Is there not some evidence that some of the bilateral FTAs signed
by the US are designed to avoid the consequences of multilateral
TRIPS Agreements? Have you come across that or is that just a
suspicion but not a reality?
Dr Gillespie: We have certainly heard the points
put forward and seen some academic analysis of this, but as an
organisation we have not focused on that ourselves.
Q1048 Baroness Hooper:
A switch of subject to the "brain drain". I was shocked
to learn that the number of foreign-trained doctors has tripled
in some OECD countries over the last few decades, and I suspect
there are even more nurses and other health workers involved in
this. I was even more shocked that this represented something
like 30 per cent of some African countries' workforce. This is
particularly so where there has been active recruitment by OECD
countries, and indeed the UK is one of the culprits and now seems
to have the bizarre situation that, having actively recruited,
we do not have enough jobs for our own home grown doctors. I wonder
if there is, in fact, a reverse "brain drain" and whether
the OECD is monitoring these trends. My main question is about
the Global Code of Practice for health worker migration which
is being developed. I wonder how effective you think this might
be and also, again, back to the question of who should take the
lead.
Dr Gillespie: Well, I think in our view the
efforts to develop a Global Code of Practice are novel. It seems
to us to be a sensible way to develop in this area, but the problem,
of course, is that a Code of Practice is exactly that, it is a
Code of Practice; so the trick, if you like, is to convince entities
to abide by that Code of Practice, particularly those who are
going out and recruiting from Africa and other countries. That
is something that I think will make or break the effectiveness
of this Code of Practice. In itself, it is a palliative, if you
like, for the problem, and the problem, as we see this, is predominantly
one that comes back to this horizontal question that, if we invest
as a global community in the development of the health systems
and create job opportunities for home-grown doctors in all of
the countries of the world, not just the country that you and
I know best, then we think that is the only sustainable long-term
solution to overcome this "brain drain", which is probably
going mainly in one direction at the moment. As far as the circulation
of medical professionals around the OECD countries is concerned,
we have a couple of metrics that look at that movement in the
OECD countries, between them and outside the OECD countries. At
this point, unless Benedicte contradicts me, I do not think we
are in a position where we can say there is a negative "brain
drain", for example, of UK-trained medical professionals
out of the OECD region. The long-term solution for us is about
the capacity of local health systems to employ health professionals.
In the short-term, a Code of Practice, if it is adhered to, perhaps
particularly by private sector recruiters, seems to us to be a
reasonable stopgap approach to addressing that.
Q1049 Chairman:
I was told a short while ago, and I do not know how correct this
is, that the Philippines has a deliberate policy of training excess
nurses on the grounds that many of them will go overseas, but
they benefit from them coming back with greater experience and
training, and it also benefits them in terms of money sent home,
which I understand in the case of the Philippines is very large
indeed. Have you heard of this being true in other situations
or is it something unique to the Philippines?
Dr Gillespie: We have no information on that
on nurses, my Lord Chairman.
Lord Desai: Can I add to this, being
an example of "brain drain", or "drain" because
I left my brain outside!
Chairman: Or a split brain, you go back
and forth!
Q1050 Lord Desai:
Is it not likely that, if people knew they could not go abroad,
they would not enter the medical profession or train to be nurses?
If I was a Nigerian woman and knew I could not go abroad, what
is the incentive to go into nursing? There are pluses and minuses
with this.
Dr Gillespie: I hope that is a very stark view.
Q1051 Lord Desai:
I am a professional economist, I take the "brain drain"
seriously.
Dr Gillespie: I think that, when we have to
try and internalise the motivation for individuals going into
the health profession, then I am sure they are not just monetary
and about going abroad.
Baroness Hooper: It is a vocation.
Q1052 Lord Desai:
You could kill the golden goose.
Dr Gillespie: If I may respond, because an economist
asking an economics question of the OECD we must respond. I think
I would go back to the long-term solution still being on a viable
job market for professionals locally. If such a viable job market
exists, then there is no need to go abroad, but that need not
necessarily mean there is no choice to go abroad. What we are
seeing is a driver for professionals to go abroad and can one
address that from the delivery of healthcare, perverse incentives
to move.
Dr Callan: I would add two comments, my Lord
Chairman, if I may. One is that our DELSA colleagues did say that
one of the issues one would have to think about if we were to
develop a code would be that denial of employment due to country
of origin would be illegal in most of the OECD countries, so it
would be difficult to imagine how to put that into place; it would
not be a Code of Conduct very much targeted at practice of the
health sector. The second issue, although we do not have the brief
to hand, is that we certainly do track remittances and, while
we do not have any information on nurses in the Philippines, there
is data in the OECD on remittances and the importance of remittances
to developing countries, and we are following this issue very
closely. It is of great importance because of the contribution
to the finances of certain countries, the Philippines being perhaps
one of the most important examples of remittances being a large
proportion of their national budget.
Q1053 Lord Avebury:
I just wondered whether in the development of the Code of Practice
regard is being had to the progressive tightening up of regulations
regarding highly skilled migrants in OECD countries as, for example,
in our Highly Skilled Migrants Programme in the UK which I believe
is being paralleled in other OECD countries. Would the Code of
Practice automatically allow the existing methodologies of picking
highly skilled migrants, including health workers of course? Or
would the Code of Practice be tighter so that our own existing
regulations would have to be changed?
Dr Gillespie: I do not think we are sufficiently
well-briefed on what the Code of Practice is to answer that, Lord
Avebury, but we can certainly write to you in response with a
view on that after this session.
Baroness Hooper: Whilst I appreciate
that Cuba is not a member of the OECD, or of many other things,
Cuba is a very interesting example in terms of medicine, because
they produce a number of doctors who do actively work in the region,
in Africa and other places, and they are not doing it for financial
reward or export in any way, and yet the recruitment of doctors
in Cuba seems to be as high as ever. Do you look at this example
from time to time?
Chairman: We are probably going slightly
outside your remit now, but it is quite interesting.
Lord Desai: Even that of the Committee!
Q1054 Chairman:
Yes.
Dr Gillespie: I think that, from the perspective
of trained science professionals, one can look at a range of different
motivations for movement, a range of different policies in place
to encourage the kind of behaviour that you have articulated from
the Philippines to actually see "brain circulation"
rather than "brain drain" one way or another as really
adding to the value of knowledge. We do not have any specific
experience of Cuba, that is a slightly problematic country for
OECD generally.
Q1055 Baroness Hooper:
I was thinking more in terms of the Code of Practice.
Dr Gillespie: I am afraid, my Lord Chairman,
this is something that we would not be briefed on.
Chairman: It is not a critical issue
actually and I probably should not have led you astray with the
Philippines example, although it interested me as to why they
suddenly seem to have embarked on this. Can we move on to the
issue of bioterrorism.
Q1056 Baroness Falkner of Margravine:
It is nice to see an alumnus from the same Masters programme.
I always wondered where people would end up. We were together
in that London centre, were we not? It is very nice to see you
again. Talking about Codes of Practice, I notice that you have
quite impressive initiatives, particularly of late, in terms of
dealing with BRCs and bioterrorism in particular, and last year
the Best Practice Guidelines on Biosecurity for BRCs and so on.
Several people we have spoken to among our witnesses have told
us that deliberately initiated disease and naturally occurring
disease are similar both in the way that they impact on populations
as well as the public health response that we need to cope with
them. What is your view on that?
Dr Gillespie: I think that, in terms of impact
on populations and response, we concur. The differences, which
is where we have focused, have been around access to dangerous
pathogens in the first place and mode of introduction, particularly
the fact that introduction might be at multiple sites, it may
be co-ordinated. So the response to a very deliberate introduction
at multiple sites at a relatively high dose of an infectious agent
that could impact a number of populations simultaneously could
become overwhelming compared to an emerging infectious disease
from the out-of-Africa or out-of-China model. On the specifics
of the progress of disease, the specifics of how public health
authorities would have to respond to the outbreak, we see clear
similarities.
Q1057 Baroness Falkner of Margravine:
In terms of your guidelines, particularly the part that focuses
on robust risk management measures, the guidelines are effectively
only guidelines. What is your assessment of the extent to which
facilities, resource centres, are going out and adopting that
best practice and being vigilant in terms of doing their risk
assessment and sticking to it? I say that particularly because
in the UK we have these spontaneous outbreaks.
Dr Gillespie: The UK, of course, was one of
the key players in articulating guidelines in the first place.
We have done some work so far looking at implementation and impact,
and we are in the process of doing more. What we have done so
far is that we have a number of countries that at the policy level,
at least, are putting these in place. The Russians are moving
to do this. The Chinese have published the guidelines in Chinese
and seem to be adopting them. The French and the Germans have
adopted them. The French have adopted them in law and the Italians
in law. The Canadians are moving forward slowly. The Brazilians
have adopted them. I have mentioned a lot of non-OECD countries,
but what we have done so far is picked up on those countries that
have worked with us and have reported to us, "This is what
we are doing". We have not yet gone out and systematically
collected data but that is something we will be doing over the
next few months because we are going into this process of enlargement
of the OECD. I am not very good at listing countries, I apologise.
We have Russia, Slovenia, Estonia, Chile and Israel at the moment
where we have entered negotiations on enlargement. One of the
things that we must do is make an assessment of the extent to
which these countries have enacted these particular guidelines
prior to the Council taking a view on whether these countries
should join the OECD. First, to be able to do that we must also
do the same analysis of the extent to which OECD countries have
adopted these guidelines. By around the end of this year we should
have a much better picture of the impact of the guidelines at
least at the policy level.
Q1058 Baroness Falkner of Margravine:
Coming back to those member countries, the existing ones that
have adopted them, in terms of what you said in answer to the
earlier question that the speed of infection would be much faster
than it would be with naturally occurring, so the time to act
in terms of a civil contingency plan would be rather shorter.
Would most of your members have in place civil contingency plans
to deal with that?
Dr Gillespie: The first thing to say is that
the guidelines are very focused on access. They are about trying
to control access by criminals to materials. They do not focus
on response, on triggers of response. Having said that, I would
say that the extent to which our member countries have engaged
in looking at programmes to respond extremely quickly and effectively
to a terrorist introduction of a dangerous pathogen are very variable
indeed. We have some countries which have taken this extremely
seriously and have strong capacities in place from civil defence,
interaction with the police force and health authorities, in the
stockpiling of vaccines, antivirals, antimicrobials. We have other
countries which have done much less. It is very, very difficult
to say.
Q1059 Lord Howarth of Newport:
My question is on another aspect of OECD's work, if I may. I would
think that the OECD is particularly well-placed to assess the
relative contributions of policies, on the one hand, which are
policies of specific medical intervention, the provision of vaccines,
medicines and qualified medical personnel, that contribution to
improving health across the globe, and, on the other hand, policies
that are addressed at the conditions in which ill-health incubates,
sanitation, poverty, education. Do you work to study the relative
contributions of medical or social interventions? Do you have
views on that?
Dr Gillespie: I think we come at this from two
angles. First, Benedicte was speaking about coherence earlier.
We look at coherence within policies, between policies internationally
in the donor countries and in the provider countries. There is
a policy coherence perspective to different interventions, whether
they be at the technical level or the capacity level, being integrated
well. At the moment there is not a huge focus in the organisation
on any one sector of this coherence although, as we said, health
is being looked at as a tracer sector for aid effectiveness. In
principle, the OECD could do more looking at coherence amongst
these kinds of policies, but at the moment we are probably not.
The second point is about what is effective. Here the focus of
our countries so far in terms of cost and clinical effectiveness
has tended to be very much on the OECD country concerns which
have mainly been around pharmaceutical supply, pharmaceutical
pricing, impacts on innovation, the cost-effectiveness of different
pharmaceutical and other interventions. We have not done that
kind of relative effectiveness assessment with a focus on particularly
developing countries. That is not to say that we could not, but
so far we have not.
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