Examination of Witnesses (Questions 1080
- 1099)
TUESDAY 20 MAY 2008
Dr Nils Billo
Q1080 Lord Desai:
I want to come to my question, but, before I do that, you spoke
about the difficulty of spreading it down to the bottom. Have
you thought of a Global Ambassador for TB and HIV together, somebody
who is so famous that their face is known everywhere?
Dr Billo: We have the former President of Portugal,
Jorge Sampaio, who is the Ambassador for TB.
Q1081 Lord Desai:
I am sure he is lovely, but his face is not known.
Dr Billo: No, it is not known.
Lord Desai: It is not like Pele or someone like
that.
Q1082 Baroness Hooper:
Elizabeth Taylor?
Dr Billo: That certainly is an idea and we have
tried that.
Q1083 Lord Desai:
I offer it to you.
Dr Billo: There are always some pitfalls with
that. We got the footballer Figo, but he ran a cat over with his
car and he now has a very bad reputation!
Q1084 Lord Desai:
One of the problems, as you said, is that HIV/AIDS is glamorous
and TB is not, but TB has been around for ages, TB is not a young
disease. The Global Fund told us that TB people are using drugs
which are 40 years old and diagnostics which are 100 years old.
Why is there a shortage of new drugs and diagnostics for TB? Is
it an intellectual property rights problem?
Dr Billo: It is a business. Why would you invest
in the development of a drug that you cannot sell at a high price?
There is no incentive. There is no incentive for companies to
produce a drug which is going to be used obviously by a lot of
people but who are not going to be able to pay $100 for a course
of treatment. A course of treatment at the moment is between $20
and $30 and most of these patients cannot afford that money. As
a matter of policy, TB drugs are being given out for free. Any
new drug that comes out needs to be cheap, otherwise neither the
Global Fund nor the governments will be able to buy those drugs.
The incentives have not been there and because of that the Global
Drug Alliance has been formed and is trying hard to find new drugs,
but it is not obvious. If we found a new compound today that would
be promising, we would need to organise clinical trials and it
would take at least three, four, five years. We do not think we
will have a new drug tested in a clinical trial before 2010/12,
and that is an optimistic view. Countries have not invested in
drug development.
Q1085 Lord Desai:
Is it a matter of encouraging basic research?
Dr Billo: Yes. I have said, and I said this
in Norway because there was a meeting on that topic, that governments
have to invest more in basic science, in the development of drugs,
but, more importantly, in vaccine development. In our opinion,
the only thing that would really help us get to grips with the
TB and AIDS epidemics is going to be a vaccine like we have seen
in other diseases.
Q1086 Chairman:
Vaccine is low profit, is it not?
Dr Billo: It has to be cheap.
Q1087 Chairman:
What about differential pricing for drugs?
Dr Billo: This is very difficult because of
the smuggling issues.
Q1088 Chairman:
So the drug ends up being a corrupted drug?
Dr Billo: Yes.
Q1089 Chairman:
You do not think that works?
Dr Billo: It is working. If you buy drugs in
the UK or in the United States or Switzerland, TB drugs are much
more expensive in the sector than if you buy it from the Global
Drug Facility, which is housed in WHO, where a course of treatment
at the moment is between $20 and $30, which is affordable for
countries.
Q1090 Baroness Hooper:
We have touched on this already and you have advocated an holistic
approach and referred to the fact that TB is a disease of the
poor, but looking at the wider picture and the need for more joined-up
thinking between health, trade, economic development and organisations,
whether IGOs or NGOs, WHO, WTO, OECD—and we talked earlier
about the role of the WHO in all of this as the orchestrator perhaps
of these—do you see enough appropriate action being taken
outside the health sector between other organisations?
Dr Billo: I would say that a lot still needs
to be done and that we are struggling with the basic technical
health-related issues. We need to make sure that patients who
have a disease have enough money to get to the health centre.
As I said before, if they do not have the money to pay for their
lorry or their taxi cab to get to the health centre, they will
not come. I will take the example of pneumonia in children, where
we have a very successful programme in Malawi. If the mothers
do not see the advantage of going to a health centre because they
will not find the drugs, they will just let the kid die and have
another one. The economy is critical, and these links need to
be much more addressed. Obviously removing poverty is not something
that we can achieve from one day to another. We have tried several
programmes where we gave incentives to TB patients, we gave them
a kilogram of rice or a travel voucher so they would come and
get the treatment they need. That certainly needs to be addressed
much more forcefully. This is not only true for TB but for any
other disease. WHO is addressing it, but getting WTO or other
governmental organisations involved in health is critical, I would
absolutely agree with you.
Q1091 Chairman:
Can I take you back to the argument between the horizontal and
the vertical.
Dr Billo: Yes.
Q1092 Chairman:
It has become an issue for this Committee in a way because we
have been told by some people that not enough is put into the
horizontal healthcare system, the basic healthcare system, and
maybe too much into the treatment of individual diseases. We have
also been given another view that these two pictures are not a
good picture of reality, that there needs to be a much more varied
approach and that both are necessary. What is your view of it?
How do you think the vertical treatment of disease should co-ordinate
with the building up of basic healthcare systems?
Dr Billo: You are absolutely right. The theme
of our World Conference this year is the importance of health
system responses and global threats to lung health. Health systems
are definitely deficient, there is not enough infrastructure and
there is a huge human resource issue presently. A lot of good
personnel in countries go to the UK, Switzerland, the United States
and do not stay in their countries because they are not able to
get a proper wage. That has not helped either. Stabilising health
systems, improving the working conditions, making sure that health
personnel are retained in their jobs, that there are incentives
to advance in their jobs, this needs to be invested in first of
all by governments themselves; it is not possible that DFID, the
Swiss Development Corporation or USAID can fund that. The Global
Fund can do quite a lot, but basically it is the governments that
need to put more money into the infrastructure and health personnel
to make sure that these programmes not only have an existence
on paper with two or three people at the top in the capital but
that all the centres, the cities, the peripheral health facilities,
are properly staffed, have adequate medicines available and adequate
infrastructure. That is certainly a big, big issue.
Q1093 Chairman:
Supposing I played the role of Devil's Advocate and said that
the money that Bill and Melinda Gates are putting in is enormous
but actually it would be better spent on providing basic healthcare
structures, what would you say to that?
Dr Billo: The question is what do you mean by
"basic".
Chairman: I mean the provision of basic
clinics on the ground in areas where people can reach them, for
example.
Baroness Falkner of Margravine: Primary
care.
Q1094 Chairman:
Would you agree with that?
Dr Billo: I think this is critical, but if you
do not have somebody who co-ordinates drug distribution to those
clinics, for instance, this infrastructure will not help.
Q1095 Chairman:
You are saying that should be the government's role?
Dr Billo: Yes. You are talking about private
clinics?
Q1096 Chairman:
When you say it is critical that it is there, you could argue
that Bill and Melinda Gates's money would be better used to provide
that.
Dr Billo: Very often what will happen, and this
is a very human thing, is that it is a business; and, if you have
private clinics, those who have money will benefit from such a
system but the poor will fall through the cracks, they will not
get the attention. They will probably go to the private sector,
and we have a lot of examples where they go first to the private
sector, they pay the first two visits to the general practitioner
or specialist but after a while they do not have money to pay
and they discontinue their treatment. We need to really reinforce
both systems. In India, for instance, the private sector is very
large. I would say that 40 to 60 per cent of TB patients probably
go first to a private practitioner to get their treatment. It
is only when you have a really strong government system where
people realise they get proper, decent treatment and drugs that
they switch, but very often they approach the private practitioner
first.
Q1097 Chairman:
I understand that. That is helpful. Do you think there is a bigger
role for the World Bank in investment in infrastructure, the infrastructure
of the health system in a country? Have you thought about that?
Dr Billo: Yes. The responsibility is first and
foremost with the governments. Certainly the World Bank should
also invest in infrastructure. Development agencies invest heavily
in roads, telecommunications, but I think infrastructure needs
to be heavily supported also. I would very much agree with that.
Q1098 Chairman:
One would obviously agree that governments matter, but the reality
is that very often the governments are corrupt, despotic, incapable
or non-existent in some cases.
Dr Billo: I agree. It should be supported heavily.
It should go hand-in-hand with human resources because it does
not help to have a nice clinic and no people who can work there.
Q1099 Baroness Hooper:
Back to the co-ordination/collaboration issue which has been touched
on, but perhaps looking at it from the perspective of a small
developing country and the way in which intergovernmental associations
co-operate with non-governmental associations, foundations, charities,
and so on, is there a problem over competition between some of
these organisations? NGOs particularly may be unwittingly reinventing
the wheel because they do not know what is going on but they move
in with the best of intentions perhaps. Therefore, is the International
Health Partnership, which seems to be the vehicle for co-ordination,
working or likely to improve the way these various agencies can
cope?
Dr Billo: This is an excellent question, which
is a real challenge. If you look at a TB programme manager or
an AIDS manager, one of the major tasks is to organise visits
for the WHO, UNICEF, NGOs, and they have hardly any time to work
because they are constantly organising visits. There is a lack
of co-ordination and I would very much agree with you that this
has to be improved. Especially in the TB area, we have a system
with WHO called the TBTEAM that co-ordinates the visits, so we
make sure on travel and try to improve that co-ordination. We
know when WHO goes, let us say, or another organisation goes to
a country to address an issue, but it is still something that
needs to be improved. If we are not able to get that better addressed,
this will be a real issue for countries. Also, this co-ordination
is hindered a lot of times by the fact that the Global Fund, DFID
or NGOs demand different ways of reporting on how money is being
used in countries. That is a huge burden on countries to report
on what they are doing. Also, when they have to make applications,
these applications are complex. So, on a Global Fund application,
for instance, they spend two or three months and the whole system
is burdened by that. This also needs to be addressed, how to apply
for funds from different sources, how to report to different agencies,
that is something that needs to be improved. You said is there
a danger if they do not collaborate; and, yes, there is a danger
if they do not collaborate with the government. There are many
NGOs that have a little funding, they start a little project and,
when the funding stops, everything collapses. The ideal situation
is where the government knows which NGO is working in which area
and they work together. There are good opportunities for that,
but it does not always work, unfortunately.
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