Empowering Civil Society Networks in an Unequal Multi-polar World (ECSN-BRICSAM) Terms of Reference
Cross-Country Case Study on Corporate Capture In Health Sector and Inequality across the BRICS
INFORMATION
REQUIRED
Commissioning team:
TO BE COMPLETED
ECSN-BRICSAM Working Group on Access to Health and
Inequality
This is a cross-network working group which will oversee
the production of the case study, with members from the
relevant countries.
Author:
TBC
Project manager:
Oleg Kucheryavenko, Coordinator for Health Policy and
Advocacy, GCAP
Working title:
Corporate Capture – a Threat to Equal Access to Health in
the BRICS?
Type of paper:
Discussion Paper
Paper on a key theme, contributing to big questions and debates to
engage with core audiences. No detailed policy recommendations
although this will provide the empirical basis for advocacy positions
and policy recommendations in the future. Presented as work in
progress, not as organisational policy. Inviting feedback that may
shape later papers and policy recommendations.
Publishing partners
Please list any partners or
allies for co-branded papers
GCAP Russia (Russia), Wada Na Todo Abhiyan and People´s
Budget Initiative (India), GCAP China (China), REBRIP
(Brazil)
Oxfam and EC as supporting partners
Expected length (number
of pages and word
count):
25 pages (8,750 words) + 2 page (700 words) summary
Purpose
The Empowering Civil Society Networks in an Unequal
Multi-Polar World programme (ECSN-BRICSAM) aims to
strengthen the collective capacity of multi-thematic civil
society organization (CSO) networks across Brazil, Russia,
India, Indonesia, China, South Africa and Mexico
(collectively referred to as BRICSAM countries) to engage in
multi-stakeholder dialogue and influence global policymaking fora, with a particular focus on issues of inequality.
Why is this being
commissioned, and why
now? How does it
contribute to the broader
ECSN-BRICSAM
programme?
At the project meeting in Fortaleza, held around the BRICS
Summit in July 2014, members of the Working Group on
Access to Essential Services (Health) reached consensus on
the topic of cross-country research and agreed that bringing
up the issue of corporate capture is very timely, as the prices
on essential medicines are soaring while the governments
seem to have lost influence and control over the policymaking process in regard to equitable access to drugs.
Recently, some of the BRICS countries have been in the news
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Empowering Civil Society Networks in an Unequal Multi-polar World (ECSN-BRICSAM) for near-final free trade agreements, as have the United
States and the 10 other countries who are hammering out the
Trans-Pacific Partnership. While these agreements could
bolster economies that were weakened by the recession or
that are struggling to emerge, they also have serious
implications for affordability of medicines. As the Guardian
Poverty Matters blog points out, India is the “pharmacy of
the developing world” – exporting more than US$5 billion
worth of generic drugs each year. The agreement would
“make it all but impossible” for operations to continue as
they do. The Guardian and MSF both argue that with these
trade agreements, the “balance has tipped dangerously far
away from public health protections towards protecting the
profits of pharmaceutical firms.”
In addition, the issue of corporate capture is starting to be
discussed at the UN agencies level but to ensure it moves
towards meaningful policies to avoid reguatory capture,
independent civil society input will be needed. Also at the
UN level, there is a global civil society campaign to
“dismantle corporate power”, which could also benefit from
the findings of this research.
Focusing on four of the BRICSAM countries (Russia, India,
China, Brazil), this case study aims to achieve the following:
1. Provide different examples of how private companies are
performing corporate capture practices over: patent laws,
patent examination process, drug regulation policies, health
facilities management.
2. Identify the different modalities of corporate capture
practices such as:
•
•
•
•
lobby (funding, trainings, cooptation)
privatization (direct management of health services
by private actors)
corruption (illegal practices, bribery, extortion,
kickbacks)
bilateral pressure (corporations take foreign
governments to court, sue developing country
regulators, and directly threaten patient groups)
3. Analyze the impact of corporate capture practices on:
a) the sustainability of public and global health
programs;
b) the compliance of policies and regulations with a
public interest perspective.
4. Describe how corporate capture leads actors to deploy law
and policies in ways that reinforce, deepen, and exacerbate
inequalities in healthcare. [For example, monopolies over
drugs are extended for the benefit of companies while access
to them is restricted to the detriment of of patients.]
5. Provide the evidence on how efforts to hold transnational
corporations accountable for their actions are being
weakened, and how their influence over regulatory bodies
divert countries from tackling the root causes of inequality in
access to healthcare.
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Empowering Civil Society Networks in an Unequal Multi-polar World (ECSN-BRICSAM) The study will answer the following questions:
●
●
●
●
What are the core causes of corporate capture which
is assumed as a driver for.inequality in access to
healthcare?
Is there an association between increased levels of
corporate capture and higher inequalities in
receiving healthcare?
What is the role of government to neglect the
harmful impact of corporate capture on the health
sector? How does increased economic inequality
limit this role (ie. political capture)?
What measures have the BRICS governments taken
to reduce the negative effect of corporate capture of
drug regulatory authorities? Did these measures
result in any reduction in inequality in access to
healthcare?
For the purposes of this research, the term ‘corporate
capture’ is taken to have a broad scope, encompassing
capture of any or all of the actors, both government and nongovernment, which have the declared intention of protecting
and enhancing the public good.
As a result of the study, the ECSN-BRICSAM program will
contribute evidence and civil society perspectives to the
debate on how tackling corporate capture in provision of
health services can reduce inequality – particularly inequality
in access to affordable medicines through transparent and
legal procedures enabled by national and international
patent legislation, and health outcomes for different
population groups, especially those from different income
groups.
Within our evolving global system, escalating healthcare
costs and apparent inefficiencies in public healthcare
provision are increasingly being dealt with through
investment from the corporate sector. Through the
privatisation of healthcare and public health institutions,
efficiency is allegedly enhanced through competition. We
observe an increasing market-driven re-structuring of the
health sector across the globe, leading to a "medicalisation" of
life and "commercialisation" of health. The effects of corporate
capture of health are becoming increasingly visible across the
BRICS countries and affect equal access to health services.
Audience
For whom is it being
written? Who are we
trying to influence? What
kind of tone/style will
the paper adopt?
Allies, partners, researchers, development professionals,
academics, specialised media, policy makers and influencers.
The ECSN-BRICSAM program aims to integrate civil society
perspectives into global policy-making processes in three
key ways, influencing: i) global governance structures by
expanding the presence and formal role of civil society; ii)
agenda setting (at national and global levels) by influencing
the issues under discussion to include development and
inequality; and iii) policy commitments made by these
institutions.
The aim of influencing policy-making processes to reduce
inequality aims to be both evidence-based, and also
grounded in the perspectives of those who are primarily
affected by the issues, through our partner CSO networks.
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Empowering Civil Society Networks in an Unequal Multi-polar World (ECSN-BRICSAM) This case study will be a key document for the CSO networks
to use for advocacy going forward in these three ways, so it
should be written in an accessible but professional style,
suitable for presenting to national-level policy-makers, as
well as government representatives in global fora such as the
G20 and BRICS, which have been identified by the CSO
networks as key influencing opportunities. It is important to
include info-graphics to present data, including graphs,
maps, particularly as a way of clearly showing the
differences or similarities between countries. If ‘killer facts’
can be identified, these should be included in both the full
document and the summary.
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Proposition
What is the paper’s core
argument?
There is a strong argument that interrelates ill health with
inequality, particularly economic inequality. Healthcare costs
can have a crippling effect not only on household economies,
but also the state budgets, and by paying high price for
medicines either people or governments face rising
opportunity costs. At the same time different inequalities in
relation to aspects such as working conditions, housing,
nutrition, can also increase susceptibility to illness. The
poorest are hit hardest by this mutually reinforcing cycle—
governments fail to provide with cheap and quality
medicines, and average-class or poor people cannot buy
them as well. Starting with the corporate capture of
regulatory authorities, it ends up with reinforcing inequality
among low-income populations. In rich and poor countries
alike, poor people have worse health outcomes than betteroff people.
Brazil, India, China and Russia have been at the forefront of
recent debates about pharmaceutical regulation, adopting
wide-ranging changes to its legislative frameworks, in order
to ensure more access to quality drugs through parallel
importation and compulsory licensing. At the same time the
drug regulatory agencies have sought to improve their
effectiveness while dealing with a substantial capacity
shortage. As with all regulation, agencies have to maintain
independence from private sector interests – in this case the
multinational pharmaceutical corporations (MNCs). In the
BRICS countries there is insufficient individual and
organizational capacity to ensure that regulation is effective.
Steps often taken to deal with the capacity shortages can lead
to agency independence being compromised. State
regulation, in the narrow sense, implies control of
monopolies.
Corporate capture is the process through which monopolies
end up manipulating the state agencies that are supposed to
control them. If we think of regulation as a market, there are
two sides to this market — the supply of and the demand for
regulation. On the supply side, the public sector responds to
political pressures. Stigler viewed politicians as potential
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On what policy-makers want from research, please see http://oxfamblogs.org/fp2p/what-do-white-house-policy-makers-wantfrom-researchers-important-survey-findings/
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4
On ´killer facts´ see http://policy-practice.oxfam.org.uk/publications/creating-killer-facts-and-graphics-253013
Empowering Civil Society Networks in an Unequal Multi-polar World (ECSN-BRICSAM) suppliers of regulation who pursue two selfish objectives:
staying in power and the desire to augment the power. In
the case of patents for drugs, the demand for regulation that
benefits the industry is clear. There are a small number of
companies involved in the pharma industry, and new entry
to the industry would be deterred by the large fixed cost
required to enter the market. The pharmaceutical industry
has a big stake in patent regulation because losing patent
protection would cost pharmaceutical companies a lot of
money. A key requisite for effective regulation is
‘independence from corporate capture’ — the ability of the
agency to take decisions that are guided by the interests of
public health , and not shaped by the interests of industry or
by a lack of government commitment (financial or
otherwise).
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The central hypothesis of the research is:
the occurrence of corporate capture by multinational
pharmaceutical corporations has contributed
significantly to decreasing access to medicines,
soaring prices and increasing inequality in the
BRICS.
We expect the core argument of the case study to be that
overall there is a positive correlation between corporate
capture in a health sector and rising inequality in access to
affordable medicines. This is probably a mutually reinforcing
cycle, i.e. economic elites as well as pharma have vested
interests in by-passing regulation. The more unequal society
is, the richer and more powerful they become.
Contents/ Research
Questions
List the contents of the
paper in detail, including
estimated page extents
for each section.
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We propose a following outline for the cross-country case
study:
1.
Outline the findings of existing academic or other
commissioned research papers related to the topic,
and the main debates in national media around
corporate capture of drug regulatory authorities and
its impact on access to health in the chosen countries.
In particular, this section will highlight any evidence
previously found (not necessarily in these countries)
to support the argument that there is a real
correlation between the level of corporate capture
and an increase in inequalities.
2.
Highlight challenges presented by other countries
where corporate capture by multinational and large
national pharmaceutical corporations is seen as a
problem and/or levels of inequality in access to
health have not been reduced. Describe the
mechanisms of corporate capture with respect to
pricing policies and resistance to alter the national
patent law. In particular, disproportionate impact of
particular policies and corporate capture as a whole
on patients with HIV/AIDS, hepatitis C and cancer
should be highlighted, as prices for medicines to
Stigler. 1971. The theory of economic regulation. Bell Journal of Economics and Management Science 2
(spring): 3-21.
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Goddard M (2003) Regulation of Health Care Markets. Journal of Health Services
Research and Policy. 8(4):194-196.
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Empowering Civil Society Networks in an Unequal Multi-polar World (ECSN-BRICSAM) treat these particular ailments are costly and
unaffordable while posing a major burden to the
society. If the time factor is influential, can any
emerging trends from initial data be identified?
Specific obstacles to achieving equal access to cheap
medicines in the chosen countries will be identified,
whether these are economic (ie. primarily about
levels of provision), or structural (ie. who is
responsible for what?), or political (ie. governments
do not recognize the issue of corporate capture). It is
also of gih importance to give a sense of how
important to hamper corporate capture in a health
sector in terms of reducing inequality in access to
healthcare.
3.
Conclusion
One key aspect that should be taken into account throughout
and referred to where possible is how health systems are
financed in these countries? What is the financing plan to
procure medications for public health needs? To what extent
is the government committed to rolling out all new
medicines to its population? To what extent does corporate
capture and control of pricing impact on this?
For the specific regulatory bodies we want to cover we need
to understand what modalities are the key ones. Possible
fields for analysis are as follows:
•
Patent laws and patent examination, which are
mostly affected by lobbying and litigation;
•
Drug regulation. Market approval and clinical trials
are mostly affected by lobbying and corruption;
•
Drug procurement, which is often affected by
bilateral pressure;
•
Public health system is compromised by
privatization and corruption.
It is suggested that each country participating in the research
selects the modality they feel they have more capacity to
work on. Therefore it will allow more engagement and
coverage of the topic in the research.
Suggested Research
Methods
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-
Review of existing policy documents for each of the
chosen countries through developing a case study
method to assess the impact of MNCs on domestic
politics regarding health in the select countries.
-
Review of existing research on relevant topics
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Review of available data through national and
international sources
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In-depth journalistic investigation to uncover how
corporate capture occurs in general in chosen countries
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If ECSN BRICSAM partners have such links at the
national level, it seems reasonable to conduct focus
groups with patient organizations, interviews with
policy-makers and high-level authorities in big pharma
of the relevant country, relevant Oxfam and partner staff,
Empowering Civil Society Networks in an Unequal Multi-polar World (ECSN-BRICSAM) and other external stakeholders as necessary
Web content
How will this briefing
paper be used and shared
online?
Sensitivities
What are the risks in
publishing this paper?
(E.g. risk to staff security
or to the programme; risk
to partners´/Oxfam´s
reputation; quality of
product and content;
consistency with plans
and priorities.)
The paper will be designed and printed as a short A4-sized
booklet, also available as a PDF to be posted on the
programme website.
The 2 page summary should be written in a style which is
suitable to post (at least in part) directly on the programme
website, with a further link to the full study
The CSO networks in the ECSN-BRICSAM programme
agreed that this should be a focus of their work. No specific
risks related to this case study focusing on access to health
have been raised, however there is no doubt that tackling the
issue of corporate capture directly is a sensitive subject in
certain countries, particularly where there are authoritarian
and even repressive tendencies towards independent civil
society. No specific companies will be pinpointed. The paper
will discuss capture in more general terms.
The researcher should be mindful of this, and follow all
guidance and advice provided by the CSO network
representatives themselves, particularly if in direct contact
with national policy-makers, through interviews, etc.
The aim of the case study is not necessarily to be provocative
or to drive a particular ideological agenda, but rather to
present comparative evidence from across the chosen
countries to highlight how good policies on provision of
health can help to reduce inequalities and cope with
corporate capture.
Translation requirements
Interpretation may be needed to interview certain people in
countries for which the researchers do not have the language
capacities
Translation of national documentation, particularly official
data sources needs to be considered
To reduce translation costs, the consultant should primarily
review research already available in the English, and only
consider translation where it is clear that there is an added
value of accessing a particular document.
All interpretation and translation costs necessary during the
research process need to be considered at the outset.
The case study will be written in English
Subsequent translation of the report into the languages of the
chosen countries will be considered at a later stage.
1.Consultant researcher
starts work by:
November 20, 2014
2. First draft due by:
February 9, 2015
3. Comments required
from:
Protiva Kundu
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Empowering Civil Society Networks in an Unequal Multi-polar World (ECSN-BRICSAM) Lanying Zhang
Felipe de Carvalho
Thomas Dunmore
Oxfam GB (Daria Ukhova – mandatory, Mohga Kamal-Yanni
or Ceri Averill – optional)
4. Comments due by:
February 13, 2015
5. Revisions by author:
February 27, 2015
6. Final draft due by:
March 13, 2015
7. Edit:
(1 day per 4000 words)
8. Author accepts/rejects
edits:
9. Sign-off: networks,
Oxfam country
offices, GPU
10. Revisions by author
in line with sign-off
comments
11. Preparation of final
PDFs etc:
12. Publication date:
13. Dissemination and
plans for Advocacy
April 1, 2015
As the ECSN BRICSAM project is meant to influence global
decision-making platforms, the following moments are to be
considered as possible influencing opportunities to
disseminate the research findings, such as the BRICS and
Civil 20 Summits, United Nations General Assembly, BRICS
Health Ministers Meeting. We should probably bear in mind
this topic of research is of priority for the World Health
Assembly, which can be put on the list of other possible key
influencing moments.
Distribution
ECSN-BRICSAM programme website
List here any specific
distribution requirements
Individual websites of partner CSO networks
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Oxfam website
Empowering Civil Society Networks in an Unequal Multi-polar World (ECSN-BRICSAM) This research is to be produced with the assistance of the European Union. The contents are the sole
responsibility of Oxfam and its partners and can in no way be taken to reflect the views of the
European Union.
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