Because present procedures by design favor the affluent, the poor are being increasingly marginalized. And because the poor are so marginalized, they can exert little influence on institutional design decisions. We need to break out of this vicious spiral and create momentum in the opposite direction.
There exist better models of decisionmaking, for the governance of states, corporations and other large organizations, for example in Germany. We need to study such models and promising pathways on which our existing decisionmaking procedures can be gradually reformed.
In order to prepare for meaningful change, we have to look at both sides of the problem. We need to examine the output of our political system, which is often very hostile to the poor abroad and hostile also to the poor and middle class domestically. And we must also look at the procedures through which this output is produced.
It is for the poor people's sake, above all, that we urgently need more unity and better organization and need to concentrate our reform efforts in order to really to achieve reforms, one by one.
In order to achieve something, in competition with the powerful and smartly wielded influence of corporations, we need to join forces and be as well-organized as they are. This does not come natural to us more intellectual types, as we tend to be averse to hierarchy and groupthink; we don't like to be part of anything like a disciplined and well-organized team or movement. But the alternative is to continue losing politically - which means continued failure to protect the world's poor, who are really bearing the brunt of our disorganization.
Ordinary people like you and me can achieve very little on their own. We need to build support. Even if you are a thought leader and have some good ideas on how to make the world better, and even if you write five or ten books - that won't have much effect unless you have people who are willing to support your ideas.
Economics is like a church, and it fulfills the same function the church had fulfilled for centuries: the justification of the status quo.
Critical journalism has gone out of fashion, or rather, it has been bought out. And so, we have much less of it than we did during the Vietnam era, where there was very critical reporting on the Vietnam War and a lot of disagreement among the media. Now you find that the media are much more homogenous, converging because they all must cater to the same community of advertisers. It's sad to see.
Economists operate with this image of the homo economicus, the rational economic agent, and while such agents are rare in the wider world, they are common in economics departments. Exemplifying the homo economicus paradigm, economists typically choose their research projects and hypotheses so as to promote their own careers, to maximize their lifetime income. This explains the astonishing pressures toward conformity in academic economics: how deviant views (except those by a few who have already achieved stardom) get crushed by an army of conformists.
America is run by the rich and powerful in their own interest. To an extent that I think is hard to exaggerate, the intellectuals - academics, journalists and so on - are bought off. And that's a big change that happened in the United States in the last 30 or 40 years.
Large companies are very good at solving extremely complex problems in a globally optimal way.
If the Health Impact Fund were to be instituted, a single company would be in charge of a medical product all the way from its conception to the health improvements realized by actual patients. The company would be paid for health impact, and it would have to arrange the entire pipeline in between - all the steps of invention, of clinical testing, of getting marketing approval in many different countries, of wholesalers and retailers and prescriptions and so on - in a holistically optimal way.
To improve global health, it's not enough just to have a really good new product and to obtain marketing approval. You still need to market the product and bring it to patients, follow up, create the infrastructure, and so on - the whole pipeline, the network. That's something that companies are extremely good at: organizing a whole pipeline in a cost-effective way.
You can get an ice-cold Coke for around fifty cents in most developing countries, not just in the major population centers, but at the most remote and surprising places. The logistical challenges to resupplying all these outlets are enormous - and yet, the entire system works with incredible efficiency as is confirmed by the price of the product.
Companies are actually much better than governments and other bureaucracies at organizing in a holistically efficient way the extremely complex path from the examination of molecules all the way to the delivery of medicines to patients. Already in the conception and selection of research projects, companies would anticipate all the challenges down the line that they will need to overcome in order to achieve actual health impact. Bureaucratic organizations, by contrast, are notoriously bad at this sort of optimizing.
Competing companies evolve toward efficiency as the more efficient ones profit and expand while those who fall behind fail. And companies being efficient and profiting under the Health Impact Fund, this is exactly what we want, because the company's profit is directly driven by the health impact its registered products achieve.
With the Health Impact Fund, the innovation is paid for separately, through publicly funded health impact rewards, and the product is sold at the cost of production to all. Here, the cruel injustice of preventing the poor from buying at cost - evidenced by today's suppression of the trade in generic versions of patented medicines - would no longer be needed.
You can think of the Health Impact Fund as a mechanism that would keep the benefits and burdens of pharmaceutical innovation for the affluent roughly as they are while massively reducing the burdens presently imposed upon the poor. This sounds like magic. But it really works because the current system is not Pareto efficient. It's a system that generates hundreds of billions of dollars in litigation costs and deadweight losses that HIF-registered medicines would sidestep. By avoiding these losses, the HIF reform can bring improvements all around - including for pharmaceutical innovators.
What is really nice about the Health Impact Fund is that it is a win-win, something that without much cost to anyone makes a lot of people better off.
For the present system to work, poor people must be excluded from the innovation, because if they could get access at an affordable price, then affluent people would find ways to buy it cheaply as well - and then the innovator would be poorly rewarded and introductions of new medicines would decline.
If you ask yourself who is paying for pharmaceutical innovation today, the answer is that it's the more affluent populations paying for still-patented advanced medicines at the pharmacy, for comprehensive insurance coverage or for a national health system.
In the domain of pharmaceuticals, we need a metric for health impact, and with this metric we can then assess the value of the introduction of a new product and pay its innovator accordingly, say on the basis of the product's measured health impact during its first ten years on the market. In exchange, innovators must of course renounce the usual rewards they are otherwise entitled to, namely the patent-protected markup on the price of their product.
Some of the developing-country governments and populations are tired of having things rammed down their throats, but we're not yet at the stage we want to get to, namely where the developing countries join forces with one another on behalf of creative alternative ideas about how to take things forward.
It is irrational to charge high prices for socially valuable innovations as this guarantees that they will be underutilized. It is much better to sell them at cost and then to reward the innovator in some other way. This is not always possible, because in some cases the value of an innovation is in the eye of the beholder; it's very difficult to value how much a new Madonna song is worth, for example. But in the case of medicines, green technologies and seeds in agriculture, such an alternative reward mechanism is fairly straightforward.
We have this highly irrational system of incentivizing innovation for clean and green technologies, where we allow the innovator to have a temporary monopoly and then mark up the price of the product or sell licenses at high prices to those who want to use the kind of product that the innovator has invented. This system is collectively irrational because many people, to avoid the inflated prices of still-patented cleaner and greener technologies, opt for some older technology that is much more polluting.
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