Should UNITAID Rethink Its Raison d’Être?

This is a joint post with Rachel Silverman. UNITAID: maybe you’ve heard of it, or maybe not. Launched in 2006, UNITAID has lived in the shadow of its older and bigger global-health siblings (the Global Fund, GAVI, and PEPFAR, to name a few). Perhaps due to its relative obscurity and late entry to a crowded global-health field, UNITAID has proactively worked to differentiate itself through a focus on commodities, market shaping, novel funding sources, and innovation. To wit, UNITAID’s stated mission is “to contribute to scale up access to treatment for HIV/AIDS, malaria and tuberculosis for the people in developing countries by leveraging price reductions of quality drugs and diagnostics, which currently are unaffordable for most developing countries, and to accelerate the pace at which they are made available.” But today, as UNITAID celebrates its sixth birthday (happy birthday UNITAID!), it stands at a potential crossroads. Last year, UNITAID’s Executive Board commissioned a five-year evaluation, requesting a “high quality, forward-looking report relevant to the future of UNITAID” with a final report expected in August 2012 – any day now. The evaluation will consider a broad range of core questions that may influence UNITAID’s future directions. For example: Where does UNITAID add value, and to what extent has UNITAID successfully complemented the roles of its older global health siblings? Can UNITAID’s “catalytic funding approach” achieve long-term market and public health impacts? To what extent has UNITAID exerted a positive influence on health commodity markets, addressing market inefficiencies in line with its market-oriented core mandate? (Hat tip to Marco Schäferhoff of SEEK Development) In light of UNITAID’s forthcoming evaluation report and its upcoming strategy for 2013 to 2015, we too examined UNITAID’s role within the global-health financing architecture. Is UNITAID’s mandate still appropriate or relevant? UNITAID tries to support the movement to scale-up access to treatment through its constitutional focus on commodities and price reductions – is this the most value-added approach? How can a commodity-centric approach respond to recent global-health trends and priorities, including country ownership, health-systems strengthening, and sustainability? More provocatively: has UNITAID’s approach of using “innovation [to] make markets work for the neediest ” devolved into a hammer in search of an innovative, market-based nail? In our paper (see consultative draft here) we outline some contradictions and limitations of UNITAID’s current approach. We worry that UNITAID’s approach to value for money “measures its success based on its impact on the markets for medicines, diagnostics and related products” – potentially conflating strategy with mission. Further, UNITAID’s focus on market-shaping and price reductions leads it to choose small, niche markets that are neglected by other donors, i.e. pediatric formulations and second-line drugs. But is this the right priority? For example, second-line TB drugs cost up to 120 times as much as first-line medications. It may not necessarily be ethical or smart to provide a single patient with second-line TB drugs instead of treating up to 120 patients with first-line drugs, all for the same cost (see table below), and especially when many people still lack first-line treatment for non-drug resistant tuberculosis. That said, there may well be good reasons for UNITAID to focus on small, niche commodities, e.g., basic arguments of fairness and justice to reach populations that would otherwise be unable to receive second-line treatment; or because children should not be born condemned to a preventable death sentence; or as part of a broader strategy to stem drug-resistant epidemics (a very worrying development, particularly for TB). But in its available documents UNITAID does not appeal to these real concerns, instead emphasizing instrumental arguments in justifying its intervention choices, where funding decisions are made because of the potential to drive price reductions or other market impact in selected commodities. This argument is analogous to purchasing something on sale because it is on sale (or purchasing something expensive because it is expensive).

We hope that the imminent evaluation provides the impetus for UNITAID to turn inward and do something truly innovative: buck institutional inertia, change course as necessary, and reinvent itself as the solution to 2012’s biggest global health challenges. One very specific recommendation: UNITAID should reframe its rhetoric away from market-based jargon, and instead appeal to arguments of fairness, justice, and health impact in justifying its intervention choices. Read the whole thing  for our full take; comments below or by e-mail are welcome as always. The authors thank Amanda Glassman for excellent comments.