Latin America Takes on Big Pharma

By Thomas Andrew O’Keefe*

Colorful pills in capsule form and tablet form

Generic pills / Shutterstock / Creative Commons

For the past decade, Latin America has attempted to reduce the prices of high-cost medications through either joint negotiations, pooled procurement, or both, but so far with limited success.  The incentive for reducing prices is that all Latin American countries have national health care systems, and in some cases (such as Colombia and Uruguay) are legally obligated to provide their citizens with any required medication free of charge and regardless of cost.

  • In the bigger countries, such as Brazil and Mexico, the prices for certain pharmaceutical products and medical devices for public-sector purchase at the federal, state, and even municipal level are negotiated by a single governmental entity. Argentina, Chile, and Mexico also have mechanisms for pooled procurement of public-sector health-related purchases at all levels of government.  Given its huge internal market, Brazil also unilaterally caps prices on medications and threatens to issue compulsory licenses to extract concessions from pharmaceutical multinationals.

Latin American countries have also tried turning to sub-regional mechanisms to protect themselves from excessively high prices, albeit with meager results.

  • The Central American Integration System (SICA) has the most active regional mechanism to negotiate the prices of high-cost drugs and medical devices. The governments of Belize, Costa Rica, the Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Panama have authorized the Council of Central American Ministers of Health (COMISCA) to negotiate lower prices on their behalf.  Those medications and devices that obtain a reduction are then acquired by the public sector utilizing each government’s procurement procedures.  By negotiating as a bloc, the SICA countries report total savings of about US$60 million on dozens of products since the initiative began in 2010.
  • In late 2015, MERCOSUR launched a mechanism to negotiate prices for both the full and associate member states. Since those 12 countries coincided with UNASUR’s membership, that entity was given a supporting role to create a continental data bank of pharmaceutical prices paid by each member government that would be used to support the MERCOSUR negotiations.  That data bank proved to be ineffective, however, as not all countries submitted the required information and the methodologies for determining prices was inconsistent.  To date, MERCOSUR has only obtained price reductions for one HIV medication, manufactured by an Indian firm eager to establish a market presence in South America, and reportedly for an immunosuppressive drug used after organ transplants to lower the risk of rejection.  Reduction offers by Gilead for its Hepatitis C cure have, so far, been rejected by the MERCOSUR governments as inadequate.

MERCOSUR’s limited achievements appear to have encouraged individual countries to press on alone.  Colombia, while initially supporting the MERCOSUR initiative as an associate member, eventually established its own national mechanism to negotiate prices, and in July 2017 announced that it had obtained cost savings of up to 90 percent for three Hepatitis C treatments.  MERCOSUR’s sparse track record also helps to explain why Chile’s Minister of Health announced in October 2018 that his country, Argentina, Colombia, and Peru would utilize the Strategic Fund of the Pan American Health Organization (PAHO) to purchase 10 state-of-the art cancer treatments.  Because of PAHO’s annual bulk purchases, it is often able to obtain significant price reductions from pre-qualified manufacturers and suppliers that are then passed on to member governments.  Member states facing a public health emergency can also make purchases without cash in hand, as the Strategic Fund will extend a short-term loan at no interest.  In the future, the Latin American countries are likely to pragmatically utilize a range of options in trying to contain the rising costs of new medications that include both national and regional mechanisms as well as PAHO’s Strategic Fund.  The challenge will be to avoid Big Pharma “red lining” the region and excluding it from accessing the most innovative medical cures such as gene therapies that can fetch a million-dollar price tag per treatment.

February 19, 2019

* Thomas Andrew O’Keefe is president of New York City-based Mercosur Consulting Group, Ltd. and a lecturer at Stanford University.  He is the author of Bush II, Obama, and the Decline of U.S. Hegemony in the Western Hemisphere (New York: Routledge, 2018).

OAS: Almagro’s Challenges

By Fulton Armstrong and Eric Hershberg

Photo Credit: OEA – OAS / Flickr / Creative Commons

Photo Credit: OEA – OAS / Flickr / Creative Commons

The OAS’s new Secretary General, Luis Almagro Lemes, appears to be steering his organization toward a coordinating role that, he hopes, places it above the fray of hemispheric tensions.  He has not chafed at Washington’s version of democracy promotion, and indeed has embraced elements of it.  He has readily admitted the “inexorable conclusion” that the OAS needs to be “revamped and modernized”; that it needs to “reinforce its legitimacy”; and that its structure and resources need to be better realigned with the four pillars of its mission—democracy, human rights, security, and integral development.  His promises of internal reform so far have not been radically different from those put forth by his beleaguered predecessor, José Miguel Insulza, or even diverged from proposals embodied in U.S. legislation passed in 2013.  They have been articulated, however, in the sort of Washington consultancy language that might help his cause in the U.S. capital, such as references to evolving “from the OAS’s traditional command and control toward an organization that operates like a matrix geared to results in which the hemispheric and national dimensions feed into and enrich each other.”  Elected in March and inaugurated in May, in June Almagro received a mandate from the OAS General Assembly to restructure the General Secretariat, reorganize old offices into new ones, and implement other aspects of his plan.

Regional reactions to Almagro’s election and reform plan have been positive if sometimes not overly enthusiastic.  At the General Assembly meeting, U.S. Deputy Secretary of State Blinken spoke of a “new chapter … in the history of the OAS” and said, “We have a new secretary general, a new strategic vision statement, and renewed attention to genuine reform.”  South America’s preeminent power has been generally aloof toward the OAS, but the Brazilian Senate in mid-July approved a new OAS permanent representative, and last week Brasilia paid $3 million of its $18 million in late dues—modest relief from the slow strangulation caused by dire cash-flow issues because of non-payment by several key countries.  Almagro has also won support in Latin America through his repeated signals of a desire to work more closely with other hemispheric bodies—even CELAC, which was created in 2011 as a direct challenge to the OAS and supposed U.S. influence over it.  He pledged to “seek out areas where we can complement the work of other bodies,” citing by name CELAC, UNASUR, SICA, CARICOM, and MERCOSUR.  According to press reports, his close cooperation with UNASUR as Foreign Minister of Uruguay in 2010‑15 lends credibility to that promise.  Almagro also has won regional praise for pledging to continue efforts for bring Cuba back into the OAS as a full member—building on the success of the Summit of the Americas in April driven by the Washington-Havana rapprochement.

Outgoing Secretary General Insulza was a relatively easy act to follow because, often unfairly, his image was tattered after 10 years in the crossfire between Washington and the countries pushing to undermine U.S. influence in Latin America.  Almagro appears eager to push the re-set button, and the success of the Summit of the Americas and his pledges on democracy, reform, and hemispheric cooperation have given him a good start.  But leading the OAS is going to take more than artful rhetoric, internal restructuring, and a few reforms.  President Obama’s move on Cuba removes one major irritant from hemispheric relations, but an effective Secretary General is going to have to navigate the shoals of longstanding North-South tensions.  The “spirit of genuine and equal partnership” that Deputy Secretary Blinken spoke of wanting with the OAS will be difficult to achieve, and the supporters of CELAC, UNASUR, and other alternatives to the OAS will find it equally tough to accept the OAS as a valid venue for debate and compromise.  Almagro will also have to show that he can run the organization in a professional and modern way to overcome the perception left by his predecessor of weak management of the institution.  He has declared himself a man of practical solutions, not ideology, but pleasing everyone—trying to be a coordinator who threatens no one’s interests—may not be a workable strategy for long.  If the OAS is to fulfill its mission, moreover, the United States and others will have to give Almagro the space to do his job.

July 27, 2015

Revitalization of the OAS: More than an act of Congress

By Carlos Portales*

OAS logoU.S. Congressional passage in late September of the “Organization of American States Revitalization and Reform Act of 2013” could either help revitalize the troubled body or contribute to its irrelevance. By directing the U.S. Secretary of State to develop and drive OAS reform options, the bill seeks to give much higher priority in the OAS and Summit of the Americas to promoting and consolidating democracy in the hemisphere – “with due respect for the principle of nonintervention” – while recognizing that “key OAS strengths” are also in strengthening peace and security, assisting and monitoring elections, and fostering economic growth. Reducing “mandates” – ongoing programs that tend to get institutionalized – is another priority. The new law also requires Secretary Kerry to devise a strategy for a new fee structure in which no member state would pay more than 50 percent of OAS’s assessed yearly fees. (The U.S. Library of Congress reports that the United States, the organization’s largest donor, contributed an estimated $67.5 million in fiscal year 2012 – nearly 43 percent of the total 2012 budget.)

The reforms parallel ideas presented by OAS Secretary General Insulza in his “Strategic Vision of the OAS” on December 2011 (updated in March 2013) striving for concentration on four main pillars: democracy and conflict resolution; human rights; development (in association with the Inter-American Development Bank); and security (mainly against drugs and organized crime). He also advocated limiting a single state contribution to 49 percent without reducing the OAS’s total budget. The Secretary General embraced similar reforms when the legislation was first introduced by then-Senator Kerry in the previous Congress.

Agreement that the OAS needs reform is nearly universal, but any strategic transformation will have to take into account important developments among the Latin American international organizations. The OAS handily accommodated the creation of subregional organizations such as SICA and CARICOM in the past.  But new bodies – such as UNASUR, CELAC and ALBA – have posed new challenges to the organization’s relevance and effectiveness. Differences among the organizations have emerged over trade, democracy (different value attributed to the independence of powers and to press freedom, as well as of handling of crises in Venezuela, Honduras, and Paraguay), security (withdrawal of five countries from the Inter-American Treaty of Reciprocal Assistance), the strategy against drugs, and relations with the United States.  The organizations have also created new arenas for leaders to meet, at times taxing governments’ ability to keep up. From 1990 to 2012 there have been 272 Latin American regional and subregional summits, including eight Summits of the Americas.  When Secretary Kerry delivers his plan, it will be difficult for him to strike a balance between bringing the OAS more in line with Washington priorities, as laid out in the legislation, and seeking a bigger tent that addresses some of the concerns that gave rise to the plethora of competing organizations.

*Carlos Portales is the Director of the Program on International Organizations, Law and Diplomacy at WCL, American University. He was Ambassador of Chile to the OAS between 1997 to 2000.”

Obama’s Second Trip to Central America

SICA logo | Wikimedia Commons | GNU Free Documentation License

SICA logo | Wikimedia Commons | GNU Free Documentation License

The White House has cast President Obama’s trip to Mexico and Central America on May 2-4 as “an opportunity for the President to demonstrate his leadership in the international community in a really important way.”  The spokesman emphasized the “important people-to-people ties” between the United States and Central America because “there are a lot of immigrants” from the region.  The Administration’s press releases stress that the summit in San José, with the presidents of the Central American countries and the Dominican Republic under the rubric of the Central American Integration System (SICA), will focus on collective efforts to promote economic growth and development in the region and on “our ongoing collaboration on citizen security.”

Regional reaction to the visit and summit has been positive – Obama’s interest is clearly welcome – but leaders are already managing expectations.  Costa Rican Foreign Minister Castillo last weekend cautioned that the United States is not able to provide significant new assistance for either economic or security programs.  Commentators note that the visit has not been preceded by the sort of diplomatic activity that would indicate the rollout of significant new policies or programs.

At a summit in Guatemala with Vice President Biden one year ago, Costa Rican President Chinchilla crystalized regional criticism of the U.S. counternarcotics strategy when she said that Central America “is sacrificing the lives, making its enormous sacrifice” and, in a clear reference to Washington, called on the “international community [to] take greater co-responsibility in this struggle.”  Hosting the SICA summit with Obama suggests she is prepared to put such criticism aside, perhaps in hopes that talks focus on the economic and immigration issues.  The White House spokesman’s reference to immigrants – at a time that Obama is pushing ahead with related legislation – may indicate that immigration will be a primary concern for him also.  The last time Obama went to Latin America, for the Summit of the Americas in Cartagena in April 2012, he seemed ill-prepared for criticism of U.S. policies, including its counternarcotics strategy, even from Washington’s closest friends.  With perhaps the exception of Nicaraguan President Ortega, the participants in this Central American get-together seem less likely to deliver a similar grilling, making what diplomats call a “successful meeting” very likely.