The member countries of the Organization for Economic Cooperation and Development (OECD), an organization which brings together 38 of the most economically developed countries in the world, are calling for greater transparency at the international level in terms of contracts concerning purchase of innovative medicines. These national governments even admit that the current lack of transparency and the proliferation of confidential clauses “erodes the accountability” of public authorities. This compromises the sustainability of health systems and “weakens” the position of states when negotiating with big pharmaceutical companies.

However, according to a recently published report by the OECDWhen things go well, it is the governments themselves that opt ​​for these types of obscure agreements. This paradox is well illustrated by the following data: all countries want greater transparency and the majority want to know the prices paid by other governments, but “only seven countries express their interest in sharing prices”. There are several reasons for this reluctance, but the main one is that by signing the secret clauses demanded by pharmaceutical companies, governments are allowed to “get cheaper prices.”

Miquel Serra, a researcher specializing in health economics at the University of Zurich, explains: “(The OECD report) is good qualitative work which shows the contradictions that exist in medicine purchasing policies. This can serve as an example of the so-called “tragedy of the commons,” in which all actors end up being harmed by putting their particular interests ahead of a shared approach that would achieve better overall results. »

The report is based on two key and seemingly contradictory ideas. The first is that “pharmaceutical markets are increasingly characterized by price opacity”. While purchasing generics is much more transparent, innovator drugs actually have two prices: one that is usually made public – the “official” or “list” price – and another that is the actual or “net” price , which is the one that the national government sets. it’s the governments that end up paying, and which is almost always kept secret. The report warns that “actual transaction prices paid by buyers increasingly deviate from official prices.”

The second starting point is that “in recent years, transparency has received increasing attention in pharmaceutical policy.” In response to public pressure to improve international price transparency, “the 72nd World Health Assembly adopted a resolution in 2019. This resolution “urges countries to share price information.”

However, through this study and other previous work, the OECD has found that countries’ desire to achieve this faces almost insurmountable obstacles. First, there are numerous limitations in national law to restrict public information considered sensitive. Added to this is a lack of consensus on how far transparency should go – what type of data it would affect, whether to make it fully public or only accessible to other governments – and a lack of knowledge (or even fear) on the consequences that such transparency could have. this step would have on transaction prices.

In fact, the report itself highlights that there are already “more than 30 initiatives aimed at sharing certain types of information” between OECD countries, including the European Medicines Price Database (EURIPID). The authors emphasize, however, that in all cases these projects exclude the most sensitive information – the prices shared are generally the official prices and not the real prices – and that “confidentiality of net prices of medicines remains the norm at the international level “.

Survey of 43 countries

Faced with this reality, the objective of the OECD report is to help “advance the political debate” and also to analyze the “feasibility” of implementing systems to share more information. To do this, the authors sent a survey to 43 countries – members of the OECD, as well as EU members that are not part of the organization – of which 34 responded fully or partially to the investigation.

The most notable results show that although “20 countries are required (by national law) to publish list prices, they often face legal and contractual constraints that prevent them from sharing information on net prices.” Spain is an example of a high-income country that publishes these prices through the resolutions of the Interministerial Commission on Medicine Prices, although it also does not communicate the prices actually paid, due to confidentiality clauses agreed with pharmaceutical companies.

All countries consulted are “interested in obtaining information on the prices paid by their counterparts”. Concretely, 24 declare that this interest concerns net prices, but only seven are willing to share this information.

“Countries have different views on the likely consequences disclosure of net price informationwhether publicly or in a closed network,” the newspaper continues. A majority considers that “sharing net prices would increase or leave unchanged” the negotiating power of national governments. There are, however, many divisions over the assessment of the impact this could have on prices. Of the 24 countries that responded to this question, seven (the document does not specify which ones) believe that these rates would “go down a little”, while eight believe that they would not change. Seven others think they would “increase a little” and two more think prices would “increase significantly.”

There are still divisions when it comes to assessing whether greater transparency could delay a particular country’s access to new therapies. Eight countries believe that the publication of net prices would significantly or slightly delay their access. Eight think that there would be no change and seven believe, on the contrary, that the publication of prices would reduce delays. Finally, the report states: “18 countries are interested in participating in a pilot mechanism to share net price information with other countries. »

José María Gimeno, professor of administrative law at the University of Zaragoza, Spain, believes the study highlights the uniqueness of the innovative medicines market: “Many medicines have no competition, because of patents . The ability to improve prices is therefore limited, and the priority for governments is to ensure that their populations have access to them at affordable prices. And, to this end, some confidentiality can be beneficial. According to this expert, Spain is a good example, since “the opacity of contracts allows (the federal government) to obtain better prices than the countries of northern Europe”.

For Juan Oliva, professor of health economics at the University of Castilla-La Mancha, a Spanish public institution, the problem with this situation is that no one (except the pharmaceutical companies themselves) can be sure what pays each country. “It is often said that Spain benefits from this system, that this type of secret negotiations allows it to assert that it is a large country, with a good network of hospitals and research, in order to obtain lower price. But we don’t really know, because none of this information is made public. And the few studies carried out by independent entities have actually observed a convergence between the real prices paid by countries,” he says.

Most of the experts consulted largely agree on highlighting four problems in the innovative medicines market. The first is efficiency. “Economic theory states that markets with multiple buyers and sellers – where everyone has access to relevant information – are more efficient. But in this case there is only one seller, due to the monopoly conferred by patents. And (this seller) is the only one who knows how much each country pays. The result is a very inefficient market,” laments Miquel Serra.

In relation to this first point, the study and the experts consulted point to a second problem: the sustainability of health systems. In an inefficient market, it is common for resources not to be allocated where they could provide better outcomes, in terms of patient health. In the long term, this can endanger the future of those who need treatment.

The third disadvantage is democratic quality, or “accountability”, in the words of the report. This point was already addressed by the 2019 WHO resolution, which called for greater transparency and was supported by virtually all OECD countries. “Citizens have the fundamental right to know the final destination of the resources they support with their taxes,” says Jesús Lizcano, professor of financial economics and accounting at the Autonomous University of Madrid and former president of Transparency International Spain.

Finally, some voices warn that the lack of transparency can also be detrimental to the health and safety of patients. “Opacity is not limited to pricing, but also surrounds clinical trials, real-world efficacy and safety data. Ultimately, we are not sure that we have all the information or the most recent information – which only pharmaceutical companies have – on the best treatments for a specific patient,” concludes Adrián Alonso, Head of Research and policy advocacy at the Right to Health Foundation.

This Madrid-based civil society entity has long filed access to information requests with the Spanish Ministry of Health regarding the prices of four prescription drugs: Kymriah, Veklury, Zolgensma and Takhzyro. All of these cases resulted in lengthy legal proceedings, due to opposition from pharmaceutical companies, as well as the ministry itself. They don’t want drug prices to be made public.

Register for our weekly newsletter to get more English media coverage from EL PAÍS USA Edition