SA is the top country in Africa for medical research and development (R&D) and one of the top in the world. It invests heavily in R&D, has world-renowned universities and research laboratories and has the highest scientific output per capita on the continent. Yet despite its pre-eminence in R&D, the country’s healthcare system is still weak.
According to the World Health Organisation’s 2017 statistics, SA’s life expectancy at birth is 62.9. This is high for sub-Saharan Africa but low compared with other mid-and high-income countries. In recent initiatives, the Department of Science and Technology directed research funds towards diseases that most affect the country. This effort has been effective, yet there is still gross inequality in research and disease burden.
For example, HIV/AIDS accounts for about 40% of the country’s disease burden, yet it receives far less attention (less than 4% by some calculations) from researchers. This is a grave injustice. SA needs to continue to orient its health innovation system to better target illnesses that affect the largest portions of society. Without guidance and investment from the government, R&D will not help the average South African and inequality will only grow.
Since 2005, SA has invested in nanotechnology research. Nanotechnology is the study and manipulation of matter below 100 nanometres in order to develop new devices and materials. Matter behaves differently at the nano scale versus larger scales and scientists can, therefore, create novel “nano” products.
In medicine, nanotechnology has the potential to enhance HIV/AIDS treatment to cut down on the presence of cancerous tumours and advance new therapeutic strategies such as gene therapy, chemotherapy drugs and immunotherapy.
The department wanted nanotechnology to benefit the poor, so it directed funding towards pro-poor initiatives by prioritising research into diseases such as HIV and tuberculosis (TB). However, many less prominent diseases received proportionately more attention. In an unpublished report by the Mapungubwe Institute, researchers found that Parkinson’s disease accounts for 2% of nanomedicine research, but is only 0.04% of South African disability-adjusted life years. In addition to Parkinson’s, South African scholars study malaria, hepatitis B and Alzheimer’s in greater proportion than their disability-adjusted life years.
On the other hand, HIV/AIDS is severely understudied. HIV/AIDS accounts for 40% of SA’s disability-adjusted life years but represents only 4% of South African nanomedicine research. The gross mismatch between R&D and the needs of South Africans shows that the interests of researchers can be at odds with the needs of the community.
We believe this mismatch is the symptom of global trends in medical R&D and the challenging economics of developing medicines that help the poor. Pharmaceutical companies have little desire to research diseases such as malaria, TB and HIV/AIDS because it will be difficult for them to recoup their R&D costs from medicine sales. In contrast, there is a robust market for cancer and Parkinson’s disease medicines and they are, therefore, willing to invest in R&D in these fields.
As a consequence, well-targeted state intervention is needed to encourage R&D on diseases that do not have a market.
In a provocative book titled The Entrepreneurial State, Mariana Mazzucato provides examples of cases in which the state has inevitably been a lead investor and risk-taker in capitalist economies through “mission-oriented” investments and policies.
They include key technologies such as the internet, nanotechnologies, microbiology and drug discovery technologies, where the state played a leading role in achieving the necessary technological breakthroughs.
The state can risk funding initial R&D in areas that have no clear market but that push the bounds of science. An outstanding example is the iPhone — all the key technologies behind it, such as the touchscreen, the internet and microprocessors, were funded by the state. The Obama administration also provided a direct $465m loan to Tesla Motors to build its model S.
The state should undertake risky investment to find solutions for its critical medicine research and drug discovery. The focus of private pharma is to focus on less innovative drugs, and private venture capitalists enter only once the real risk has been absorbed by the state.
Bill Gates said the key element to getting a breakthrough is more basic research, and that requires the government to take the lead. Only when that research is pointing towards a product, can we expect the private sector to kick in.
The government should play a leading role as an “entrepreneurial” investor and reap some of the financial rewards over time by retaining ownership of a small proportion of the intellectual property created.
Rather than succumb to its preassigned role as a “market fixer”, the government’s role should include resource mobilisation and setting the conditions for widespread market commercialisation.
It is time for SA to ask: what is it that the public and private sectors can do together to tackle the dire healthcare situation?
There is a great need for science and politics to combine efforts. A diverse set of governance actors, programmes, instruments and influences are needed by each form of new technology.
These recommendations will not immediately solve all of SA’s health problems, but would put the country in a better position to improve its health-innovation system and the wellbeing of its people.