Partial progress: governing the pharmaceutical industry and the NHS, 1948-2008

Interconnected influence: Unraveling purdue pharmaceutical's role in the global response to the opioid crisis

BACKGROUND

The global pharmaceutical industry has a long history of prioritizing profits over public health through widespread practices such as price gouging, deceptive marketing, and fraud. A prominent example of this issue is the mislabeling and mass-marketing of OxyContin by Purdue Pharmaceuticals (Purdue) that catalyzed the opioid crises in and beyond the United States.

METHODS

Guided by Actor-Network Theory, this case study employs Visual Network Analysis to map the actors-networks involved in responding to the harms caused by Purdue. Data was generated from peer-reviewed and grey literature published between 2007 and 2022 (n = 40) and imported into Gephi visualization software where centrality metrics were applied.

RESULTS

A total of 39 actors and 99 relationships were visualized based on the relational thinking that actors who are heavily interconnected with others are rendered important. Centrality measures identified the socio-technical centrality of Purdue in influencing the response to the harms it caused. Purdue exerted influence through various avenues, most prominently through the creation and cooptation of pain advocacy groups, their close ties with United States elected officials, and through embedding pro-opioid messaging in international guidance documents. In doing so, Purdue was able to extend the reach and impact of their opioid promotion, while simultaneously limiting the capacity of regulatory bodies to pursue accountability and implement policies to mitigate opioid-related harms.

CONCLUSION

This study advances understandings of the complex interplay between transnational pharmaceutical companies, global health systems, regulatory bodies, and public health. In doing so, we underscore the need for stronger regulation and increased transparency surrounding the interactions between pharma, patient groups, governments, and international organizations to better address and prevent future harms.

Tip of the Iceberg? Country- and Company-Level Analysis of Drug Company Payments for Research and Development in Europe

BACKGROUND

Creating new therapies often involves drug companies paying healthcare professionals and institutions for research and development (R&D) activities, including clinical trials. However, industry sponsorship can create conflicts of interest (COIs). We analysed approaches to drug company R&D payment disclosure in European countries and the distribution of R&D payments at the country and company level.

METHODS

Using documentary sources and a stakeholder survey we identified country- regulatory approaches to R&D payment disclosure. We reviewed company-level descriptions of disclosure practices in the United Kingdom, a country with a major role in Europe's R&D. We obtained country-level R&D payment data from industry trade groups and public authorities and company-level data from eurosfordocs.eu, a publicly available payments database. We conducted content analysis and descriptive statistical analysis.

RESULTS

In 32 of 37 studied countries, all R&D payments were reported without named recipients, following a self-regulatory approach developed by the industry. The methodological descriptions from 125 companies operating in the United Kingdom suggest that within the self-regulatory approach companies had much leeway in deciding what activities and payments were considered as R&D. In five countries, legislation mandated the disclosure of R&D payment recipients, but only in two were payments practically identifiable and analysable. In 17 countries with available data, R&D constituted 19%-82% of all payments reported, with self-regulation associated with higher shares. Available company-level data from three countries with self-regulation suggests that R&D payments were concentrated by big funders, and some companies reported all, or nearly all, payments as R&D.

CONCLUSION

The lack of full disclosure of R&D payments in countries with industry self-regulation leaves considerable sums of money unaccounted for and potentially many COIs undetected. Disclosure mandated by legislation exists in few countries and rarely enhances transparency practically. We recommend a unified European approach to R&D payment disclosure, including clear definitions and a centralised database.

State capture through indemnification demands? Effects on equity in the global distribution of COVID-19 vaccines

Background

State capture by the pharmaceutical industry is a form of corruption whereby pharmaceutical companies shift laws or policies about their products away from the best interest of the public and toward their private benefit. State capture often limits equitable access to pharmaceutical products by inflating drug prices and increasing barriers to entry into the pharmaceutical industry. During the COVID-19 pandemic, the high demand and low supply of COVID-19 vaccines has put governments that manage vaccine procurement at risk of capture by COVID-19 vaccine manufacturers, both through bilateral deals and the COVID-19 Vaccine Global Access (COVAX) Facility; this threatens equity in the global distribution of these products. The purpose of this study is to determine whether COVID-19 vaccine manufacturers have been engaging in state capture and, if so, to examine the implications of state capture on equitable access to COVID-19 vaccines.

Methods

A targeted rapid literature search was conducted on state capture by the pharmaceutical industry. Results were limited to journal articles, books, and grey literature published between 2000 and 2021 in or translated to English. A literature search was also conducted for information about state capture during the COVID-19 pandemic. Results were limited to media articles published between March 2020 and July 2021 in or translated to English. All articles were qualitatively analyzed using thematic analysis.

Results

COVID-19 vaccine manufacturers have demanded financial indemnification from national governments who procure their vaccines. While most high-income countries are legislatively capable of indemnifying vaccine manufacturers, many low- and middle-income countries (LMICs) are not. A number of LMICs have thus changed their legislations to permit for manufacturers’ indemnification demands. Amending legislation in this way is state capture and has led to delays in LMICs and vaccine manufacturers signing procurement contracts. This has critically stalled access to vaccines in LMICs and created disparities in access to vaccines between high-income countries and LMICs.

Conclusions

COVID-19 vaccine manufacturers’ indemnification demands constitute state capture in many LMICs though not in high-income countries; this has enhanced global COVID-19 vaccine inequities. Results underscore the need to find alternatives to financial indemnification that do not hinder critical efforts to end the pandemic.

A 'patient-industry complex'? Investigating the financial dependency of UK patient organisations on drug company funding

We examined the minimum extent of dependency of UK patient organisations on pharmaceutical industry funding using drug company disclosure reports and patient organisation financial accounts from 2012 to 2016. We used linear regression to explain the overall share of industry funding ('general dependency') and top donor funding ('company-specific dependency') in organisations' income. Predictors included patient organisations' goal; having members and volunteers; geographical scope of activity; headquarter location; expenditure/income ratio; and disease area. The prevalent low levels of general dependency (IQR, 0.1%-6.0%) and company-specific dependency (IQR, 0.1%-4.3%) made a widespread capture of patient organisations unlikely, though only if one excludes the possibility of significant payment under-reporting. However, organisations with considerably higher dependency than others might be more prone to co-optation by industry. Of the 398 organisations, 18 (4.5%) and 8 (2.0%) had general and company-specific financial dependency over 50%, respectively. However, the shares of outliers exceeding the third quartile plus 1.5 times IQR were 51 (12.8%) and 56 (14.1%) for each dependency type. Certain characteristics including activity profile (advocacy) or indicating limited access to resources (remote location) made organisations vulnerable to developing financial dependency. Future research should examine both financial and non-financial links between the two sides and their impact on patient organisations' activity.

Divergent spender: State-societal and meso-organisational mechanisms in the containment of public spending on pharmaceuticals in a liberal capitalist democracy

For two decades, New Zealand has been placed consistently at the foot of OECD rankings for state expenditure on pharmaceuticals. In this article, we explore New Zealand's containment of pharmaceutical spending as a 'divergent' case of pharmaceutical policy in a liberal democracy. To elucidate the likely institutional mechanisms and interests behind this phenomenon, we conducted a case study of New Zealand's drug reimbursement policy. In doing so, we derived sensitising concepts from major accounts of pharmaceutical policymaking (Corporate Bias Theories and Reputational Theory) and theories of the western state (Historical Institutionalism and Corporate Domination Theory). Drawing on 28 expert interviews and documentary analysis, we identified three main mechanisms of spending containment. First, New Zealand's state bureaucracy use pricing strategies that rely on a spending containment strategy coordinated by bureaucratic managers. Second, these managers shape the policy preferences of expert committees involved in scientific drug assessment. Third, on a meta-level, conditions for spending containment are enabled by the judicial-legislative arena. As such, we find support for Historical Institutionalism and Reputational Theory and more limited support for Corporate Bias Theory and Corporate Domination Theory. Our explanation posits further conceptual linkages between the macro/societal and meso-organisational theoretical levels.

How the United Kingdom Controls Pharmaceutical Prices and Spending: Learning From Its Experience

To control costs and improve access, nations can adopt strategies employed in the United Kingdom to control pharmaceutical prices and spending. Current policy evolved from a system created in 1957 that allowed manufacturers to set launch prices, capped manufacturers' rates of return, and later cut list prices. These policies did not effectively control spending and had limited effects on purchase prices. The United Kingdom currently controls pharmaceutical spending in 4 ways. (a) Since 1999, it has typically paid no more than is cost-effective. (b) Since 2017, for medicines that will have a significant budget impact, National Health Service England seeks discounts from cost-effective prices or seeks to limit access for 2 years to patients with the greatest need. (c) Since 2014, statutes and a voluntary scheme have required branded manufacturers to pay the government rebates to recoup the difference between the global pharmaceutical budget and actual spending. (d) For hospitals, generics and some patented drugs are procured through competitive bidding; community pharmacies are reimbursed through a system that provides an incentive to beat average generic market prices. These policies controlled the growth of spending, with the largest effects following budget controls in 2014. Changes since 2008 have reduced savings, first by paying more than is cost-effective for cancer drugs and then by applying higher cost-effectiveness thresholds for some drugs used to treat cancer and certain other drugs.

Pharmaceuticals as a market for "lemons": Theory and practice

Drawing on economic theory and institutional analysis, this paper reframes Akerlof's theory of how a market for lemons operates and argues that each of the many markets for lemons must be studied empirically to document how different stakeholders cope with the problems of information asymmetry, secrecy, and power. Such markets are a new field for sociological analysis. To illustrate, the paper characterizes pharmaceuticals as a multi-tier market of information asymmetry in which actors in each tier have substantial control over how much they disclose about hidden risks of harm. Such a market rewards the production and sale of "lemons." Current incentives and institutional practices reward developing a large number of barely therapeutically innovative drugs and ignoring their often hidden or understated harmful side effects. They reward designing and executing substandard, biased trials that mislead the FDA and regulators abroad to approve new drugs without clear evidence of their degree of harm. Approved drugs are likely to be "lemons" but promoted as "safe and effective." The result is substantial hospitalizations and deaths from adverse drug reactions. A "risk proliferation syndrome" of institutional practices maximizes sales, profits, and exposure to toxic side effects. An "inverse benefit law" of marketing operates as companies try to maximize sales. The probability of benefits decreases but the chances of lemons adverse events do not. The details presented here deepen understanding of how markets for lemons thrive on information asymmetry, secrecy, and power. Lessons can be applied to other markets.

Regulatory Capture in Pharmaceutical Policy Making: The Case of National Medicine Agencies Related to the EU Falsified Medicines Directive

BACKGROUND

Regulatory capture describes the phenomenon in which regulators (e.g. medical agencies) protect the interest of the companies they regulate rather than the interest of the public. Not much is known about the mechanisms of this potential threat within the area of pharmaceutical regulation.

OBJECTIVES

Through a comparison of two EU member states, the Netherlands and Denmark, this study aimed to investigate how regulatory capture could exist in pharmaceutical regulation. The EU Falsified Medicines Directive was used as the case, as it provided an opportunity for national medicine agencies to interact with various stakeholders.

METHODS

The processes of negotiation and implementation of the directive were mapped by interviewing 23 stakeholder representatives and triangulated with relevant documents. A meaning condensation method was applied to show how stakeholders were involved with authorities, and the theory of regulatory capture was used to interpret how the two countries were susceptible to capture.

RESULTS

The Danish Medical Agency was central in all relevant processes, whereas in the Netherlands, the Ministry of Health initiated the processes during the negotiation phase and, subsequently, three medical agencies shared responsibilities in the implementation phase. During the negotiation phase, the Dutch process was more focused on consensus among stakeholders while the Danish process focused on preparing the subsequent implementation. Neither member state prioritised transparency during implementation, but rather focused on timely implementation.

CONCLUSIONS

The processes of EU negotiations and implementation of the Falsified Medicines Directive were handled quite differently in Denmark and the Netherlands. It is possible that regulatory capture could be prevalent in both member states as policy makers were only in limited dialogue with patients. EU countries must decide whether this technocratic approach is acceptable, or whether they should make a more concerted effort to include the public.

Revisiting the pharmaceuticalisation of pandemic influenza using Lukes' framework of power

The power of social actors to drive or block pharmaceutical uptake has been a concern in sociological debates on pharmaceuticalisation, including in the case of pandemic vaccination. We build on Steven Lukes' three-dimensional view of power to explore the 2009 H1N1 pandemic vaccination in Sweden and Denmark - two similar countries that arrived at conflicting vaccination strategies. Drawing on interviews with members of each country's pandemic steering group and on document analysis, we explore three consecutive stages of pandemic vaccination response: planning, vaccine procurement and the vaccination campaign. The paper makes two contributions to studies of pharmaceuticalisation and pandemics. Conceptually, we advocate the suitability of Lukes' framework over the 'countervailing powers' framework repeatedly used to model power in the pharmaceutical field. Empirically, our study confirms that government-appointed experts steered pandemic planning in both countries, but we show that the state, industry and the WHO also exerted power by enabling and constraining experts' decision-making, including by keeping some information secret. Furthermore, we argue that mass vaccination in Sweden was a pervasive expression of state power, in Lukes' sense, since it rested on keeping latent the tension between many individuals' health interests and the state's interests in protecting social and economic functioning.

'In the hospital all is taken care of': a practice-theoretical approach to understand patients' medication use

Drawing from case examples of medication review implementation in three hospital settings in Sweden, this article examines patients' medication use. Based on a practice theory approach and utilising data from interviews with patients and participant observation, we reconstruct three practices of everyday medication use centring on accepting, challenging or appropriating medication orders. This article argues that patients' medication practices are embedded in wider practice arrangements that afford different modes of agency. Reconceptualising patients' medication use from a practice-based perspective revealed the meaning-making, order-producing and identity-forming features of these practices. Also, we illustrated how different modes of agency were achieved in patients' medication practices, suggesting a fluidity of both the meanings attached to and the identities related to medication use. Our findings have practical implications as these practices of medication use can be transformed when altering the arrangements they are embedded in, thus going beyond the clinical encounter.

Paradigms in operation: explaining pharmaceutical benefit assessment outcomes in England and Germany

Health technology assessments (HTAs) are used as a policy tool to appraise the clinical value, or cost effectiveness, of new medicines to inform reimbursement decisions in health care. As HTA organisations have been established in different countries, it has become clear that the outcomes of medicine appraisals can vary from country to country, even though the same scientific evidence in the form of randomised controlled trials is available. The extant literature explains such variations with reference to institutional variables and administrative rules. However, little research has been conducted to advance the theoretical understanding of how variations in HTA outcomes might be explained. This paper compares cases of HTA in England and Germany using insights from Kuhn (1962, The Structure of Scientific Revolutions, 2nd edn. Chicago: The University of Chicago Press) and Hall (1993, Policy paradigms, social learning, and the state: the case of economic policymaking in Britain. Comparative Politics 25, 275-296) to demonstrate how policy paradigms can explain the outcomes of HTA processes. The paper finds that HTA outcomes are influenced by a combination of logical issues that require reasoning within a paradigm, and institutional and political issues that speak to the interaction between ideational and interest-based variables. It sets out an approach that advances the theoretical explanation of divergent HTA outcomes, and offers an analytical basis on which to assess current and future policy changes in HTA.

A historical argument for regulatory failure in the case of Primodos and other hormone pregnancy tests

The drug Primodos and other hormone pregnancy tests (HPTs) remained on the British market for about a decade after they were first implicated, in 1967, as a possible cause of birth defects. In November 2017, an expert working group (EWG) set up by the Medicines and Healthcare Products Regulatory Agency (MHRA) concluded against such an association. However, it was explicitly 'not within the remit of the EWG to make formal conclusions or recommendations on the historical system or regulatory failures', a situation that has left many stakeholders dissatisfied. Placing the question of a teratogenicity to one side, this article takes a more contextual and comparative approach than was possible under the auspices of MHRA. It asks why an unnecessary and possibly even harmful drug was allowed to remain on the British market when a reliable and perfectly safe alternative existed: urine tests for pregnancy. Based on archival research in several countries, this article builds a historical argument for regulatory failure in the case of HPTs. It concludes that the independent review which campaigners are calling for would have the potential to not only bring them a form of closure, but would also shed light on pressing issues of more general significance regarding risk, regulation and communication between policy makers, medical experts and patients.

Beyond unequal access: Acculturation, race, and resistance to pharmaceuticalization in the United States

Trends toward pharmaceuticalization in Western countries have led to increased research and theorizing about the roles macro-level institutions, structures, and collective actors play in contributing to patients' reliance on prescription drugs. Relatively less work has focused on the degree to which patients resist pharmaceuticalization pressures, and even less research has explored the factors contributing to patients' resistance to pharmaceuticalization. Drawing on focus groups with patients who had been recently prescribed a prescription drug, this paper investigates how marginalization in the mainstream US society, as measured by acculturation and race, contributes to differences in patients' subjective experiences and responses to prescription drugs. We find that racial minorities report a greater skepticism of prescription drugs compared to whites and express that they turn to prescription drugs as a last resort. While highly acculturated participants rarely discuss alternatives to prescription drugs, less acculturated racial minorities indicate a preference for complementary and alternative remedies. We draw on the literatures on the pharmaceuticalization of society and the social nature of medicine to examine the role marginalization plays in patients' views of prescription drugs. Public health research conceives of racial minorities' lower rates of prescription drug usage compared to whites as primarily a problem of lack of access. Our results suggest another piece to the puzzle: minorities resist pharmaceuticalization pressures to express their cultural and racial identities.

Active ageing, emotional care and the threat of stigma: Identity management in older adults using sleeping medication long-term

Amid fears about the medicalisation of old age, the high prevalence of sleeping medication use in older cohorts is a significant public health concern. Long-term use is associated with a plethora of negative effects, such as cognitive impairment and risk of addiction. However, little is known about the lived experience of older adults using sleeping medication longer term. Episodic interviews lasting approximately 90 minutes were conducted with 15 independently living adults, aged 65-88 years, who were using sedative-hypnotic or tricyclic sleeping medication for more than 11 years on average. Thematic analysis shows that participants divided their rationale for use into two temporal periods: (1) to ensure physical ability in the daytime and (2) to ensure emotional stability at night. Long-term sleeping medication was thus characterised as a form of 'emotional self-management' of the negative emotions associated with later life, blotting out feelings of loss and loneliness by inducing sleep. Participants feared loss of access to their medication 'supply', employing strategies to ensure its continuity, while expressing shame about their dependence. However, identity management, in the form of explanations, minimisations and social comparisons, functioned to downplay their addiction. Through this, long-term sleeping medication users were able to elude the spoiled identities and multiple stigmas of both the 'out of control' addict and the unsuccessful older adult by asserting a positive identity; that of the 'new' older adult, actively medicating for success both day and night.

Food for thought? Potential conflicts of interest in academic experts advising government and charities on dietary policies

BACKGROUND

A conflict of interest (CoI) can occur between public duty and private interest, in which a public official's private-capacity interest could improperly influence the performance of their official duties and responsibilities. The most tangible and commonly considered CoI are financial. However, CoI can also arise due to other types of influence including interpersonal relationships, career progression, or ideology. CoI thus exist in academia, business, government and non-governmental organisations. However, public knowledge of CoI is currently limited due to a lack of information. The mechanisms of managing potential conflicts of interest also remain unclear due to a lack of guidelines. We therefore examined the independence of academic experts and how well potential CoI are identified and addressed in four government and non-governmental organisations in the UK responsible for the development of food policy.

METHODS

Policy analysis. We developed an analytical framework to explore CoI in high-level UK food policy advice, using four case studies. Two government policy-making bodies: Department of Health 'Obesity Review Group' (ORG), 'Scientific Advisory Committee on Nutrition' (SACN) and two charities: 'Action on Sugar' (AoS), & 'Heart of Mersey' (HoM). Information was obtained from publicly available sources and declarations. We developed a five point ordinal scale based upon the ideology of the Nolan Principles of Public Life. Group members were individually categorised on the ordinal ConScale from "0", (complete independence from the food and drink industry) to "4", (employed by the food and drink industry or a representative organisation).

RESULTS

CoI involving various industries have long been evident in policy making, academia and clinical practice. Suggested approaches for managing CoI could be categorised as "deny", "describe", or "diminish". Declared CoI were common in the ORG and SACN. 4 out of 28 ORG members were direct industry employees. In SACN 11 out of 17 members declared industry advisory roles or industry research funding. The two charities appeared to have equally strong academic expertise but fewer conflicts. No HoM members declared CoI. 5 out of 21 AoS members declared links with industry, mainly pharmaceutical companies. We were unable to obtain information on conflicts for some individuals.

CONCLUSIONS

Conflicts of interest are unavoidable but potentially manageable. Government organisations responsible for policy development and implementation must institutionalize an approach to identify (disclose) and manage (mitigate or eliminate) perceived and actual CoI to improve public confidence in government decision-making relevant to food policy.

The persistence of cliques in the post-communist state. The case of deniability in drug reimbursement policy in Poland

This article explores a key question in political sociology: Can post-communist policy-making be described with classical theories of the Western state or do we need a theory of the specificity of the post-communist state? In so doing, we consider Janine Wedel's clique theory, concerned with informal social actors and processes in post-communist transition. We conducted a case study of drug reimbursement policy in Poland, using 109 stakeholder interviews, official documents and media coverage. Drawing on 'sensitizing concepts' from Wedel's theory, especially the notion of 'deniability', we developed an explanation of why Poland's reimbursement policy combined suboptimal outcomes, procedural irregularities with limited accountability of key stakeholders. We argue that deniability was created through four main mechanisms: (1) blurred boundaries between different types of state authority allowing for the dispersion of blame for controversial policy decisions; (2) bridging different sectors by 'institutional nomads', who often escaped existing conflicts of interest regulations; (3) institutional nomads' 'flexible' methods of influence premised on managing roles and representations; and (4) coordination of resources and influence by elite cliques monopolizing exclusive policy expertise. Overall, the greatest power over drug reimbursement was often associated with lowest accountability. We suggest, therefore, that the clique theory can be generalized from its home domain of explanation in foreign aid and privatizations to more technologically advanced policies in Poland and other post-communist countries. This conclusion is not identical, however, with arguing the uniqueness of the post-communist state. Rather, we show potential for using Wedel's account to analyse policy-making in Western democracies and indicate scope for its possible integration with the classical theories of the state.

Towards a genealogy of pharmacological practice

Following Foucault's work on disciplinary power and biopolitics, this article maps an initial cartography of the research areas to be traced by a genealogy of pharmacological practice. Pharmacology, as a practical activity, refers to the creation, production and sale of drugs/medication. This work identifies five lines of research that, although often disconnected from each other, may be observed in the specialized literature: (1) pharmaceuticalization; (2) regulation of the pharmaceutical industry; (3) the political-economic structure of the pharmaceutical industry; (4) consumption/consumerism of medications; (5) and bio-knowledge. The article suggests that a systematic analysis of these areas leads one to consider pharmacological practice a sui generis apparatus of power, which reaches beyond the purely disciplinary and biopolitical levels to encompass molecular configurations, thereby giving rise not only to new types of government over life, but also to new struggles for life, extending from molecular to population-wide levels.

Disease-mongering through clinical trials

Our goal in this paper is to articulate a precise concept of at least a certain kind of disease-mongering, showing how pharmaceutical marketing can commercially exploit certain diseases when their best definition is given through the success of a treatment in a clinical trial. We distinguish two types of disease-mongering according to the way they exploit the definition of the trial population for marketing purposes. We argue that behind these two forms of disease-mongering there are two well-known problems in the statistical methodology of clinical trials (the reference class problem and the distinction between statistical and clinical significance). Overcoming them is far from simple.

Drugs, cancer and end-of-life care: a case study of pharmaceuticalization?

There is evidence from some countries of a trend towards increasingly aggressive pharmacological treatment of patients with advanced, incurable cancer. To what extent should this be understood as a progressive development in which technological innovations address previously unmet needs, or is a significant amount of this expansion explained by futile or even harmful treatment? In this article it is argued that while some of this growth may be consistent with a progressive account of medicines consumption, part of the expansion is constituted by the inappropriate and overly aggressive use of drugs. Such use is often explained in terms of individual patient consumerism and/or factors to do with physician behaviour. Whilst acknowledging the role of physicians and patients' expectations, this paper, drawing on empirical research conducted in the US, the EU and the UK, examines the extent to which upstream factors shape expectations and drive pharmaceuticalisation, and explores the value of this concept as an analytical tool.

The shaping of pharmaceutical governance: the Israeli case

This article focuses on governance of the pharmaceutical sector in Israel. It traces the relationships between the state, industry, and sick funds from before the establishment of National Health Insurance (NHI) in 1995 to the beginning of this decade, in particular as they have grappled with the challenge of making national formulary decisions in a rational manner. Subsequent to the introduction of NHI there have been shifts in the modes and mix of governance. This research shows empirically that a relatively complex mix of hierarchical and network modes of governance can be successfully established over an extended period of time when flexibility is maintained through the implementation process. The system for defining and updating a standard basket of health services has coped well with the challenge of managing a range of difficult and potentially volatile stakeholder relationships in the pharmaceutical sector and of distancing ministers from controversies of funding and listing decisions. Government has succeeded in containing drug costs whilst still maintaining a basket of reimbursable drugs that, from an international perspective, is comprehensive and technologically advanced. On the other hand, network arrangements appear to have delayed the introduction of suitable accountability relationships and hindered their development. The state has traditionally played an intermediary role between unavoidable corporate interests of industry and sick funds, with little transparency and to the detriment of more pluralistic access to decision making. Governance arrangements in Israel appear to limit the potential and incentive of the state and the sick funds to realize their potential countervailing powers in subsidy and pricing decisions.

A deviation from standard design? Clinical trials, research ethics committees, and the regulatory co-construction of organizational deviance

Focusing on the high-profile drug disaster at London's Northwick Park Hospital in 2006, this article explores how such an event can be seen as an example of organizational deviance co-constructed between the company running the research and the research ethics committee which approved the trial. This deviance was the result of the normalization of a specific dosing practice in the broader regulatory field, allowing the researchers and regulators to take a risky dosing strategy for granted as best practice. Drawing on the work of Diane Vaughan, this article uses interview data with researchers and members of the research ethics committee concerned as well as documentary material, to show how work group cultures between regulators and those they are intended to oversee are maintained, and how the culturally embedded assumptions of such work groups can result in organizational and regulatory deviance.

Regulating drug information in Europe: a pyrrhic victory for pharmaceutical industry critics?

Informed by recent sociological debates on pharmaceuticalisation, this article examines the evolution of the current EU legal proposal on prescription drug information to patients, as well as the surrounding controversies. In 2008 the European Commission proposed the relaxation of the existing rules governing drug information provision to patients by the pharmaceutical industry. Critics of the industry's influence over health policy and markets, including consumer organisations, industry-independent patient organisations and health professionals, rejected the Commission's proposal, claiming that the industry cannot be considered a reliable source of patient information due to inherent financial conflicts of interest. Since these critics were at least partially successful in rallying opinion against the Commission proposal, they functioned as countervailing forces to promotion-driven pharmaceuticalisation. Even so, as a watered-down version of the proposal moved through the European Parliament it was further modified to ultimately resemble the Swedish system that was held up as a high-quality example of industry-based information provision. Yet this article contends that the Swedish system displays evidence of corporate bias. Significantly, basing EU policy on a drug information system not resistant to corporate bias risks creating practices that violate the legally mandated mission of EU drug regulation, which is to 'promote and protect public health'.

The politics and strategy of industry self-regulation: the pharmaceutical industry's principles for ethical direct-to-consumer advertising as a deceptive blocking strategy

As the pharmaceutical industry lobbies European regulators to permit direct-to-consumer advertising (DTCA) of prescription drugs in the European Union, we found that five leading companies violated industry-developed and -promulgated standards for ethical advertising in the United States. Utilizing multiple data sources and methods, we demonstrate a consistent failure by companies that market erectile dysfunction drugs to comply with the industry's guiding principles for ethical DTCA over a four-year period despite pledges of compliance by company leaders. Noncompliance resulted in children being exposed to sexually themed promotional messages more than 100 billion times. We argue that the guidelines are a coordinated effort by the industry to prevent unwanted federal regulation, and we introduce the concept of a blocking strategy to explain company behavior and to advance theoretical understanding of firms' public affairs strategies. We recommend policy responses to prevent deceptive practices, protect children from adult content, and promote genuine health care education.

The politics of health technology assessment in Poland

OBJECTIVE

First, to identify risks associated with the scientific evaluation of drugs considered for state reimbursement in Poland through exploring strategies of influence employed by multinational drug companies in relation to the Agency for Health Technology Assessment (AHTAPol). Second, to ascertain whether the outcomes of drug evaluation meet the interests of the public payer in reimbursing cost-effective drugs supported by robust pharmacoeconomic evidence.

METHODOLOGY

We conducted 109 in-depth semi-structured interviews with a purposive sample of stakeholders involved in the reimbursement process in Poland. We analysed four available documentary sources, including recommendations issued by the AHTAPol.

RESULTS

AHTAPol recommendations were an instrumental part of the blame avoidance strategy by political elites. Drug producers utilised direct and indirect strategies of influence. The direct strategies involved building relationships with a circle of health technology assessment analysts and medical experts working for the Agency. The indirect strategies employed leaders of opinion in the medical milieu, patient organisations, and political elites to endorse policy positions favourable to drug companies. The AHTAPol positively recommended an increasing proportion of the drugs it assessed, many of them reported as not cost-effective or supported by dubious pharmacoeconomic evidence.

CONCLUSIONS

The strategies of influence entail a number of risks that may undermine the scientific evaluation of drugs. Some outcomes of drug evaluation may favour the interests of multinational drug companies over those of the public payer. We suggest that the risks involved in drug evaluation might be mitigated through (1) professionalization of health technology assessment; (2) restriction of job seeking and post public-payer employment; (3) disclosure and management of experts' conflicts of interest; (4) institutionalisation of patient and public involvement; and (5) increased institutional separation of the AHTAPol from political elites.

Assessing stakeholder opinion on relations between cancer patient groups and pharmaceutical companies in Europe

BACKGROUND

The relationship between the pharmaceutical industry and cancer patient groups has been the subject of much scrutiny and skepticism, and some high-profile negative media coverage has focused attention on some of the problematic aspects of the relationship. Both the pharmaceutical industry and cancer patient groups have made an effort in recent years to improve the transparency and openness of their relations, specifically with regard to the financial support offered by pharmaceutical companies to patient groups.

OBJECTIVE

The objectives of this survey were to benchmark perceptions held by different stakeholder groups about current relationships between cancer patient groups and pharmaceutical companies in Europe, and to explore opinions about ways in which partnerships between patient groups and pharmaceutical companies could evolve to the benefit of cancer patients.

METHODS

The survey was conducted using a structured questionnaire that contained a combination of matrix, scaled, and open-ended questions. The questionnaire was developed based on a literature search and the findings from ten in-depth interviews conducted with policy makers and advocates working at an EU level. Telephone interviews were carried out using a structured questionnaire with a convenience sample of 161 policy makers, cancer healthcare group representatives, and cancer patient group leaders from France, Germany, Hungary, Italy, Latvia, the Netherlands, Poland, Portugal, Romania, Spain, Sweden, and the UK. The interviews took place in the relevant language of the country.

RESULTS

The current relationship between the pharmaceutical industry and cancer patient groups in Europe is generally viewed as positive, but it is also viewed as being unequal, not transparent enough, and not sufficiently patient-centric. There is broad agreement that cancer patient groups can help companies identify unmet needs and contribute to the development of innovative medicines; however, there is some concern about cancer patients' competence to take on this role. Also, pharmaceutical companies and patient groups have a common interest in working together on the development of non-promotional patient information and strategies to support medicines adherence. Respondents also indicated that the two sectors have a legitimate interest in ensuring that patients in need access appropriate treatments in a timely manner. Ongoing cooperation between health professionals, pharmaceutical companies, and cancer patient groups is also viewed as important. Efforts should continue to make relations between pharmaceutical companies and cancer patient groups as equal, open, and transparent as possible.

CONCLUSION

Despite ongoing concerns about the openness and transparency of relations between pharmaceutical companies and patient groups, there is scope for these two sectors to work together on issues of common interest.

Pharmaceutical lobbying under postcommunism: universal or country-specific methods of securing state drug reimbursement in Poland?

This paper aims to fill in the gap in research on the effect of pharmaceutical lobbying on drug reimbursement policy, particularly in Poland, a post-communist country. To this end, we conducted in-depth, semi-structured, anonymous, elite interviews in Poland, supplemented by a review of legislation, policy documents, official reports and press articles, as well as observations. Overall, 109 representatives of stakeholders involved in reimbursement policy were interviewed. We identified two key lobbying methods: informal persuasion and third-party endorsements. These methods are coupled with two supplementary ones: lobbying through parliament and ministries, as well as diplomatic pressure. Pharmaceutical lobbying methods in Poland clearly resemble those used in other European countries. What is notable about the Polish case is extensive reliance on informal lobbying and diplomatic pressure.

Desperately seeking cancer drugs: explaining the emergence and outcomes of accelerated pharmaceutical regulation

Government regulators have increasingly accelerated new cancer drugs on to the market by granting them approval based on less clinical data supporting drug efficacy than permitted under standard regulations. With more lenient regulatory standards, pharmaceutical companies have keenly sought to develop cancer drugs. Focusing on the US, this article examines how the emergence and implementation of such accelerated approvals should be understood, particularly in relation to corporate bias and disease-politics theories. Drawing on longitudinal and case study data analysis, it is argued that the emergence of accelerated approval regulations for cancer drugs should be regarded primarily as part of a deregulatory regime driven by the interests of the pharmaceutical industry in partnership with all major aspects of the state, rather than as a response to patient activism in the aftermath of AIDS. Furthermore, even in cases when some patients successfully demand accelerated marketing approval of cancer drugs, such approval by regulators, while in manufacturers' interests, may not be in the interests of patients' health because the political culture of the regulatory agency is reluctant to uphold its own techno-regulatory standards of public-health protection when that would challenge the agenda-setting influence of manufacturers, including industry collaborations with patients and the medical profession.

Marketing before patenting: implications for price controls in Canada

The Patented Medicine Prices Review Board (PMPRB) regulates the introductory price of new patented medications in Canada. Some drugs are marketed before they are patented and are therefore outside the authority of the PMPRB. This study was undertaken to determine how many drugs fall into this category, the time period between marketing and patenting, and the excess revenue, if any, earned before prices are subject to regulation. Between 2000 and 2008 a total of 42 drugs were marketed before being patented. Complete data were not available for 9 of these, leaving 33 of the 42 for analysis. Drugs were potentially being marketed between 54 and 2707 days before they came under PMPRB jurisdiction. Three products were eventually deemed to have exceeded the maximum introductory price, and the total excess revenue for these 3 was $9,289,688. Although only 3 of 33 drugs were found to be overpriced, the fact that prices can go unregulated for up to 7.4 years is troublesome. If companies are charging excessive prices, then the additional payments they receive may limit the ability of provincial formularies to list additional drugs. Controlling prices on the basis of patent status has significant limitations, and a new system that deals with prices of all medications should be developed.