CIAO DATE: 9/5/2007

Interview with Thai Health Minister Mongkol Na Songkhla

Nermeen Shaikh

May 2007

Asia Society

Mongkol Na Songkhla is the Minister of Public Health in Thailand. He has served in the Ministry of Public Health since his appointment on October 9, 2006. Dr. Mongkol Na Songkhla spoke with Asia Society's Nermeen Shaikh during a visit to New York where he joined a press conference with President Bill Clinton and the Clinton Foundation to announce a global pooled procurement of anti-retroviral drugs.

Thailand has been at the center of a controversy over affordable access to medication because of its recent decision to pursue generic versions of patented pharmaceuticals. As a member of the World Trade Organization, Thailand is obligated to abide by the rules and regulations in the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS). TRIPS sets a minimum international standard for forms of intellectual property such as patent pharmaceuticals. Compulsory licensing is a flexibility of TRIPS that permits all member countries to manufacture generic alternatives of patented pharmaceuticals to increase accessibility to affordable medicine. Thailand's universal healthcare system is one of the country's strengths, but the country lacks affordable access to high priced antiretroviral HIV treatment and medications for priority health conditions such as cancer, hypertension, and heart disease. Dr. Mongkol Na Songkhla defends his government's contentious policy and talks about the critical issues that plague Thailand's healthcare system.

Thank you very much, Your Excellency, for your time. I'd like to begin by asking you what the key issues are that you have confronted as you have assumed the leadership of the Ministry of Health. There are issues having to do with access to medicine, to clean water, and of course the spread of HIV/AIDS. Right now you just spoke about an aging population as well. What would you say are the highest priorities?

The highest priority right now is to respond to the top causes of death in the Thai population. The first one is HIV, the second one is cardiovascular disease, the third one is cancer, the fourth one is accidents, and the fifth one is chronic diseases associated with aging.

Could you explain the major initiatives that you have undertaken since you've assumed the position? What are the main policies that you have pursued?

The main issue that I inherited from the previous government is an emphasis on HIV. We severely lacked an emphasis on HIV in the past six years. For six years there were only two meetings of the National HIV/AIDS Committee, and the budget for HIV/AIDS prevention was stagnating and decreasing. Also, there is very little budget for other ministries to carry out necessary intersectoral actions. The only budget is the initial budget set by the Ministry of Public Health when we began to fight HIV/AIDS. During that time every ministry set up their own budget to fight HIV/AIDS. But for more than six years, there has been no budget from the other ministries. Currently, the Department of Disease Control in the Ministry of Public Health is the only agency that has a budget for HIV/AIDS prevention, which is very small. At the beginning, condoms were provided to everyone who needed them, free of charge. But for the last five or six years, needy people are not provided with condoms. There is no overt talk about AIDS prevention.

So the first thing to do is to restructure the budget, as well as the National AIDS Committee, and invite the very high profile people who used to fight HIV/AIDS to join a subcommittee. This includes Senator Mechai Viravaidya, the famous "Mr. Condom".

Right now the National AIDS Committee and subcommittees are much stronger. We still have some problems of budget allocation, but we can do better. The National AIDS Committee has already had two meetings in the last six months, and in this new fiscal year, every ministry is setting up its own budget to fight HIV/AIDS - similar to the policy six years ago.

I think that we need to strengthen education for young people more than before. The target group right is not only the sex worker anymore. Casual sex is the main cause of infection. So the tactics used to fight HIV/AIDS have to change. We need to closely cooperate with the Education Ministry and the Labor Ministry more than we did previously. It's not easy when we have left HIV/AIDS to run its course for more than five years and now want to start it again. It will take time. This government is an interim government, and it has only been around for six months. Right now we only have another six months left. The main problem facing me is that we have to speed up the process.

Why is it that the policy with respect to HIV/AIDS and other health related matters changed so much in the last six years? You said several things about how in the beginning there was much greater initiative.

It is because the Health Minister has been changing very often and none of the ministers have come from medical backgrounds. They are just laymen and do things according to the advice of their own political party. They don't know how to prioritize their work.

Moving to one of the initiatives that you have been responsible for, could you just explain for our audience, many of whom will not be familiar with this, what the importance of compulsory licensing is? First of all, what does it mean, and second of all, why is it relevant in terms of access to medicine for people in countries like Thailand?

Access to essential drugs is not possible for all people. There are problems with the national health insurance plan. We provide health services free of charge for the Thai people. There are three main schemes to achieve this. First, about 48 million people are under the Social Welfare scheme, and the budget is provided by the central government. Another five million are part of the Civil Servant Medical Benefit Scheme. The last group is the Social Security scheme, which includes nine million private and temporary public employees. In these three schemes, the budgets come mostly from the central government and are paid to private or public hospitals. However, in spite of increases in the budget, it is not enough to cope with the rapid increase in demand. For high-priced patented drugs, the central government cannot shoulder the costs, especially for some second line HIV drugs, cancer drugs, chronic disease medications, or even hemodialysis-they cannot shoulder it.

So you can see that even though we try to provide health services free of charge for people, it's actually not for everyone because the budget is not enough. Some people can use health services with payment from their own pocket. It is possible for rich people; they have access. But more than 80 per cent cannot access necessary drugs such as carcinoma drugs and second line HIV drugs. We know that the patent holder invests a lot for each medicine but actually the percentage who can access patented drugs is only 20 or 25 per cent. These are the groups of people who are paying for the research and development costs. The rest of the people who have no access do not contribute at all to the research and development cost, as they cannot pay for the patented drugs. How can we take care of the other 80 per cent of the people who are left behind? So we decided to try to find the generic alternative to serve these neglected people. Actually, we never disturbed the current consumer of patented drugs - those 20 per cent of people who can afford to pay out of pocket to get access to these drugs. They will never change, they will never switch from the original drug to a generic drug. These are well-off people who receive their services from the private sector and pay out of pocket, and also civil servants whom the government pays for their high price patented drugs, as well as about two million foreign patients a year.

But we only want to share the patent. We are very willing to buy the original drug for neglected people from patent holders if they want to compete with the generic drug in this new market for 80 per cent of Thais-paid by the government budget not out of pocket. We tried to negotiate with them officially for more than two years and unofficially for more than four years. But it's never a success.

Why is it not successful? What are the main problems?

Patent holders did not want to negotiate when we tried to find out their thoughts about making their drugs accessible to more people. They haven't agreed to talk. We have the paper to confirm that the negotiations fail every time. For the last two years they set up a subcommittee to negotiate officially and before that unofficially. Even officially during the last two years, the report back to the Ministry has shown failure because no company or patent holder wants to talk about lowering the price or sharing drugs with poor people. When they saw the report and after discussions with lawyers, many groups were concerned. So we decided to announce our intention to implement compulsory licensing on a few patented drugs. We made the first announcement for one first line anti-retroviral drug Efavirenz, and the second announcement for Lopinavir/Ritonavir (Kaletra), then the third one for an anti-platelet drug, Clopidogrel (Plavix). But actually right now after the announcement only one item was put into practice, Efavirenz. Negotiations are now going on: two years before they never wanted to sit down to talk with us and right now they are coming to sit and talk. But one of the companies requested that we abolish the compulsory licensing announcement before negotiations. We cannot go back on our announcement. An announcement is an announcement. Our announcement was not put into practice; it was made to allow for negotiations. The announcement will be put into action if and when the negotiations fail, and we need to buy the drugs.

Do you think that governments either in the North or in the South can play any role in persuading pharmaceutical companies to permit licensing under particular conditions? In other words, what role do you see for governments to play?

I think that we already have that under international law, namely the regulation under TRIPS flexibility. All member countries should try to strongly support every country to use the TRIPS flexibility in cases of necessity, in only some cases, even though there are so many patented drugs. There are very few items that need and can be implemented under compulsory licensing. Not more than that. Given the costs, we just really try to allow our low-income people to live a little bit longer and I think that no one wants to do compulsory licensing for a cosmetic drug or something like that. It's only for life saving drugs.

But in your view, Your Excellency, the problem is not with the intellectual property rights regime of the WTO because they in fact make concessions and have flexibility? The problem is the intransigence of pharmaceutical companies in granting these patents to developing countries, is that correct?

Yes.

Access to medicines is an extremely important issue in America's relations with many countries in Asia since the majority of the research and development pharmaceutical market is here, but the majority of generic manufacturing occurs in Asia. How can this relationship-between the R&D pharmaceutical market here and generic manufacturing in Asia-be made more enabling in your view?

I think that we have to strike a balance between generics and the original drug. If the consumer in a developing country could afford to buy the original drug, no one would need to use the generic alternative. Right now most people in developing countries do not have access because patent holders never think to make the drug accessible. How can you compare the original and generic price? You can say that they invest a lot on the original drug, it's true, but most of the patented drugs are not a huge investment. They spend a lot from their budget for marketing to make a profit.

So what is the problem then? It's just greed on the part of the pharmaceutical companies?

No, I think that there have to be adjustments on that side, and at the same time, an adjustment has to be made on generic drugs to save the life of the consumer.

Do you see places like Thailand and India where there is a generic manufacturing market developing their own competitive research and development in drugs? Do you see that happening in the future?

Yes, they are trying.

What has Thailand's experience been?

In Thailand, I do not think that we have enough people who can conduct comprehensive drug research. With malaria drugs they tried to do research for many years and the same with Dengue Hemorrhagic fever, but they only achieved some progress. They have to collaborate in research with other countries. We do not have enough scientists and budget for research and development.

So the last question Your Excellency: as my colleague Betsy mentioned, one of Thailand's leading HIV advocates and former Public Health Minister Mechai Viravaidya has just been appointed to design a new federal HIV prevention plan that will target the country's youth. Could you comment on the significance of this?

It is significant because he has so many tactics to tackle HIV/AIDS. He especially knows the nature of young people. I don't think that anyone knows a better way of dealing with young people than Senator Mechai. After his appointment he launched a condom for children. So many people were excited, but also criticized him for children condoms. Actually, children condoms are not really put into use, but I know he wants to educate the young people from the beginning.

From what age?

Six or seven. In kindergarten, everyone knows about condoms and the benefits of condoms. Children can become acquainted with prevention, which is very helpful for their life in the future.

That's extremely impressive at such a young age. Are there any countries that have started sex education at that age?

Not yet. You see that Senator Mechai Viravaidya has a lot of tactics! I am so glad that he accepted our invitation.

Is there anything else you would like to add before we close?

I would like to ask the rich countries from the North to cooperate with countries in the South-to take care of poor people. Let them live a little bit longer, save their lives, and let them die with some dignity. Don't let them die without any treatment. Especially in Thailand, there are so many cases of cancer when patients have to die without any medicine because the hospital refuses to treat them with very high priced patented drugs. For some chronic leukemia, a tablet per day costs 4,000 Thai Baht, and you can multiply it by 365 to get the figure for a year [$US 120 per day or $US 44,000 per year].

Some of them have to turn to herbal medicine that has no proven effectiveness. There are no studies, just only believing or faith that it can help. Finally they die without any modern medicine. There are so many cases like this. I used to work in the rural areas, and I saw so many cases. I just ask for kindness from rich countries to pay some attention to granting humanity to poor people. That's all.

Thank you very much.

Thank you.