Everyone’s talking markets and access, but which ones?
Whether people have access to medicines, vaccines, or diagnostics is strongly dependent on how societies view the markets for these products, and whether they agree across or within about markets are appropriate institutions for their production and distribution.
While textbook economics suggests that vaccines are public goods, it has taken some time in this pandemic for clinicians to agree about what this means in practice, and longer for economists and other policy analysts to understand the chaotic and unexpected data coming in from 2020 and industrialized countries where a more successful response to the pandemic was expected. The concentration of vaccine manufacturing capabilities in India to a large degree also meant that traditional public goods and technology transfer mechanisms were not working through standard aid and trade channels.
Two finer points are worth elaborating: our expectation of access is a contingent expectation based on the degree of technological advance. This scale of testing or vaccination was absent in prior pandemics, and this pandemic has generated significant within-country variety of organizational and technical innovations despite the breakdown of global trading for many months. Yet, as we have seen, this ability to produce baseline products and services or even the innovation as we see, does not guarantee access (including affordability and availability).
A discussion about which institutions are appropriate to ensure that people have access to life-saving medicines, vaccines, or diagnostics brings us to this pandemic. The complexity of national and global responses has hinged on having to assess day by day which countries and ‘whose’ firms are closely tied to each other bilaterally, through supply chains, or by prior advance market commitments. Free markets these were not, but neither pure public goods, nor transparent multilateralism.
Well before the pandemic, Market Menagerie: Health and Development in Late Industrial States offered one way based on national and comparative data between approximately 1950 and 2000, to analyze evolving policy design and emphasize national and firm-level capabilities and priorities over time.
Dividing the spheres of health decisions into production, consumption/demand, and delivery policy domains, the book showed how Indian, Japanese, and other countries with supplier capabilities in vaccines, medicines, or other biotechnologies, were able to juggle multiple markets and policy priorities. A country that may have been successful during one epidemic may not be successful in another; or strategies in which vaccines may play a role in one period may need to be reassessed in another.
Technological advance complicated, not necessarily simplified, the regulatory challenge or clarified the policy priority. Democracies may have an even more difficult task because many more potential actors and institutional pathways open up. Dynamic change is the norm, not necessarily continuity; markets have many varieties and goals, and policy design at any point in time will have competing goals to sift through to decide what types of markets to create, sustain, and regulate.
The book offers some arguments and aids for why we should be cautious about drawing too easy comparisons between an India or Brazil, Japan or Nigeria. The more market types or wider institutional variety one sees in a society, the more a combinatorial approach in institutional analysis is needed, not crude contrasts of countries by GDP or R&D investment measures alone.
The pandemic has shown us that high GDP/capita countries may have been able to purchase many vaccines, but their overall response to the pandemic has been uneven, deadly in many richer countries with strong medical systems; similarly lower GDSP/capita countries demonstrate some innovative responses to the pandemic, despite limited capabilities under import restrictions which may have helped with the first wave of the coronavirus but the second waves have proved deadly for many, with lockdowns and swamped hospitals creating challenges that vaccines purchases may have helped stall.
A series of challenges, often with combinatorial characteristics of productive capabilities as well as access roadblocks has left all countries facing their individual and quite unique dilemmas and phasing of policy resolution, even though they have many features in common. Market Menagerie’s discussion opens up a theory and methods debate on tracking and responding to the pandemic in each location, while drawing out some common features of policy design that cannot be resolved without attention to institutional variety (technology contingent) and its consequences.