THOMAS POGGE| THE HEALTH IMPACT FUND 6. The Need for Pilots The second hurdle is related to the first. Governments will muster the political will to create the HIF only if they are convinced that it would work. In this regard, their main concern is the measurement of health impact. Is it really possible, at reasonable cost, credibly to assess the therapeutic benefits of a new medicine in poor and rich countries around the world? Substantial progress in this regard was made in April 2010 at a collaborative work ­shop with many health economists and epidemiologists at the National Institute for Health and Clinical Excel­lence(NICE) in London. But full reassurance of govern­ments and innovators requires conducting»pilots« of the HIF concept. Each pilot would consist of a contrac­tual arrangement in which a firm is rewarded explicitly on the basis of assessed health impact for one product in a single jurisdiction. Depending on the scale of the jurisdiction and the prevalence of the target disease, a pilot could be run at a relatively low cost. A pilot would show whether health impact can be reli­ably assessed at reasonable cost and also how an in­novator firm behaves differently when it is rewarded according to health impact rather than through a mark­up built into the price of its product. A pilot would also provide practical evidence on the best methods for as­sessing health impact and provide an opportunity to learn how to write contracts governing rewards based on health impact. In a suitable pilot, a firm would agree to reduce the price of a newly launched(or existing) product in one juris­diction, which could be a city, province, country, or re­gion. In exchange, it would receive rewards based on its product's measured health impact. The incentives should be designed so that, if the firm appropriately responds to them(enhancing the health impact of its product by safe­guarding freshness, focusing on patients who benefit the most and promoting proper adherence to treatment protocol), its net profits would be no less than what they would be without the pilot. The firm's sales would be rewarded differentially: it would receive no reward for patients switched from an equally effective drug, small rewards for patients switched from a less effective drug (e. g. one with greater toxicity and therefore typically low­er compliance), and large rewards for patients switched from no treatment at all. The scheme of rewards would be agreed with the firm in advance. Several promising pilot possibilities emerged from a workshop held in May 2011 at the Rockefeller Foundation's conference centre in Bellagio with experts in epidemiology, health econom­ics, health outcomes, and trial design from Canada, China, Colombia, India, Mexico, South Africa, the UK, the US, and Vietnam. Each pilot will share with the HIF itself the desirable property that its costs are straightfor­wardly related to its health impact. The cost of each pilot is unknown in advance, but it is known that, the more it will cost, the more health gains it will have produced. 7. In Conclusion: Joining Forces for Justice in Global Health The current international system for encouraging phar­maceutical innovation is highly inefficient because the rewards it offers are only very tenuously related to health outcomes. 12 This system is unsustainable as even the wealthiest countries cannot afford skyrocketing health care costs forever. The HIF is a concrete propo­sal for tying cost to therapeutic benefits in the impor ­tant domain of pharmaceutical innovations. The HIF is not cheap, and its creation therefore involves financial and political risks. These risks can be greatly reduced through appropriate pilots. The paramount task now is to gather financial and political support for a suit­able set of pilots, each of which requires a willing firm, a cooperative jurisdiction, funding for the reward pay­ments and funding for the health impact assessment. Fortunately, these pilots have their own intrinsic value by delivering health improvements at reasonable cost. But their potentially much greater value consists in preparing the way for the HIF itself which could be an amazing revo­lution in global health and a concrete model of a just global institution. Were it to work as expected, the med­icines it supports would bring enormous health gains, especially in the world's impoverished areas, even while its net costs would be negligible or(more likely) negative. While funding the HIF, taxpayers would save through reduced expenses on public health facilities, foreign aid, insurance premiums and private drug purchases. They would save expenses for costly hospitalizations avert­ed by timely pharmacological interventions. And they 12. See Thomas Pogge:»The Health Impact Fund: enduring innovation incentives for cost-effective health gains«, in Social Europe Journal 5/2 (Winter 2010/2011), 5-9, www.social-europe.eu/2011/01/the-health­impact-fund-enduring-innovation-incentives-for-cost-effective-health­gains/#comments. 7