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GLOBAL CANCER INITIATIVES

29 CANCER CONTROL 2021

the economy. Different institutional combinations exist in

all societies. Because these combinations are dynamic and

change over time, an older static, non-equilibrium, analysis of

technological change is entirely misleading.

The "War's" foundational metaphor arguably reflects a time

when cancer was less well understood and the economics

of learning and innovation was nascent. Yet, advances in

evolutionary and institutional economics in the last 50 years

has revolutionized the study of technological change (7).

It dislodges an equilibrium perspective and emphasizes an

uncertain search and learning process of firms with no "best"

technology (8). One simple heuristic suffices to show different

pathways: three domains of an 'institutional triad' of production,

demand, and delivery can distinguish national health industries,

each of which has distinct technological histories (9). "Health

policy" and "industrial policy" are separated in this heuristic

(10). Laboratory science also historically emerges as only one

type of institutional combination, not a universal paradigm. For

example, India's cancer profile where a significant incidence is

preventable, needs a rethinking of its economics and policy

design, with science channelled and publicly supported in

priority areas, and firms and other organizations with ears to

the ground, encouraged to assess health problems and learn,

create, and adapt technologies or service solutions.

Countries with greater industrial self-reliance can more

confidently shape their health priorities. While there is no

inevitable link between health policies and industrial policies,

there may well be a jostling for power by some dominant

firms to create and protect the institutional combinations

that favour them e.g. intellectual property, market design,

technical standards or even their "brand" as friends to NGOs

or other communities, or other favourable business strategies.

Competition can thus prove to be critical in differentiating

effective firms by technology, price, quality, or other patientfriendly features and rejecting expensive

solutions by

building value-based strategies. At the same time, other social

institutions such as welfare regimes and ethos of assistance

should be encouraged alongside individual lifestyle shifts. This

attention to real-world variety, complexity and uncertainty

against an artificial "rigour" of clinical and economic evaluation

is also supported by clinicians who study the variable nature of

health interventions (11).

The benefits of viewing cancer through the evolution

and institutions lense

I have argued that the health industry is best seen as a multiple

markets and combinatorial problems requiring close attention

to non-market institutions. That the social determinants of

health might include industrial organization and especially

industrial policy is a relatively new acknowledgement, also supported by the need to appreciate complexity of health

interventions (12). Successful supplier countries are those with

active firms (public, private, hybrid) and other organizations

(non-profits, grassroots, or cooperatives) which will generate

new problems and where new markets have to be constituted,

regulated, phased out, or cancer priorities addressed through

non-market means. Notably, countries with wider health

knowledge systems and home-grown abilities to prototype,

develop hybrid organizations, and develop treatments or

equipment, are a special case of countries, and democracies an

especially important sub-group. This is not a normative view

but informed by the different historical pathways of nations

and products, and far removed from the idea that an "invisible

hand" of efficient markets should dominate society. With this

conceptual shift comes uncertainty and the need for new

methods, but provides a historically more accurate approach

toward realistic long-term health policy and plans driven by

robust problem-solving (13).

The pharmaceutical industry history is based largely on

chemical industry progression, while biotechnology has had

its own evolution (14). Mixed together as they are in cancer

science and clinical treatment, there is no definable trajectory

of a single industrial pathway, but there certainly can be

priorities for accelerating access, accuracy, and humane care.

Neither are the dynamic features of industrial organization

easily collapsed into a traditional profit-driven description of

a "medical-industrial complex", because there are increasingly

more actors in the health industry world - public hospitals,

non-profits, hybrid platforms and service organizations,

charities, or others, who play often invisible search, learning,

and solution provider roles, and whose primary motivation

may not be profit. Moreover, different sub-sectors have their

own learning and regulation requirements, with equipment

manufacturers and generic pharmaceuticals difficult to

compare; the former suffering industrial rules devised for the

latter (15). Similarly, the measures of industry impact and scale

have to be context-driven: the degree of vertical integration

and industry diversification goals can then be used to assess

whether the policy goal is greater numbers of start-ups in

handheld devices for breast cancer diagnostics, "big data",

fewer cases altogether, or something else entirely.

The industrial foundations of "choosing wisely"

Articles I and V of the Alma Ata Declaration 1971 require a

commitment from governments that policy design will ensure

responsibility for improvements in population health. Cancer

response is therefore shaped by which demand institutions

ensure such improved and judicious consumption of care and

treatment. Therefore, industrial policies will need to situate

cancer strategies beyond a single disease and its clinical

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