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