【桑葛石原研翻译系列】高盛在全球医疗领域中的作用分析

意味著性仅为5%左右，总少于开发计划成本约为15亿美元。为了减免可能会和开发计划成本，化工子公司拥有其低价销售新的产品的溢价利润率。由于上述可能，里医疗保险第三世界偿还债务非常标价处方的能力实际，造成了化工子公司将其制造工作集里在主要冲击非常高收益第三世界的癌症上。从而造成了医疗卫生一般来说缺少科技，非常高收益第三世界也未赢得处方。只有不到5%的私人制造税收归入全球性医疗卫生教育领域。宏观在经济上、政治可能会和缺少系统设计数据等可能也造成了全球性医疗卫生被置于大众化商业化制造该组织的聚光灯之外。

可能会入股（VC）方式而将物理转化为商业化新的产品方面的力量

与此同时，在癌症和罕见癌症等教育领域正在得到更大的进展。突破性的物理推测诸如基于基因用药和免疫学的电子技术，针对以在此之前未用药的癌症正在被转化为可用药的和新的疗法。罕见病与医疗卫生教育领域的相似之处，都被并不认为是没有实用性的科技低价。每种癌症很少被并不认为推选实际的低价更进一步。每一种癌症只有少数高血压被并不认为推选着实际的低价更进一步。为了克服科技水平低的可能，带入了降低药理学试验规模拒绝和政府机构审批一段时间的政府机构激励措施，结果是显着的，例如，2018年美国食品和制剂管理局批准的59种制药里，有31种用于罕见癌症。此外，将高血压分为非常小、非常同质的群体，再行加上精准医学的转型，冲击了其他医学教育领域应用相同的靶向制剂开发计划方法——这是如何为特定这群人进行科技也能对其他群体激发重大冲击的一个事例。

VC和其他注资方式而在这个时代背景发挥了重要起到，尤其是通过资助未经证实的非常高可能会电子技术，并证明它们的药理学成本。VC是企业和知识的结合，知道如何建立和较快物理类子公司的低价。VC入股者将全力支持子公司在药理学和商业化策略、商业化、的业务转型、注资、建立正确的网络，确定正确的董事会和顾问，所有的旨在是放缓开发计划现实贫困和较快收益的激发。

典型的一一个人物理VC该基金会将入股时间尺度改为5-8年。之后他们将出售给大型化工子公司，或通过该子公司在商业银行交易所上市进行交易。退出是VC现实贫困不可分割的部分，因为它允许入股者反过来将企业返还给其入股者，或者在常青该基金会的情况下，入股于新的子公司。因此，大型化工子公司和大型医疗卫生器械子公司在生态系统设计里的起到至关重要，它们是VC全力支持的始创子公司的买主。

始创与大型药企共同开发方式而显着提非常高了整个化工行业的科技率

在即使如此的几十年里，科技现实贫困从大型化工子公司和大型医疗卫生设备子公司普遍外包到小型的、通常是VC全力支持的始创子公司。这一相当程度转变在化工行业最为明显——自2013年以来，美国食品和制剂管理局批准的制药里，有2/3早先由较小的生物化工子公司开发计划，造成了大型化工子公司被选为外部来源科技的大买主，随着一段时间的发生变化，各方在复杂的静态里补足开发计划和其他可能会。VC始创子公司-大型化工子公司共同开发方式而显着提非常高了整个化工行业的科技率。因此，科技新的产品的收购毕竟可对于大型化工子公司维持科技并赢得优质结算的自觉或多或少重要。

除了通过对每家子公司的普遍尽职调查和主动所有权静态掌控可能会各种因素外，VC静态主要环绕能够赢得溢价结算的新的产品构建。在罕见癌症的案例里，VC入股者推测了一个有实用性的人口为120人，鉴于高血压一般来说缺少，药理学试验规模拒绝并不一定较小，同时有更进一步应用肥胖症在经济上论证来赢得溢价结算。

它还侧重于新的产品而不是服务，这主要是因为新的产品非常容易跨地域、第三世界和中国文化进行扩张。

当然，VC静态并不美妙，非常高可能会非常高回报方式而在即使如此几十年里激发了好坏参半的结果。此外，它有时与阴险和非多元中国文化中国文化有关。本文论述了VC方法论和一个大的特点，它们绝不比如说上述类型的该组织中国文化。

在全球性医疗卫生教育领域进行VC的更进一步

鉴于VC在罕见癌症和肿瘤等较强娱乐性教育领域的尝试，但它回避了一个可能：VC方式而可以做些什么来较快科技和克服全球性卫生教育领域的低价失灵？

通过开发计划新的新的产品和系统设计设计，起死回生一一个人，降低人类所的苦难。 跨第三世界和区域扩大科技新的产品。在原则上资助科技的能力下，里医疗保险第三世界可以赢得大规模的肥胖症收益 冲击入股的案例已经重申，全球性医疗卫生是财政和全球化回报可以一致的较好的事例。这个教育领域的科技新的产品可以起死回生一一个人/降低人类所的苦难，也借以里医疗保险第三世界的在经济上转型。 VC入股者有更进一步在不那么拥挤的空间里，以合理的作价进行科技。为里医疗保险第三世界设计的低开发计划成本体外受精或糖尿病护理方案在非常高收益第三世界也意味著较强有实用性的低价潜力。 将非常大比例的可能会企业直接改装成里医疗保险第三世界的方式也。尽管许多科技早先意味著来自欧美，但一些最具科技的系统设计设计应该来自当地第三世界本身，这些第三世界通常不在VC入股者或其他利益管理者的地形图上。因此，企业流入借以提高地方科技生态。

【出处】

Investing for good - the case for venture capital in global health

Nina Rawal, Ph.D

Global health - much has been won and much remains

The area of global health, here defined as diseases affecting low and middle income countries (LMIC), has seen some major wins over the past decades. Mortality rates for infectious diseases such as cholera have halved and polio is all but completely eradicated worldwide (1, 2). The malaria death rate in children under five has fallen by 69% since the year 2000 (3). These improvements have not only saved lives and reduced human sufferings they have also significantly contributed to strengthened economies in India and several African countries. They are the result of large scale efforts by players such as the WHO, The Global Fund to combat Malaria, TB, and HIV, and the Bill and Melinda Gates Foundation. They have all invested significant resources towards long term health improvement goals.

There are however large remaining challenges in the area of global health. Infectious diseases still cause one out of four deaths worldwide, and around five million children die every year before the age of five (4). In addition to communicable diseases such as tuberculosis and measles, and the increasing problem of antimicrobial resistance, LMIC increasingly struggle with lifestyle related diseases such as diabetes, cardiovascular disease and dementia 一 the so called double burden of disease. LMIC already account for 70% of all lifestyle related deaths worldwide and that number is expected to increase going forward (4, 5). Finding cost effective solutions for diabetes and dementia will thus be of utmost importance when thinking about global health issues ahead. The notion that low and high income countries face different disease challenges is increasingly outdated, cost effective innovations for LMIC could have large scale impact also in high income countries. Aravind Eye Care Systems which offer the best medical outcomes in the world at the lowest cost, and the Leveraged Freedom Chair, a wheelchair with superior features compared to Western competitors at half the price, are two examples of innovation with such potential (6).

'They became wealthy because they were healthy' - the importance of health for a country to move up the economic prosperity ladder

In addition to reducing human suffering and improving quality of life for the individual, good health also correlates with GDP development. Indeed, healthy people make for healthier workers, who can contribute more to society and economic growth. Experience from countries such as Japan illustrates that introduction of universal health coverage resulted in stronger financial growth 一 ‘they became wealthy because they were healthy' (7). Underlying economic growth, a willingness to spend tax income on health, and a system-wide perspective on its introduction are also important factors (8). Currently only 58 out of 195 countries offer universal health coverage, leaving around 6 bn people globally to finance their health care costs either partially or completely at their own expense (9).

For the 2.7 bn population living on less than 2.50 USD a day, that equation is virtually impossible to balance. When disease strikes people without health care insurance, poverty is a common consequence.

Looking ahead, LMIC economies are growing faster than high income countries and will soon account for 50% of the total global economy (2). Not only does it make financial sense for governments to invest in health, it also increases the attractiveness for corporations to develop product offerings tailored for this segment.

Equitable access - the mother of all global health challenges

Equitable access to health care services and products is perhaps the most complicated issue surrounding global health. Some will argue that access to basic health care must be addressed first. That challenge requires a different set of tools than outlined here. However, high quality and cost effective products, the focus of this whitepaper, offer unparalleled scalability and can also allow focusing of health care services where they are most needed.

Under current international Intellectual Property (IP) legislation, patent protected drugs and other treatment options are controlled by the company owning the IP and distribution of products is subject to their discretion. Low income persons or countries unable to afford the cost of drugs cannot access it unless the company decides to reduce the price or other stakeholders such as WHO or NGOs step in to finance the purchasing of product. This is one of the main reasons for the limited number of pharmaceutical companies focusing on global health diseases.

Countries such as India and Brazil have questioned the IP system, arguing that it disproportionately targets the world's poorest populations. These countries have developed large generics industries where the pharmaceutical is produced at a fraction of the cost of branded drugs. Indian generics companies are now global players with strong know how in reverse engineering of drugs and low cost production.

Well intended at the time of inception by providing incentive for development of new therapies, the current system is decreasingly relevant for areas such as antimicrobial resistance as well. Looking ahead, there is thus reason to believe that novel approaches will be identified. Low cost solutions that people can afford would also reduce the incentive to copy illegally.

Global health RMaxD is chronically underfunded, resulting in fewer available treatment options and large unmet medical needs

Pharmaceuticals remain the most scalable treatment modality but is a difficult business. The likelihood for a drug to pass from pre- clinical stage to approved product is only around 5%, and the total average cost amounts to around 1.5 bn USD (10, 11). In order to compensate for risk and cost, pharmaceutical companies enjoy premium margins on their marketed products. For the reasons outlined above, the limited ability for LMIC to pay for premium priced drugs have lead pharmaceutical companies to focus their RMaxD efforts on diseases mainly affecting high income countries. This results in a relative lack of innovation within the global health sector as well as lack of access to medicines available in high income countries. Less than 5% of total private RMaxD spending falls within the global health area (12). Issues such as macroeconomics, political risks, and lack of systematic data also contribute to global health being placed outside the spotlight of mainstream commercial RMaxD organizations.

The power of the venture capital model in translating science into commercial products

Meanwhile, great strides are being made in areas such as cancer and rare diseases. Breakthrough scientific discoveries such as gene therapy and immunology based technologies are being translated into cures and novel therapies for previously untreatable diseases. Rare diseases hold similarities with the global health area in that it was considered an unattractive market segment to innovate for. Few patients per disease were considered to represent a limited market opportunity. To address the low level of innovation, regulatory incentives reducing clinical trial size requirements and regulatory review time were introduced. The results have been remarkable；as an example 31 out of the 59 new drugs approved by the US Food and Drug Administration in 2018 were for rare diseases (13). Furthermore, the sub-categorization of patients into smaller, more homogenous groups, combined with the developments in precision medicine have influenced other areas of medicine to apply the same targeted drug development approach - an example of how innovating for a certain population can also have significant impact on other groups.

Venture capital (VC) and other active ownership financing models have played an essential role in this successful era by funding unproven high risk technologies and demonstrating their clinical benefits in patients. VC is the combination of capital and know how around building and accelerating science based companies to market. This is usually done through so called active ownership where the VC investor will support the company on clinical and commercial strategy, business development, financing, building the right networks, identifying the right board of directors and advisors - all with the purpose of speeding up the development process and accelerating revenue generation.

The typical life science VC fund will invest in a company with a 5-8 year investment horizon. After that, they will look to exit the company through an industrial trade sale to e.g. big pharma, or through listing of the company's shares on a stock exchange. The exit event is an integral part of the VC process as it allows the investor to in turn return capital to its investors, or in the case of evergreen funds, to invest in new companies. The role of big pharma and large medical device companies in the ecosystem is thus essential, acting as buyers of VC backed startup companies.

'The startup-big pharma partnership model has significantly increased the innovation rate in the pharmaceutical industry as a whole1

Over the past decades, there has been extensive outsourcing of the innovation process from big pharma and large medical device companies to small, often VC funded, startups. This fundamental shift, most clearly seen in the pharma industry - of the new drugs approved by the US Food and Drug Administration since 2013, 2/3 were initially developed by smaller biopharma companies (14)- has resulted in big pharma becoming large buyers of externally sourced innovation where development and other risks are shared between the parties over time in sophisticated models. The VC startup-big pharma partnership model has significantly increased the innovation rate in the pharmaceutical industry as a whole. The acquisition or in-licensing of innovative products is thus equally important to big pharma in their quest to stay innovative and command premium pricing.

In addition to mastering the risk component through extensive due diligence into each company, and the active ownership model, the VC model is mainly built around products that can command premium pricing. In the case of rare diseases, VC investors have identified an attractive niche where clinical trial size requirements tend to be smaller given the relative lack of patients, combined with the opportunity to apply health economic argumentation to command premium pricing.

It also focuses on products rather than services, mainly due to the easier scalability of products across geographies, countries, and cultures.

Of course the VC model is not perfect；the high risk high reward model has yielded mixed results over the past decades. Also, it is sometimes associated with greed and non-inclusive cultures. This paper addresses the merits of the VC methodology and toolbox, which in no way rely on the above mentioned types of organizational culture.

The opportunity for venture capital in global health

Given its success in challenging areas such as rare disease and oncology 一 areas until recently considered unsolvable, it begs the question what the VC model can do to accelerate innovation and address the market failure in global health?

Save lives and reduce human suffering through the development of new products and solutions Scale innovative products across countries and populations. Large scale health gains could be achieved across LMIC with limited ability to individually fund innovation The case for impact investing has been made and global health is a great example of where financial and social returns can coincide. Innovative products in this space could save lives/reduce human suffering as well contribute to economic development in LMIC Opportunity for VC investors to access innovation in a less crowded space, at reasonable valuations. Low cost options for in vitro fertilization or diabetes care designed for LMIC could also have attractive market potential in high income countries A way to direct larger share of VC capital to LMIC. Although many innovations might initially come from USA/Europe, some of the most innovative solutions should be expected from the local countries themselves, which are typically not on the map of VC investors or other stakeholders in the innovation ecosystem. Inflow of capital could thus contribute to the strengthening of local innovation environments.

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