POLITICAS GUBERNAMENTALES LEGALES

financialization, and capital and capitalization as power – provided conceptual tools with which I investigated the innovation process and pricing behind sofosbuvir-based medicines. I returned to them iteratively throughout my research in the pursuit of building a synthetic representation of the innovation process. This analytical orientation towards my investigation offered three

possibilities: (1) exploring the relationships between a triad of key actors rather than a single actor or state-business dyad, (2) a consideration of multiple political-economic mechanisms, and (3) a framework with which to not only describe the process but also evaluate its outcomes.

First, the literatures together gave me the tools with which to explore the potential roles of three key sets of multivalent actors in the innovation process – the state, finance, and business – as well as the relationships between them. Rather than locate pricing as a hermetically sealed matter for a single actor to determine or an outcome of a single relationship (state-business, for example), this triad motivated a search for the relations of power at play. By ‘multi-valent’ actors, I mean that multiple organizational types with different strategic interests and positions in the innovation process comprised each ‘set’ of state-business-financial actors contained. For example, I did not take the ‘state’ to be singular: though an entrepreneurial state is the explicit focus in the first thread, state actors appear in different forms vis a vis financialization as well as with

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businesses – such as in governing financial actors (the SEC) and regulating pricing possibilities (health delivery systems).29 I thus attempt to account for this heterogeneity across the triad.

Second, with a single case as a ‘strategic site’ of inquiry, I could test the multiple

mechanisms offered by the three threads in explaining the sofosbuvir case and bring together the comparative advantages of each. The financialization literature offers a macro-economic and firm-level view of regimes of accumulation, yet questions of how specific assets are valued and priced largely falls from view. The literature on capitalization provides a way of studying this quantification process (i.e. pricing) as a set of ‘valuation strategies’ that also tell us about the relations of power constituting such strategies. The literature on the capitalization of assets refers, via Veblen, to a ‘community of assets’, but does not explicitly trace the role of the state. The conception of an entrepreneurial state offers one way to give ‘the community’ a more specific form with which to investigate the genesis and evolution of assets. Finally, though the

entrepreneurial state helps explain the confrontation with Knightean uncertainty and brings the state into the upstream-downstream process, this literature alone cannot explain the trajectory of the innovation process through financial markets or the pricing and valuation of medicines by businesses. The literature on financialization and capitalization provide insights into this trajectory.

A final opportunity of this synthesis is an interrogation of the distributive outcomes at stake in an innovation process. Viewing innovation as a cumulative and collective endeavor between these actors, we can take stock of the actors that took risks in the process (and what kind of risks), as well as the actors that accrued the rewards in the process. This push towards

evaluating the outcomes of an innovation process is emphasized in Lazonick and Mazzucato’s (2013) framework of the ‘risk-reward nexus’, which I explore in the case of sofosbuvir. Lazonick and Mazzucato (2013:1094) argue that that though “one might expect that those economic actors who take the risks of investing in the innovation process would be ones to reap the rewards of when the innovation process succeeds and suffer the losses when it fails”, this link is in fact broken in contemporary capitalist economies in which a small number of financial actors are able to reap outsize rewards. The extent to which this framework holds true in this case is made

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Rather than assume and reify a unitary view of the state, I view the state a la Bourdieu: a set of public organizations engaged in institutional processes producing and struggling over scientific, technological, and economic capital while also deploying a type of “meta-capital” that set the rules of the game for social spaces, which can alter the distribution of capital between actors in those social spaces (Bourdieu,

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possible by mapping out the distribution of risks and rewards across the innovation process behind sofosbuvir.

Understanding this distribution aims at evaluating the innovation process. As Lazonick and Mazzucato (2013:1096) suggest, we can then assess “whether it (the given ‘risk-reward nexus’) supports or undermines the innovation process.” I measure this in two ways in the case of

sofosbuvir. First, I evaluate the direction and sustainability of the innovation process. I use Stirling (2009) and Mazzucato’s (2016) conception that innovation has a direction – a set of end-outcomes around which a process may be aimed – that can be empirically assessed (i.e. the extent to which a process yields clinically significant therapeutic advances or incremental and me-too medicines). By sustainability, I consider the extent to which the process supports further innovation (i.e. the reproduction of positive directional outcomes, such as breakthroughs in other areas of biomedical innovation). Second, because I hold the innovation process to also include the deployment phase of the technology (see Chapter 2, section 2.1 for my definition), I measure its patient and public health impact. Such an evaluation entails assessing the ways in which health systems adopted the medicines and, in the context of an infectious disease, were able to (or not able to) mount a public health response.