Lead Author: Katie Dain
Additional Author(s): Priya Kanayson, Tiphaine Lagarde
Organization: NCD Alliance
Country: UK, USA, Switzerland
Non-communicable diseases (NCDs) – including cancers, cardiovascular diseases, chronic respiratory diseases, diabetes, and mental health and neurological disorders – are the leading causes of death worldwide, accounting for 38 million of the world’s 56 million deaths in 2012. Populations in low- and middle-income countries (LMICs) bear a disproportionate share of the burden, with over 80% of all preventable deaths under the age of 70 occurring in these countries, resulting in high economic losses. Due to their chronic and sometimes life-long nature, NCDs demand a responsive, person-centred health system. People living with NCDs often have multiple interactions with the health system over long periods and may require disability management and long-term care. Access to essential medicines and technologies is a vital component of chronic-disease management, and in many LMICs, availability and access is inadequate, with large disparities persisting between and within countries. WHO estimates that there are 5.5 billion people living with minimal or no access to adequate pain treatment, of which millions endure pain due to acute illness or end of life. Understanding the current environment around availability and affordability of essential medicines and basic technologies for NCDs is key to identifying structural bottlenecks and implementing adequate approaches to improve access to these commodities.
We welcome the opportunity to submit a contribution for consideration by the United Nations Secretary-General’s High-Level Panel on Access to Medicines. The NCD Alliance is a global civil society network of over 2,000 organisations working collectively to elevate the profile of non-communicable diseases on the global development agenda.
Non-communicable diseases (NCDs) – including cancers, cardiovascular diseases, chronic respiratory diseases, diabetes, and mental health and neurological disorders – are the leading causes of death worldwide, accounting for 38 million of the world’s 56 million deaths in 2012. Populations in low- and middle-income countries (LMICs) bear a disproportionate share of the burden, with over 80% of all preventable deaths under the age of 70 occurring in these countries, resulting in high economic losses. Due to their chronic and sometimes life-long nature, NCDs demand a responsive, person-centred health system. People living with NCDs often have multiple interactions with the health system over long periods and may require disability management and long-term care.
Access to essential medicines and technologies is a vital component of chronic-disease management, and in many LMICs, availability and access is inadequate, with large disparities persisting between and within countries. Studies show that mean availability of essential NCD medicines in 36 LMICs is very low, and lower than availability for medicines targeting acute diseases. In the public sector, availability for NCDs was 36% compared to 54% for acute diseases, while in the private sector the comparison was 55% versus 66%. A particular issue is the insufficient access to controlled opioid analgesics for pain relief and palliative care. WHO estimates that there are 5.5 billion people living with minimal or no access to adequate pain treatment, of which millions endure pain due to acute illness or end of life. Understanding the current environment around availability and affordability of essential medicines and basic technologies for NCDs is key to identifying structural bottlenecks and implementing adequate approaches to improve access to these commodities.
Numerous political commitments have been made to reducing the global burden of NCDs and investment in NCD diagnosis, treatment, and care. These commitments include the WHO Global Action Plan (GAP) on the prevention and control of NCDs, which specifies a target on achieving 80% availability of affordable basic technologies and essential medicines required for NCDs by 2020 ; the 2030 Agenda for Sustainable Development, which discusses a target on reducing the burden of NCDs and supporting research and development of vaccines and medicines; and the 2011 United Nations Political Declaration on the Prevention and Control of NCDs. Achieving the targets set forth in these commitments is critical to reducing the global burden of NCDs and improving the health and wellbeing of all.
The difficulties in access to essential NCD medicines and basic technologies highlight a number of factors and complexities that can arise at multiple levels across the patient’s healthcare ecosystem, including prevention, early detection, screening, treatment, care and disease management. It is important to consider access to essential medicines and technologies for NCDs from a holistic perspective to recognise the special and varied needs of people at risk or living with NCDs along the life-course, e.g., the mismatch between global palliative care needs and medicines and technologies available. Understanding issues from a patient’s individual socio-economic context is also critical to improving the availability of medicines and technologies for NCDs and as part of a broader universal health care (UHC) agenda. For example, the availability of medicines and technologies at treatment facilities is irrelevant if patients are unable to access them due to distance and cost of transport.
In most cases, the reasons for inadequate access to essential medicines lie with important factors such as underdeveloped national health infrastructures and financing systems rather than patents. Given that the majority of essential medicines for NCDs are off patent (including all bar 3 of the cancer medications on the WHO Essential Medicines List), it would suggest that procurement price is less an issue than the effective distribution and delivery of medicines and technologies to those most in need.
Optimisation of supply chains for NCD medicines and technologies requires procurement of quality goods, with involvement from government and both private and public sector partners. In many LMICs, essential medicines and technologies for NCDs are available in the private sector, but at a much higher cost than in the public sector. Fragmentation between the private and public sectors results in further inequalities in access to medicines and technologies, the brunt of which is often borne by those already in poverty. Additionally, in many countries, mark-ups and duties are disproportionately high, making essential medicines for NCDs further out of reach. Reconciling these gaps and pursuing responsible public-private partnerships will be vital for governments as they develop national plans.
Health systems should be able to react to new medicines, technologies, and guidelines through continuing professional education to ensure the best care for patients. Given the central role played by health workers in NCD management, it is critical they have the skills and knowledge to treat and care NCD patients throughout the life-course, and to make the most appropriate choices about the use of medicines and technologies available to them.
A further issue relates to the disconnect between international guidelines, e.g., WHO Essential Medicines List, and their use and translation at national levels. Work needs to be done to counter the misperception that NCD medicines and technologies, and particularly those for treatment of cancer, are too complex and expensive to be feasible.
Health system strengthening is essential for achieving equitable and affordable access to essential medicines for NCDs. This can be achieved by implementing UHC, fulfillment of which will ensure that all people can access the health services they need without financial hardship. Increased resource allocation to strengthening health systems will rely on increased domestic resource mobilisation and continued international assistance, both of which were outlined in the Addis Ababa Action Agenda that was adopted at the Third International Conference on Financing for Development in July 2015.
As governments scale up services in order to increase coverage, the quality of services must be maintained. Due to poor quality control, procurement practices, and regulation, a particular challenge for NCDs is ensuring safe, quality-assured essential NCD medicines and technologies. In Rwanda for example, 20% of hypertensive medicines purchased on the market were of substandard content and 70% were of insufficient stability. Quality assurance systems and mechanisms established for other health issues, such as HIV/AIDS, could be drawn upon to improve quality and access for NCDs; and, equal attention must be given to both NCD medicines and technologies. Research, innovation, and cost-effectiveness are critical elements for improving quality of care.
While the ultimate responsibility to provide essential medicines and basic technologies lies with national governments with guidance provided by WHO, other stakeholders can and do have an important role to play. International non-governmental organisations have significant experience in implementing programs and projects to facilitate improved access to medicines and technologies for health. As such, they have a series of important roles to play: a) dispelling myths and misconceptions around the cost and feasibility of access to essential NCD medicines and technologies amongst governments and donors; b) delivery and planning of NCD services, including before and during humanitarian emergencies; and, c) holding governments, service providers, and international organisations accountable to their commitments. Investing directly in capacity building for NCD community organisations and alliances will facilitate implementation, evaluation, and monitoring of activities, and can result in improved care and reduced cost of NCD treatments and services. The private sector can also play a role in developing and delivering training and support for essential medicines and technologies. Building on these relationships will unlock a wealth of experience and expertise to further advance the prevention and control of NCDs.
In addition to the targets set forth in the WHO GAP, the WHO Global Coordinating Mechanism has recommended a set of low-cost key interventions to improve access to essential medicines and affordable technologies required for detection and treatment of NCDs. These recommendations are developed around four components: rational selection of medicines; affordable pricing; universal health coverage and sustainable financing; and reliable health and supply systems. We strongly urge the High-Level Panel to take these under consideration and highlight that Member States, particularly LMICs, need more detailed technical guidance in implementing the recommendations and must take concerted action to ensure essential medicines for NCDs are included as a core component of the WHO Model List of Essential Medicines.
The NCD Alliance and its network stand ready to support the High-Level Panel and Member States as they work to improve access to essential medicines and technologies that will improve the health and wellbeing of all.
Bibliography and References
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