Availability of Essential Medications for Non-Communicable and Chronic Diseases in Low and Middle Income Countries

| February 1, 2012 | 0 Comments

Rajesh Balkrishnan, PhD is the Associate Director of the Research and Education at the University of Michigan Center for Global Health; the Director of the Center for Medication Use, Policy and Economics; and an Associate Professor in Health Management and Policy.

Sofia D. Merajver, MD, PhD is the Director of the University of Michigan Center for Global Health; a Professor of Epidemiology in the Department of Internal Medicine; and the Director of the Breast and Ovarian Cancer Risk and Evaluation Program.

Non-communicable and chronic diseases (NCDs) are on the rise throughout the world, but they pose an especially great challenge in low and middle income countries (LMIC). With limited resources for healthcare and prevention, these regions, still affected by a high burden of infectious diseases, are now facing a double epidemic.

Many of the chronic diseases such as diabetes, chronic respiratory disease, cardiovascular disease, and cancer, require medications to prevent, treat, and alleviate their painful and persistent symptoms.

The availability of reliable and efficacious medications for those populations that most need them is a constant and growing challenge. A significant proportion of the 35 million chronic disease related deaths can be prevented if medications are made accessible and affordable. This challenge can and should be met. Here, we briefly summarize why and how.

Medicines Exist in LMIC, They Are Being Sold, but Few Can Get Them

In most LMIC, the availability of medicines in the public sector is much lower than in the private sector. This is a reflection of ineffectual or lack of coordination between government, the regulatory body, and pharmaceutical providers and industries.

This status quo is not bad for everyone, as profits are being made, but it violates a basic human right to health: up to 90 percent of the population in developing countries would need to pay out-of-pocket for medicines, which can then be priced at many times their retail price.

This unregulated system impoverishes those who can afford even some of the medicines and further marginalizes and violates the rights of those who could never afford any of them.

Policies of Access to “Free Medicines” are Often neither Free nor Accessible

Policies of access to “free medicines” are often neither free nor accessible. Although there are policies and systems stating that many medicines are provided free of cost by the public sector, they are not consistently available and must, in reality, be purchased from private outlets.

These medicines then cost more due to add-on costs in the supply chain or due to retail mark-ups. Therefore, public distribution facilities are a primary “access” option for the poor and the revenue gained from them can be used to subsidize other parts of the government, not at all the intended end.

This is inherently inequitable and denies these essential medications to the patients that most need them. Many families in LMIC are being plunged into poverty by unaffordable life-saving medicines.

Proposed Solutions

The solutions to this crucial challenge in global public health and human rights, are not very complicated. According to a recent report by the NCD alliance, a majority of the medications needed to treat NCDs are present and potentially available in LMIC regions in generic versions for very nominal prices (some diabetes medications for as low as 10 cents per month and asthma inhalers for $3-4 per month).

However, many of these medications are not yet available to the people in the poorest regions of the world. Governments impose duties, taxes, and levies greatly increasing the costs of these medications by the time they might reach the public.

Therefore, health care systems need to be developed cooperatively in LMIC settings that will enhance widespread access to a list of low-cost generic medicines tailored and optimized to ameliorate the regional burden of disease.

Policies and infrastructure that can be implemented towards this end include:

  1. eliminating taxes/duties by governments and regulating mark-ups;
  2. registration procedures that preferentially promote the use of generics;
  3. regulate, monitor, and ensure the quality of generic products;
  4. encourage competition in the private sector to provide inexpensive medicines.

Price negotiations/buyer co-payment, local production (which can be very costly in small quantities), compulsory licenses and government use orders with adequate compensation, and pooled procurement (countries with small purchasing volumes pool their purchases) of essential medications for NCDs are other suggested strategies to increase access to essential NCD medications.

The treatment of patients with NCDs is different from the treatment of acute infectious diseases. Patients with NCDs generally need care over extended periods of time, sometimes life-long, and should have a continuum of care provided to them by trained health care workers or health professionals.

It is a basic human right to have access to essential controller and reliever medications and to provide low cost monitoring strategies to help adherence to suggested medication regimens. Appropriate diagnosis, treatment and longitudinal monitoring of patients with NCDs is crucial for good outcomes, as in many of these conditions, there is no cure available.

Patient education thus becomes a cornerstone of successful management of NCDs, and this education should include discussions about the appropriate medication use behaviors that are needed to improve patient outcomes in these conditions.

Strategies for Potentially Effective Solutions

What can we do about this challenge from a global perspective? We need to work more closely with NGOs in LMIC in monitoring, pricing, availability, and affordability of NCD medicines and identifying and promoting successful interventions to improve access to these medications, while strongly advocating for the elimination of any added costs.

We need to mobilize additional resources and develop strategies to increase not only access to essential NCD medications, but also conduct more evidence-based policy analyses that will help remove some of the financial barriers in access to these medicines.

The development and maintenance of cost-effective evidence-based guidelines regarding NCD treatment in LMIC as well as the development of insurance/payment systems that will target and pay for low cost generic medications, are going to be key interim metrics for improving outcomes related to NCDs .

To quote the former director general of the WHO, Dr. Brundtland: “Access to essential medicines is a prerequisite for the progressive realization of this fundamental human right, and, as such, is an issue of great consequence to the health and well-being of individuals throughout the world”.

Thus it becomes paramount that we all recognize that we all need to be willing to share critical assets, resources, skills and capabilities to facilitate the alleviation of the burden of NCDs in LMIC by working with governments to develop health care systems that can provide patients with NCDs access to the most essential medications.

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Category: Development, Expert Submissions, Spring 2011

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