The Challenge of Non-Communicable Diseases and Road Traffic ...
The Challenge of Non-Communicable Diseases and Road Traffic ...
The Challenge of Non-Communicable Diseases and Road Traffic ...
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An Overview 55<br />
to fragmentation <strong>and</strong>/or duplication in distribution<br />
functions [388].<br />
Medicines may be <strong>of</strong> poor quality <strong>and</strong> the number<br />
<strong>of</strong> cases <strong>of</strong> counterfeit medicines is increasing.<br />
<strong>Challenge</strong>s also exist around the promotion <strong>of</strong> rational<br />
use <strong>of</strong> medicines: given the long-term market<br />
potential <strong>of</strong> drugs for ‘chronic diseases’, the pharmaceutical<br />
industry can be actively engaged in the<br />
development <strong>of</strong> clinical guidelines which can lead to<br />
potential conflicts <strong>of</strong> interest [389].<br />
Responses<br />
Equitable access to essential medicines, vaccines,<br />
<strong>and</strong> technologies, their assured quality <strong>and</strong> safety,<br />
<strong>and</strong> their effective use by prescribers <strong>and</strong> consumers<br />
are important goals [373]. For some NCDs, as<br />
for AIDS, prevention may be aided by treatment: it<br />
is estimated that appropriate use <strong>of</strong> medicines alone<br />
could reduce the burden <strong>of</strong> NCDs by up to 80 percent<br />
[388]. Many patients will require long-term, if<br />
not life-long, access to medicines as well as other<br />
equipment; living with Type 1 diabetes mellitus for<br />
example requires not just insulin but also syringes,<br />
needles, <strong>and</strong> diagnostic <strong>and</strong> monitoring tools [390].<br />
Both price- <strong>and</strong> non-price barriers to access need<br />
to be overcome. Improving purchasing efficiency,<br />
eliminating taxes, <strong>and</strong> regulating mark-ups could<br />
reduce medicine prices; <strong>and</strong> more efficient procurement<br />
<strong>and</strong> distribution <strong>of</strong> medicines would increase<br />
access [385]. Guidelines for good pharmaceutical<br />
procurement have been published <strong>and</strong> capacity<br />
building <strong>and</strong> information exchange could improve<br />
essential procurement <strong>and</strong> regulatory capacities in<br />
many countries [391].<br />
Countries could save an estimated 60 percent <strong>of</strong><br />
their pharmaceutical expenditures if they shifted<br />
from originator medicines to generic products, but<br />
only a few wealthy <strong>and</strong> middle-income countries do<br />
so [371]. Most first-line drugs for the treatment <strong>of</strong><br />
NCDs are <strong>of</strong>f-patent <strong>and</strong> inexpensive: even for cancer,<br />
many medicines are <strong>of</strong>f-patent generics, costing<br />
less than US$100 per treatment course [214]. Generic<br />
products could be promoted through patient<br />
<strong>and</strong> pr<strong>of</strong>essional education, alongside technology<br />
assessment <strong>and</strong> evidence-based guidelines which<br />
are enforced <strong>and</strong> adapted to the local situation.<br />
National Essential Medicines Lists need to include<br />
drugs for NCDs chosen by national experts based on<br />
considerations <strong>of</strong> cost-effectiveness, budget impact,<br />
affordability, <strong>and</strong> so forth.<br />
Lessons might be learnt from the scale-up <strong>of</strong> ART<br />
where transparency in price information, generic<br />
competition, <strong>and</strong> price negotiation helped achieve<br />
dramatic decreases in price; some steps have already<br />
been applied in Brazil to reduce the cost <strong>of</strong> certain<br />
cancer medicines [392]. A GAVI-like capacity at regional<br />
or global level could be useful to negotiate,<br />
bulk purchase, <strong>and</strong> distribute vaccines <strong>and</strong> drugs.<br />
Mechanisms such as Advance Market Commitments,<br />
as used for vaccines [393], could be considered<br />
to <strong>of</strong>fer an improved market for drugs now in<br />
development, ensuring that drugs are bought only if<br />
they meet pre-determined st<strong>and</strong>ards <strong>of</strong> efficacy <strong>and</strong><br />
safety <strong>and</strong> helping to assure a sustained <strong>and</strong> affordable<br />
supply in the long term.<br />
<strong>The</strong>re are emerging concerns regarding intellectual<br />
property rights in relation to NCD drugs,<br />
particularly for cancer <strong>and</strong> diabetes, <strong>and</strong> how these<br />
might interfere with innovation models <strong>and</strong> access<br />
to treatments [394]. Since the WTO TRIPS<br />
(trade-related aspects <strong>of</strong> intellectual property rights)<br />
agreement, health <strong>of</strong>ficials need a good underst<strong>and</strong>ing<br />
<strong>of</strong> patent status in order to procure lower-cost<br />
generic products, use health budgets efficiently, <strong>and</strong><br />
determine the ‘freedom to operate’ in research <strong>and</strong><br />
development <strong>of</strong> new medicines; this may require national<br />
<strong>and</strong> regional capacity to be built.<br />
An additional area requiring joint commitment<br />
<strong>and</strong> resources to strengthen the overall response to<br />
NCDs, involves the need for improving governance<br />
<strong>and</strong> regulation in the pharmaceutical sector, building<br />
upon ongoing efforts as noted in Box 9.<br />
Health-Care Delivery<br />
Health service delivery systems in LMIC are typically<br />
more suited to providing episodic care for<br />
acute conditions. Models for the delivery <strong>of</strong> care for<br />
chronic conditions, such as integration <strong>of</strong> care across<br />
levels, may be unfamiliar to policymakers <strong>and</strong> practitioners,<br />
<strong>and</strong> their establishment hindered by limitations<br />
<strong>of</strong> space, staff, systems, <strong>and</strong> infrastructure<br />
[211, 396]. To some extent, HIV/AIDS may have