The Challenge of Non-Communicable Diseases and Road Traffic ...

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