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Critical issues in the prevention and control of non communicable diseases

There is now worldwide recognition of the global health and economic impact of non- communicable diseases (NCDs). The health goal of the Sustainable Development Goals (SDGs) has a specific target to “reduce by one third the level of premature mortality from NCDs”. However, progress towards achieving the target has been poor.

The WHO set up a special Commission to make actionable recommendations for governments to act on in order to respond to the crisis of NCDs. The commission outlined six recommendations, including the critical importance of strong political will to ensure that NCDs prevention and treatment are top national and international priorities.

These recommendations will contribute to the third UN High Level Meeting on NCDs to be held in September. If NCDs are to be prevented and controlled, governments and international institutions need to address the following issues to curb the resulting health and economic impact:

  1. Women

Women bear the brunt of chronic diseases as the most likely unpaid carers of sick family members. Women’s unpaid health care work has been valued at 3.09% of the global gross domestic product – a hidden subsidy to countries’ health budgets. Lack of access to treatment for any member of the family adds to women’s unpaid care work. Moreover, some of the NCDs carry stigma for women. For example, a young women may never get married if it is known that she is diabetic, and the cost of treatment is a factor in her rejection. The costs of treating cancer and the stigma attached to the disease, especially breast cancer, may lead to women being rejected by husbands without financial or other support.

Just two weeks ago, the WHO called for the elimination of cervical cancer given that vaccination and screening programmes are feasible. It is critical that governments expand awareness and delivery programs for early detection, diagnosis and treatment of breast and cervical cancer, as well as other NCDs. These programmes are critical not only for health but also for removing stigma against affected women.

  1. Access to medicines

High prices are a major barrier for patients’ use of medicines that save lives, significantly improve the quality of life and decrease suffering. Globally there is stark inequality in access to medicines for NCDs, which is reflected in the higher morbidity and mortality rates in poorer populations and poorer countries.

Cancer is the second cause of mortality worldwide. Early detection of cancer without affordable treatment could feel as a death sentence for patients. Anecdotal data shows the serious impact of high prices of medicines on patients’ lives.

The UN and its member states must find sustainable solutions to the crisis in medicines if they are to tackle NCDs in a meaningful way. Prevention alone is not the answer for the millions who already suffer NCDs, nor for their families who suffer the economic and emotional impact of ill health and of lack of treatment. The UN High-Level Panel on Access to Medicines proposed actionable recommendations for governments and relevant international agencies that pave the way to improving access to medicines and innovation. These must be urgently implemented. By doing so, governments would adopt strategies that make medicines affordable to payers.

It is also time that the WHO lead in developing an R&D convention that ‘de-links’ financing R&D from the price of medicines so that research is driven by public health needs, not financial incentives, and thus produce medicines at low prices.

  1. Health in trade

Free Trade Agreements (FTAs) usually include conditions that have negative implications on the health of the population in the signatory countries, especially in relation to NCDs. Firstly, FTAs usually include further protection of intellectual property rules beyond the TRIPS[1] agreement, and therefore increase the potential of high prices for new medicines.

Secondly, Investor-state dispute settlement clauses (ISDS) prevent governments from implementing policies that aim to protect public health. There are recent examples of this impact in the case of a Lily pharmaceutical company using ISDS to stop the Canadian government from adopting policies to cut the price of a medicine for treating Attention Deficit Hyperactivity Disorder. Another example is Philip Morris tobacco company taking legal action against the governments of Uruguay and Australia for including warnings against smoking on cigarette packets. In three cases the companies used ISDS clauses in an FTAs that considered governments’ actions not as protection of population’s health, but as cutting companies’ profit. Although the companies lost their cases, threat of arbitration can be a deterrent to developing countries preventing the adoption of policies to respond to NCDs.

Therefore, before signing an FTA, governments must conduct impact assessments of the potential impact of the agreement on health policies and access to medicines with meaningful engagement of civil society, parliament and media. WTO needs to monitor and condemn pressure from countries and companies on those governments who intend to use the flexibilities enshrined in the TRIPS agreement to decrease the price of medicines.

  1. Universal Health Coverage

Sustainable investment in healthcare is critical to creating resilient public health systems that can prevent and treat NCDs.  Strategies that tier services according to ability to pay, result in increased societal inequality and ill health in addition to being inefficient. No country has achieved or made progress towards achieving UHC without the majority of financing coming from the public purse. Lack of government spending and delivery of health care results in more unpaid caring work for women and high impoverishing out of pocket spending. Most countries face a health work force crisis, which requires long term investment in training and remunerating workers.

Governments need to increase investment in public healthcare systems in order to reach a minimum of 15% of public expenditure or 5% of GDP. Public investment has to prioritise financing of healthcare through progressive taxation, and avoid regressive and unaffordable insurance schemes, which tend to exclude the poorest and most vulnerable people at scale in countries with large informal sectors. Health services should be free at the point of use to ensure equity of access to healthcare. Public investment in comprehensive primary health care should be prioritised including the training and remuneration of Community Health Workers, especially women workers to enhance reaching women in rural and remote areas.

Donor countries must support developing countries to invest in building resilient public healthcare systems; including training and remuneration of health workers, through aid.

  1. Private sector’s engagement

Clearly the private sector has a role to play in responding to NCDs. However, commercial determinants of health present huge risks given that profit motives of tobacco, processed food and beverage companies, are directly at odds with public health goals. It is highly unlikely that “voluntary” actions by companies would result in cutting the negative impact of those products, given that cuts in sales act directly against companies’ commercial interest.

State-led initiatives and strong regulation are critical to tackling the NCDs crisis. “Sin taxes” on sugar products, tobacco and alcohol have been heavily opposed by those industries, despite the clear evidence of the positive impact of tax on lowering consumption of those harmful products and generating revenue for public spending on health.

Yet governments’ engagement with the private sector has been heavily promoted without emphasis on these crucial safeguards. Engagement with commercial actors should be driven by public health concerns not by economic interest.

  1. Promoting mental health

According to WHO, depression is a leading cause of disability in the world. Yet there is a lack of political support for the promotion of mental health and for investing in the diagnosis and treatment of mental health problems. Governments need to invest in evidence based training, to develop appropriate and adequate services for those suffering from mental health problems. Furthermore, integration of mental health awareness, diagnosis and treatment is needed in primary health care. National awareness campaigns in collaboration with civil society and the media are also critical to remove stigma associated with mental health, especially for adolescents who usually suffer in silence.

Conclusion

The forthcoming UN HLM on NCDs is an opportunity for world leaders to commit to protecting their citizens, by turning rhetoric into reality through serious political will and adequate financial commitments. Actions at national and international levels are necessary and feasible to prevent and control the pandemic of NCDs.

[1]Trade Related Aspects on Intellectual Property Rights, which countries automatically sign when they join the WTO

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World Cancer Day 2018: It’s time to bring down the price of medicines. Authors: Tabitha Ha, Advocacy and Campaign Officer, Oxfam International and Mohga Kamal-Yanni, Senior Health policy Advisor, Oxfam GB

Sunday 4th February is #WorldCancerDay and the theme is #WeCanICan – a message uniting the world in the fight against cancer. Indeed, the world must unite to stop high prices being charged for medicines, which prevent patients from getting the treatment that can save their lives. People across the globe need to unite to push for tough actions by governments and UN bodies to change the system that leads to high medicine prices.

The high price of medicines can be a death sentence to those who cannot afford it. Tobeka, a mother from South Africa, spoke in 2016 about her experience with breast cancer. She said that she wanted to live so that ‘I can bring up my two boys’. However, neither herself nor her insurance company were able to cover the high price of the medicine that could have saved her life. Tobeka passed away in 2017, spurring on action amongst people who stood in solidarity with her. They came together to demand that Roche (the pharmaceutical company that markets the breast cancer medicine) drop the medicine’s price so that other breast cancer patients could dramatically increase their chance of survival.

Cancer incidence is increasing all over the world including in low and middle-income countries. Women bear the brunt of lack of access to health services and to medicines. They are often the last in the family to seek healthcare if cost is an issue and they carry the lion’s share of the burden of care for sick family members, especially those who cannot access treatment. Breast and cervical cancer are the main cancer killers amongst women in developing countries. More than 95% of cervical cancer deaths occur in low and middle income countries. Breast cancer cases are increasing at a greater speed in these same countries.

This is the case even though prevention for cervical cancer and treatments for breast cancer already exist. The problem lies in the fact that prices of cancer medicines are soaring and are a major access barrier for patients. In South Africa, a 12-month course of Herceptin, a breast cancer medicine produced by Roche, costs approximately $38,000 or around five times the country’s average household income. Yet at least one possible supplier of the medicine suggests it could be produced and sold for as little as $245. The HPV vaccine that helps prevent cervical cancer, marketed by Merck and GSK, is one of the most expensive vaccines in developing countries. Merck’s vaccine is sold by Gavi, The Vaccine Alliance, at $ 4.5/dose (total of $13.5 for the recommended three doses).

High prices of medicines are not only a developing country issue. In the past 15 years, the average cost of new anti-cancer treatments in Europe has more than quadrupled and some women in the UK have had no choice but to seek charitable donations  to pay for their medicines.

Pharmaceutical companies can charge high prices because new medicines are patented. This gives companies a monopoly on a newly created medicine. Without competition, companies can sell medicines at whatever price they want. The pharmaceutical industry often justifies high prices by claiming that they are necessary to recoup high research and development (R&D) expenditures. However, little is known about the true costs of R&D due to the secrecy of the industry. The ever-escalating figure quoted by the industry and its supporters is based on studies by one university, which has been funded by the pharmaceutical industry. The figure is contested by experts, some of whom estimate that in fact as much as two-thirds of upfront R&D costs are paid by the public sector and not pharmaceutical companies. The lack of evidence to justify high prices of patented medicines, and the devastating consequences of these prices, demonstrates the urgent need for transparency around the costs of R&D.

The fight for access to cancer medicines is inextricably linked to a wider access to medicines fight: the fight to ensure public health has supremacy over profit. Oxfam advocates for governments to adopt the recommendations of the UN High Level Panel on Access to Medicines (HLP) , which tackle the issues caused by the current R&D model that prioritises profit over public health.

Last week at the WHO Executive Board (EB), Oxfam spoke[1] of Tobeka’s story and the reality of the impact of high prices of medicines on patients. The WHO EB debate on medicines represented a fierce battle between protecting the public health of patients all over the world and protecting the commercial interest of pharmaceutical companies. There was wide support from developing countries to urge the WHO to take action on the recommendations of the independent review of the ‘Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property’ without delay. Many of the strategy’s recommendations echo those from the HLP. A number of European countries also raised the issue of high prices in their own domestic markets and called for fair pricing.  But the US and Japan objected to implementation of the recommendations of the review of the Global Strategy – and to specific language on transparency on the cost of R&D. Eventually a draft decision was agreed and will be put forward at the upcoming World Health Assembly in May. If passed, the final decision text would allow member states to implement the majority of recommendations except for a few that require further discussion, including on the transparency of R&D costs,.

High prices affect everyone but they affect the poorest most and especially women. The fight for affordable and accessible medicines is a fight for women’s health. Governments have a set of promising solutions in the form of the HLP recommendations. These recommendations must be implemented without further delay. World Cancer Day is a strong reminder why action must be taken to implement them.

 

 

[1] Under agenda item 3.7

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Half the world’s population can’t access essential healthcare by Anna Marriott, Public Services Policy Manager, Oxfam GB

Underlying the goal of Universal Health Coverage (UHC) is a very simple principle – everybody, everywhere, must be able to access decent, effective healthcare without facing financial hardship or being pushed into poverty. Underlying this principle is an equally simple truth – as long as people have to pay out of their pockets for treatment at the time of need there will be vast inequalities and injustices in access to healthcare.

The right to health is a fundamental human right. It cannot be realised if getting treatment or care is subject to the amount of money in your pocket or how much you can beg from your neighbour – who is likely to be equally poor.

A new World Health Organisation and World Bank Global UHC Monitoring report launched yesterday reveals some uncomfortable truths about the state of the world’s progress. These are a damning indictment of government action:

  • At least half of the world’s 7.3 billion people do not have full coverage of essential health services. Healthcare coverage has been increasing at an unacceptably slow rate of just over 1% a year.
  • 3 people every second are pushed into extreme poverty by paying for healthcare.
  • 800 million a year face severe financial difficulties because of health expenditure. The number facing financial ruin has been growing sharply since 2000.
  • The richest mothers and infants are four and half times more likely than the poorest to receive essential maternal and child health interventions in low and lower middle-income countries.
  • Sub-Saharan Africa and Southern Asia have the worst healthcare coverage – scoring just 42 out of 100 and 53 out of 100 respectively in the new global UHC service coverage index.
  • Latin America and the Caribbean has the highest percentage of people facing unmanageable healthcare costs (14.8 percent). Africa and Asia have seen the fastest rate of increase in people facing unmanageable out-of-pocket healthcare costs – with numbers rising by an average of 5.9 percent a year in Africa and 3.6 percent a year in Asia.

Healthcare – a basic human right – has become a luxury only the wealthy can afford. Millions of people are facing unimaginable suffering as a result: parents reduced to watching their children die; children pulled out of school so they can help pay off their families’ healthcare debts; and women working themselves into the ground caring for sick family members. There are even patients imprisoned in hospitals, held hostage until they can pay their fees. Just one of these powerful stories can be viewed in our film here.

A radical change of approach is needed. Governments must massively increase spending on public healthcare services and end all fees for healthcare and essential medicines. It is the only proven route to achieving UHC.  The additional money needed should be raised through progressive tax reform – not expensive private finance or unworkable health insurance schemes that exclude millions of ordinary people.

Governments must stop looking to poor vulnerable people, including those in the informal economy, to pay what they can’t afford. Contributory insurance schemes have become the health financing model of choice in many low and middle income countries. But with large informal economies these schemes become de facto voluntary and fail to cross-subsidise between the wealthy and healthy to the sick and the poor. They fail to reach scale and they leave the poor behind.

Instead, we as a global health community need to pay more attention to growing and extreme levels of economic inequality. The concentration of wealth and power in the hands of a minority is an obstruction to human development, and tackling this can provide the financing needed to deliver health for all. Today 8 men own as much wealth as the poorest half of humanity. Poor countries lose an estimated $170 billion a year because of tax dodging by corporations and the super-rich. Unfair tax systems cost them even more – Nigeria loses $2.9 billion a year because of unfair corporate tax incentives alone – equivalent to 13 times the countries total health budget in 2015. And if Kenya increased its tax to GDP ratio by 3 percentage points in 2014 – from 17.9 to 20.9 percent –  it could have raised enough additional funds to ensure all Kenyans had access to free, quality healthcare.

In light of the scale of the challenge described in yesterday’s UHC report, business as usual is just not acceptable. We need urgent action from governments to deliver on their duty to fulfil the right to health. The resources are there, what is missing is the political will to redistribute them!

 

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Unhealthy partnerships: Karnataka Public Private Partnership, India By Dr. Sylvia Karpagam

The Rajiv Gandhi super-speciality hospital, in Raichur, Karnataka, has been celebrated as an example of a successful public-private partnership (PPP). The Planning Commission of India described it as a ‘possible model for replication and up-scaling’, while the National Institute for Transforming India (NITI) Aayog has been active in promoting PPPs across the health sector in India, with the World Bank as the technical partner. The Confederation of Indian Industries (CII), which has submitted a report to the NITI Aayog on options for PPP for select Non Communicable Diseases, hails this as a successful model. The fact that this PPP has been a complete failure and has led to the termination of the contract as early as 2012, figures nowhere in any of these discussions. This calls into question the agenda behind the promotion of hospital PPP models.

The Rajiv Gandhi Super-speciality hospital was set up in 1997 to provide tertiary care with Rs 600 million (US$150,000) in financial aid from the Organisation of Petroleum Exporting Companies as a one-time grant and as a PPP between the state government and Apollo Hospitals Enterprise Limited . The government was to pay a monthly Rs. 10 million on top of providing the 73 acre campus land, hospital building, staff quarters, roads, power, water and infrastructure. A one-off government grant covered building and civil works, medical equipments, furniture and fitting, non medical equipment, computers and software, vehicles, pre-operative expenses and working capital. Moreover the government agreed to pay Rs. 95 million for re-equipping the hospital and Rs. 101 million for administrative expenditure.

One of the key objectives of establishing this PPP was to provide quality healthcare to patients below the poverty line (BPL) in the districts of the Gulbarga division where the BPL population has been identified to constitute the majority (67%) of the population. However, data on the utilisation of the hospital services reveals that of the 340 hospital beds, only 154 were operational, of which only 40 (25.9% of operational beds and 11.4% of total beds), were available to BPL patients.

Figure 1 and 2 of the utilization of In-patient and Out-patients services show failure to achieve the hospital’s primary objective of providing services to BPL patients.

Figure 1: Rajiv Gandhi Super-speciality hospital: Utilization of In-patient services by BPL and Above Poverty Line (APL) 2002–2003 to 2010–2011 (Feb 2011)

 

India PPP- Apollo Hospital-Fig1

(Source: Government of Karnataka, 2011)

 Figure 2: Rajiv Gandhi Super-speciality hospital: Utilization of Out-patient services by BPL and APL 2002-2003 to 2010 -2011 (Feb 2011)

India PPP- Apollo Hospital-Fig1

(Source: Government of Karnataka, 2011)

The evaluation report of the government of Karnataka states that “this sub-optimal capacity utilisation has seriously affected the sustainability of the hospital, thereby leading to serious question on the commitment towards the PPP model of functioning”. The report has also found this model to have poor governance and accountability, with poor maintenance of records and failure to deliver on many fronts.

On May 31, 2012, the state government terminated the contract with Apollo and the hospital went into a ‘coma’. In August 2016, hospital equipment was seized by the Principal District and Sessions court for defaulting on payments. According to S.K. Purohit, the lawyer for the company that supplied laboratory items to the hospital “The material seized is nothing as compared to the outstanding. This is just a warning to the hospital authorities. We will hand over the seized material to Court which will auction them. If the Hospital does not pay the remaining amount, the court may again order for further action for recovering the remaining dues. ”

The government has handed the hospital from the Ministry of Health to the Ministry of Higher Education to set it up as a teaching hospital. This was widely protested for fear of adversely affecting poor communities and employees.

It is unacceptable that a failed hospital is being promoted as a successful example of a PPP. Why is this model being called successful in spite of no documented evidence of the success? As Dr. Sujatha Rao, Former Union Secretary, Ministry of health says ‘The NITI Aayog has an obligation and a duty to consult, listen, collect evidence, analyse, understand and reflect, not prescribe based on the advice of the World Bank and a few interested corporate houses.’

The writer is a public health doctor and researcher who has studied the PPP models in Karnataka and works with urban marginalised communities.

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Will WHO candidates for the big job commit to ending user fees? By Aishah Siddiqa, Global Inequality Campaign Officer

Every year one billion people worldwide are denied medical care because they cannot afford to pay for it. At the same time, 100 million people are pushed into poverty due to having to find or borrow money to pay for health care[1].

My father’s family is one of those nameless millions. They live in rural Bangladesh where healthcare is inaccessible because of having to pay for services. My family had to delay mortgage payments so that my grandmother could get the cancer treatment she desperately needed. They also struggled to get medicines for my little cousin, Ismael, so that he could continue at school and one day hope to escape the cycle of poverty.

Ismael

For countless others, however, such options aren’t available so they are denied medical care altogether. Sometimes people are even imprisoned in hospitals until their families can pay their bills.

The World Bank president, Jim Kim, described user fees as “unjust and unnecessary” and said that “even tiny out-of-pocket charges can drastically reduce use of needed services”. In her address to the World Health Assembly last year, the current WHO Director-General Dr Chan said: “User fees punish the poor. User fees discourage people from seeking care until a condition is severe and far more difficult and costly to manage. User fees waste resources as well as human lives. Yet too little has been done since then to help those millions of people to access health services without paying user fees.

That is why, ahead of the elections for the next Director General of the World Health Organisation, more than 200 NGOs, academics, health professionals and influentials have signed an open letter to the three shortlisted candidates: Dr. Tedros Adhanom Ghebreyesus, Dr. David Nabarro and Dr. Sania Nishtar. The letter urges the candidates to publicly pledge to support countries to replace user fees with progressive, publicly financed health care that is free at the point of use. Signatories include Dr Gro Brundtland, the former DG of the WHO and former PM of Norway, Dr. Ricardo Lagos, former President of Chile, Ms. Hina Jilanni, Human Rights defender and Advocate of the Supreme Court, and organisations and networks such as Action for Global Health and Oxfam International.

Removing user fees is essential to achieve the SDG target of Universal Health Coverage.

Footnote

[1]Xu K, Evans D, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending, Health Aff airs 2007; 26: 972–983.

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Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni