Free and Public

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

Share

Leave a Reply

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