A novel initiative to improve access to medicines for control of non-communicable diseases in low-and middle- income countries

Introduction

Health financing: Differential pricing

Differential pricing is one of the approaches to achieve the goal of Universal Health Care (UHC). UHC is defined as the ability to access quality, needed health services, while ensuring that the use of these services does not expose the user to financial hardship. UHC is now a Sustainable Development Goal (SDG) goal: “Achieve UHC, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.” The concept of UHC ensures a “system-wide effective coverage combined with universal financial protection,” thus avoiding exorbitant out-of-pocket costs⁸. Out-of-pocket financing for chronic disorders poses a real barrier to increasing access to medicines for poor populations⁹.

Differential pricing, an approach used to price medicines based on the purchasing power of payers in different socioeconomic segments, within countries or between countries, has been shown to be beneficial and lead to improvement of access and affordability^10,11. Thus far, the use of differential pricing has generally been limited to vaccines, contraceptives, antimalarials and antiretrovirals in the context of the Global Fund and Global Alliance for Vaccine Initiative, where price reductions were achieved through such strategies as high-volume purchasing, reliable and adequate financing, public advocacy, negotiation, and market competition^12,13. Some of the challenges in the roll out of differential pricing stand out, as this approach doesn’t completely address non-price barriers to access, such as challenges related to regulation and weak supply chain and health systems. With regards to supply chain challenges, frequent stockouts, inability to forecast accurately, inefficient distribution systems, or leakage of medicines for private resale, can all impact access⁹. Therefore in order to improve access and affordability using differential pricing as a financing scheme, it is important that an integrated approach be utilized which includes robust partnerships between multiple stakeholders (governments, donors, biopharmaceutical companies, UN agencies, non-governmental organizations), as well as targeted efforts to strengthen supply chain and health systems.

Key international commitments recognize the need for improvement in access and affordability for essential medicines

The WHO Global Action Plan for the Prevention and Control of non-communicable diseases was endorsed by the 66^th World Health Assembly to strengthen national efforts to address the burden of NCDs¹. The goal of the WHO Global Action Plan is to improve availability of essential medicines in both public and private facilities and reduce premature mortality from non-communicable diseases by 25% by the year 2025¹. In 2015, NCDs were included in the SDGs, thus recognizing NCDs as a challenge for sustainable development (SDG target number 3).

One of the objectives of the WHO Global Action Plan is to “Implement other cost-effective interventions and policy options to strengthen and orient health systems to address non-communicable diseases and risk factors through people-centered health care and universal health coverage”¹³. Through differential pricing, the cost of medicines in populations with limited access in LMICs can become more affordable and, when coupled with needed health system improvements, has the potential to dramatically increase access to medicines for specific conditions among lower income segments of the population.

These key commitments on the part of the international community are critical in helping achieve improved access for patients living with NCDs in LMICs.

The WHO recently launched the #beatNCDS campaign, which aims to assist countries to achieve nine global voluntary NCD targets to reduce premature deaths from cancers, heart and lung diseases, and diabetes by 25% by 2025. In order to successfully achieve these goals, it is essential that access to medicines be improved by health financing reforms.

Study: Access and Affordability Initiative

The Access and Affordability Initiative (AAI) is a multilateral collaboration between multiple stakeholders with the aim of improving access to and availability of essential medicines for the treatment of NCDs and strengthening of health systems. It brings together four major biopharmaceutical companies – Merck, Sharp and Dohme Corp. (MSD), a subsidiary of Merck & Co., Inc., Kenilworth, N.J., U.S.A., Novartis, Pfizer and Sanofi – and the Bill & Melinda Gates Foundation, who have initiated a public private partnership with the Ministries of Health in Ghana and the Philippines. AAI is one of the initiatives supporting Access Accelerated, a global partnership of a coalition of biopharmaceutical companies to address the barriers to access for NCDs in LMICs. Access Accelerated was launched at the World Economic Forum’s Annual Meeting in Davos by twenty-two leading biopharmaceutical companies to advance access to NCD prevention and care in low and lower-middle income countries¹⁴.

Through this novel initiative a prospective cohort of patients with hypertension and diabetes were followed in Ghana and the Philippines at multiple sites, allowing these countries, with the support of the Ministry of Health, as well as academic institutions, to study the effect of within-country differential pricing of innovative medicines and health systems strengthening on access to innovative medicines, clinical outcomes, including disease control, complications and adherence, for diabetes and hypertension. Health system strengthening activities included the development of clinical guidelines, training on supply chain and clinical management, strengthening of supply chain management. Each of the participating companies independently and made decisions involving the AAI. The initiative will provide a unique opportunity to determine whether this type of public private collaboration can improve access to affordable medicines in the developing world and thereby help to achieve SDG3. Additional evidence will be needed to determine the generalizability of such an intervention in other LMIC to tackle the issue of access to treatment.

The AAI study will help provide essential data on access to medicines, affordability of treatment, clinical outcomes, as well as out-of-pocket expenditure by rural and urban populations in both Ghana and the Philippines. This information system will be shared with the respective Ministries of Health in both countries and will assist in providing important policy recommendations to these respective Ministries.

Conclusions

Given the growing cost to the health system of poorly managed NCDs and of the limited availability of financial resources, targeted, cost-effective interventions are needed. Additional evidence will be required to examine the ability to implement differential pricing as a means to improve access to and affordability of medicines for the treatment of NCDs in a variety of contexts. “To explore viable health financing mechanisms and innovative economic tools supported by evidence” is a policy recommendation in the updated WHO Global Action Plan for the Prevention and Control of NCDs¹⁵.

The AAI presents one example of such an exploration through differential pricing of innovative medicines for the control of NCDs, coupled with health systems strengthening and may reveal an innovative means to improve access to critically needed medicines and thereby help curb the disturbing trends of excess morbidity and mortality from NCDs in LMICs.

Disclaimer

The views expressed in this article are those of the authors. Publication in Gates Open Research does not imply endorsement by the Gates Foundation.

Data availability

No data are associated with this article.