EDITORIAL
INT J TUBERC LUNG DIS 19(1):1 Q 2015 The Union http://dx.doi.org/10.5588/ijtld.14.0862
Essential medicines for chronic respiratory diseases: can people breathe easily in low-income countries? HIGH MEDICINE COSTS are a frequently quoted barrier to the management of chronic respiratory diseases (CRDs) such as asthma and chronic obstructive pulmonary disease (COPD). Unfortunately for many people with such conditions, particularly those in low- and middle-income countries (LMICs), even the medicines recommended by the World Health Organization (WHO) in its Essential Medicines List (EML) are costly and are often not available. Newer single inhalers that combine an inhaled corticosteroid and bronchodilator are not yet on the WHO EML, and these are significantly more expensive. The gravity of this situation hits home on reading the State of the Art article in this issue of the Journal on the global burden of CRD in adults,1 in which the authors examine the best available data on prevalence, mortality, disability and risk factors. With COPD ranking ninth in the world among causes of years of life lost in full health, millions of people will be seeking medicines to improve their quality of life — hopefully having first stopped any tobacco use. The authors warn that as the global population ages the CRD burden will continue to increase, and that the consequences will likely be harder to address in lowincome countries. Mortality from both COPD and asthma is already more common in poorer areas. A second paper in this issue, by Gnatiuc et al., reports that use of essential respiratory medicines and influenza vaccination is lower in LMICs than in highincome countries, when adjusted for similar clinical need, and that use is strongly associated with gross national product per capita.2 After three decades of supposedly prioritising access to these products, we are still talking about improving their availability, affordability and use. A survey reported in the Global Asthma Report 2014 shows that between 2011 and 2013 the number of countries following national asthma guidelines increased, which sounds positive.3 However, a second survey demonstrates that many country EMLs do not have the WHO-recommended essential asthma medicines in the recommended dosages, and that many countries, especially LMICs, are not providing them free or subsidised for patients. Thus, the CRD burden is massive and increasing, and patient access to affordable medicines remains insufficient and inequitable. A number of medicine-related measures should be considered. First, essential respiratory medicines should be included not only in national EMLs, but also in procurement lists, reimbursement lists, management guidelines and training materials. Second, countries should focus on efficient selection, procurement and use of generic medicines for CRDs.4 Good procurement practices and regular monitoring of procurement prices and quantities can help reduce expenditure, even in challenging environments.5 More competition and rigorous quality assurance procedures in accordance with WHO norms and standards should
greatly improve quality and prices. Third, countries will need to mobilise domestic funding for the longterm CRD care and medicines their populations will require. Fourth, we need effective CRD management strategies that are based on essential medicines and tested through country-led operational research. These strategies should include tobacco cessation, irrespective of the availability of stop smoking products, and should be accompanied by solid implementation of all MPOWER measures to control tobacco.6 Improving access to essential respiratory medicines would be concrete action towards addressing the CRD component of the non-communicable disease (NCD) epidemic. As we move on medicines, however, we should avoid medicalised framing of the NCD agenda.7 Some big industries are going to need to change their products and behaviour. Conflicts of interest, including those of pharmaceuticals, will need to be identified and managed so that NCD agendasetting is transparently informed and led by public health principles, and not financial interests.
KAREN BISSELL Department of Research International Union Against Tuberculosis and Lung Disease (The Union) School of Population Health University of Auckland Auckland, New Zealand e-mail: [email protected] Conflicts of interest: none declared.
References 1 Burney P, Jarvis D, Perez Padilla R. The global burden of chronic respiratory disease in adults. Int J Tuberc Lung Dis 2015; 19: 10– 20. 2 Gnatiuc L, Buist S, Kato B, et al. The gap in use of bronchodilators, inhaled corticosteroids and influenza vaccine among 23 high- and low-income sites. Int J Tuberc Lung Dis 2015; 19: 21–30. 3 Global Asthma Network. The Global Asthma Report 2014. Auckland, New Zealand: Global Asthma Network, 2014. 4 Hogerzeil H V, Liberman J, Wirtz V J, et al. Promotion of access to essential medicines for non-communicable diseases: practical implications of the UN political declaration. Lancet 2013; 381: 680–689. 5 Ewen M, Al Sakit M, Saadeh R, et al. Comparative assessment of medicine procurement prices in the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). J Pharm Policy Pract 2014; 7(1): 13. 6 World Health Organization. Tobacco Free Initiative: MPOWER. Geneva, Switzerland: WHO. http://www.who.int/tobacco/ mpower/en/ Accessed November 2014. 7 Clark J. Medicalization of global health 3: The medicalization of the non-communicable diseases agenda. Glob Health Action 2014; 7: 24 002.
INT J TUBERC LUNG DIS 19(1):1 Q 2015 The Union http://dx.doi.org/10.5588/ijtld.14.0862
Essential medicines for chronic respiratory diseases: can people breathe easily in low-income countries? HIGH MEDICINE COSTS are a frequently quoted barrier to the management of chronic respiratory diseases (CRDs) such as asthma and chronic obstructive pulmonary disease (COPD). Unfortunately for many people with such conditions, particularly those in low- and middle-income countries (LMICs), even the medicines recommended by the World Health Organization (WHO) in its Essential Medicines List (EML) are costly and are often not available. Newer single inhalers that combine an inhaled corticosteroid and bronchodilator are not yet on the WHO EML, and these are significantly more expensive. The gravity of this situation hits home on reading the State of the Art article in this issue of the Journal on the global burden of CRD in adults,1 in which the authors examine the best available data on prevalence, mortality, disability and risk factors. With COPD ranking ninth in the world among causes of years of life lost in full health, millions of people will be seeking medicines to improve their quality of life — hopefully having first stopped any tobacco use. The authors warn that as the global population ages the CRD burden will continue to increase, and that the consequences will likely be harder to address in lowincome countries. Mortality from both COPD and asthma is already more common in poorer areas. A second paper in this issue, by Gnatiuc et al., reports that use of essential respiratory medicines and influenza vaccination is lower in LMICs than in highincome countries, when adjusted for similar clinical need, and that use is strongly associated with gross national product per capita.2 After three decades of supposedly prioritising access to these products, we are still talking about improving their availability, affordability and use. A survey reported in the Global Asthma Report 2014 shows that between 2011 and 2013 the number of countries following national asthma guidelines increased, which sounds positive.3 However, a second survey demonstrates that many country EMLs do not have the WHO-recommended essential asthma medicines in the recommended dosages, and that many countries, especially LMICs, are not providing them free or subsidised for patients. Thus, the CRD burden is massive and increasing, and patient access to affordable medicines remains insufficient and inequitable. A number of medicine-related measures should be considered. First, essential respiratory medicines should be included not only in national EMLs, but also in procurement lists, reimbursement lists, management guidelines and training materials. Second, countries should focus on efficient selection, procurement and use of generic medicines for CRDs.4 Good procurement practices and regular monitoring of procurement prices and quantities can help reduce expenditure, even in challenging environments.5 More competition and rigorous quality assurance procedures in accordance with WHO norms and standards should
greatly improve quality and prices. Third, countries will need to mobilise domestic funding for the longterm CRD care and medicines their populations will require. Fourth, we need effective CRD management strategies that are based on essential medicines and tested through country-led operational research. These strategies should include tobacco cessation, irrespective of the availability of stop smoking products, and should be accompanied by solid implementation of all MPOWER measures to control tobacco.6 Improving access to essential respiratory medicines would be concrete action towards addressing the CRD component of the non-communicable disease (NCD) epidemic. As we move on medicines, however, we should avoid medicalised framing of the NCD agenda.7 Some big industries are going to need to change their products and behaviour. Conflicts of interest, including those of pharmaceuticals, will need to be identified and managed so that NCD agendasetting is transparently informed and led by public health principles, and not financial interests.
KAREN BISSELL Department of Research International Union Against Tuberculosis and Lung Disease (The Union) School of Population Health University of Auckland Auckland, New Zealand e-mail: [email protected] Conflicts of interest: none declared.
References 1 Burney P, Jarvis D, Perez Padilla R. The global burden of chronic respiratory disease in adults. Int J Tuberc Lung Dis 2015; 19: 10– 20. 2 Gnatiuc L, Buist S, Kato B, et al. The gap in use of bronchodilators, inhaled corticosteroids and influenza vaccine among 23 high- and low-income sites. Int J Tuberc Lung Dis 2015; 19: 21–30. 3 Global Asthma Network. The Global Asthma Report 2014. Auckland, New Zealand: Global Asthma Network, 2014. 4 Hogerzeil H V, Liberman J, Wirtz V J, et al. Promotion of access to essential medicines for non-communicable diseases: practical implications of the UN political declaration. Lancet 2013; 381: 680–689. 5 Ewen M, Al Sakit M, Saadeh R, et al. Comparative assessment of medicine procurement prices in the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). J Pharm Policy Pract 2014; 7(1): 13. 6 World Health Organization. Tobacco Free Initiative: MPOWER. Geneva, Switzerland: WHO. http://www.who.int/tobacco/ mpower/en/ Accessed November 2014. 7 Clark J. Medicalization of global health 3: The medicalization of the non-communicable diseases agenda. Glob Health Action 2014; 7: 24 002.
