KIGALI, Rwanda – Confronted by a huge and growing burden of non-communicable diseases (NCDs), governments worldwide are under pressure to devote more of their domestic budgets to these illnesses.

Patients carry the burden of both the diseases and an estimated 60% of the cost of treating these, which include cardiovascular disease, cancer and diabetes.

Yet the sheer range of diseases, the high cost of NCD medicines and treatment and an apparent lack of donor interest in NCDs are daunting obstacles. (Only around 3% of official development assistance goes to NCDs.)

Ahead of the United Nations High-Level Meeting (HLM) on NCDs in September, NCD advocates want governments to commit to concrete implementation targets in whatever declaration is adopted.

Civil society organisations meeting at the NCD Alliance Forum in Kigali last week discussed various options for governments to increase domestic resources for NCDs, which are responsible for almost three-quarters deaths each year. 

Despite Africa’s youthful population, 37% of deaths on the continent are due to NCDs – and this is growing annually. Cardiovascular diseases such as strokes and heart attacks have overtaken tuberculosis and respiratory infections as the biggest killer on the continent.

Various possibilities exist for bolstering countries’ domestic resources for NCDs, including excise taxes, pooled procurement with other countries to bring down medicine prices and incentives to encourage the private sector to invest in NCDs.

Excise taxes are a win-win

If the excise taxes currently imposed on tobacco, alcohol and sugary drinks are increased by 50%, this would save 50 million lives over the next 50 years, said Vital Strategies CEO Mary-Ann Etiebet, quoting research from the Task Force on Fiscal Policy for Health.

Aside from deterring people from consuming these unhealthy products, these taxes could raise over $3.5 trillion in five years which could be ploughed back into NCD prevention, treatment and care.

Many governments have not embraced these taxes thanks to intense lobbying by the tobacco, alcohol and junk food companies.

Removing government subsidies for harmful products such as oil or sugar can also improve the overall pool of financing available for health, said Kimberly Green, PATH’s global director of primary health care and part of the Coalition for NCDs Access to Medicinces and Products (Coalition4NCDs).

But this too faces huge industry pushback.

Forecasting demand

For Green, “one of the fundamental challenges is demand forecasting”. Governments need to identify their priority NCDs and project how many people will be affected over the next five to 10 years.

“Without this, it is impossible to know how much medicine they will need. This is a fundamental gap yet demand forecasting has been very well done in HIV, TB and malaria,” said Green.

The Coalition4NCDs has developed a forecasting tool that it has shared with some parliamentarians to enable them to increase the budget for NCDs

But Rwanda’s Dr Evode Nyibizi warned that accurate data alone is not enough.

His country’s health system is fully digitised, so financial decisions are based on data fed from all tiers of the health system.

“In 2023, we were only utilising around 10% of the data that we collected on daily basis. So we established the National Health Intelligence Centre, which is helping us to draw insights from the data that we collect,” said Nyibizi, who heads the centre.

“The centre tells you what the problems are and where you need to invest your money,” Nyibizi explained.

Particularly in light of the global health financing crisis experienced by the withdrawal of United States aid, many countries need to reprioritizing where “the small amount of money left goes”, he added.

Creating demand

But even before demand forecasting, Ben Kamark’s organisation, Reach52, works to generate demand for essential health products to reach the 52% of the world who don’t have access to these.

“Out-of-pocket markets have peculiar market dynamics. They get stuck in a vicious cycle. Every distributor, every seller of pharmaceutical products, is incentivized to sell less products at a higher price,” explained Kamarck. 

“So they come into the market with a higher price, expecting a lower demand. But a higher price leads to lower demand, which also importantly, leads to lack of investment.”

Insulin is an example of a product for which the price is higher than it should be because demand is lower than it should be, he explained.

“Then the market doesn’t move. We believe that the only way to actually intervene in an out-of-pocket market is to be a market participant.”

And it takes a lot of risks. Reach52 launch medicines at prices that “would make sense in high volumes, even when there aren’t high volumes”, said Kamarck. 

They register products “that no one’s asking for and no one’s wanted, because we know there’s a need for them”.

Then Reach52 runs “hyper-targeted public health interventions and healthcare provider engagement” to create demand and drive sales of essential medicines.

“That’s a hard choice to make for a lot of private sector companies,” admitted Kamarck.

Reducing risks

Mayank Anand works for MedAccess, a social finance company established in 2017 with the support of donors, health advocacy organisations and pharmaceutical companies. 

Its aim is to reduce the risks in the NCD treatment supply chain for suppliers and procurers through volume guarantees, procurement guarantees, and concessionary loans.

“We’ve has done 11 guarantees so far across areas such as TB, HIV, malaria, syphilis, and COVID-19 with range of partners such as the Clinton Health Access Initiative (CHAI),” he explained.

“A volume guarantee is a backstop agreement between ourselves and supplier where we assure sales volumes over a period of two to six years in return for the supplier bringing the price down to an affordable price, but also making commitments to accelerate registration in markets,” said Anand.

The 11 deals done so far has enabled half a billion people to get access to medicines.

Another public-private partnership is the Financing Accelerator Network for NCDs (FAN), a new initiative started by Access Accelerated, the World Bank, and Results for Development (R4D), aimed at building sustainable health financing systems for NCDs.

Leadership is at the centre

Amref Health Africa’s Dr Mercy Mwangangi injected come realism into discussions by pointing out that almost 80% of the $9.8 trillion spent annually on health is spent in the global North.

In Kenya, where she is based, the per capita expenditure is $90 whereas in the US, it is $14,000.

“How do we ensure that drugs are available to the American who is spending $14,000 are also available to the Kenyan, where there’s a $90 spent every year?” she asks.

Aside from lack of finances, health systems also have to be ready to roll out medicines should innovative finances make them available, she adds.

Can a country screen for cancer? Does it have a national registry of the burden of disease?  Do supply chains work so that citizens can access care? Are the legal and regulatory frameworks amendable to access to medicines? 

To spell out the challenges, Mwangangi gave a rundown of Amref’s engagements with pharmaceutical company Roche to enable Kenyans to get access to the breast cancer drug, Herceptin.

“From the initiation of those conversations to having patients access these commodities took about two years of back-to-back conversations with government players, procuring agencies and with repayment systems,” she said.

Despite this energy investment, the programme has stalled because facilities are not able to pay the procuring agency for the medicine that they have been issued with.

“Leadership and governance is at the centre of innovative financing,” stressed Mwangangi.

Image Credits: Reach52.