National drug policy reform for noncommunicable diseases in low-resource countries: an example from Bangladesh.

Abstract

In recent years, the incidence of cardiovascular diseases, diabetes, cancers and chronic respiratory diseases has increased in epidemic proportions in many low-resource countries, including Bangladesh. (1) Noncommunicable diseases accounted for an estimated 38 of 56 million deaths worldwide in 2012. Yet most of the deaths (74%, 28 million) occurred in low- and middle-income countries, where access to essential medicines to prevent and treat these diseases remains low. (2,3) The Global Burden of Disease study projected that noncommunicable diseases will be the leading global cause of disability by 2030. (4) Lack of access to essential medicines for noncommunicable diseases is a major challenge for the health systems in many low-resource countries, potentially contributing to increased mortality and morbidity in these countries. (5) The World Health Organization (WHO) has recommended that every country should have a national drug policy that ensures access, quality and rational use of medicines as an integral p art of its broader strategic health-care policy. (6) It has also recommended that noncommunicable diseases be incorporated into the strategic plans of national drug policies. (7) The WHO Model list of essential medicines contains 95 basic medicines for most noncommunicable diseases, including 16 new medicines for cancer that were added in May 2015. (8) Despite the wide adoption of national drug policies in low- and middle-income countries, the majority of these do not include essential medicines for noncommunicable diseases. Bangladesh is one of the pioneer countries to develop a national drug policy, launching its first in 1982. Based on the WHO essential medicines concept, the national drug policy identified 150 essential drugs for controlled pricing. The policy was instrumental in improving the supply and accessibility of quality essential drugs at an affordable price. (9) However, during the 1980s and 1990s in Bangladesh the quality assurance of medicines started to be neglected, the price of local medicines increased and there was a shift in production from essential medicines to more profitable unregulated medicines by the major pharmaceutical industries. Despite being one of the world's poorest countries, Bangladesh has made great progress over the last few decades in reducing maternal and child mortality, decreasing the burden of communicable diseases and improving life expectancy. (10) In 2011, the Government of Bangladesh adopted a new national health policy, incorporating a strategic plan for the surveillance and prevention of noncommunicable diseases, along with a plan for the provision of essential drugs for these diseases. (10) However, these policy documents did not mention specific medicines for noncommunicable diseases or requirements for their availability, price, quality assurance or rational use. Many issues prevented the optimal implementation of the essential drugs and noncommunicable diseases' policies in Bangladesh: lack of specific financial resources; lack of leadership and accountability; insufficient planning and forecasting; inefficient procurement; coordination and monitoring; and other competing priorities. However, several countries have undertaken initiatives to promote access to medicines for these diseases. For example, the Brazilian government, through its popular pharmacy programme, partnered with private pharmacies to market subsidized medicines for noncommunicable diseases, a scheme that can be replicated in other countries. (11) Most noncommunicable diseases can be treated or managed with a small range of low-cost generic medicines such as anti-hypertensives, statins and other cardiovascular drugs, analgesics, anti-asthmatics and some common anti-cancer drugs. (2) However, many of the essential medicines for diabetes in Bangladesh are too expensive for the general population or are not available in government facilities. (12) A study in 2016 found that for patients with diabetes the cost of drugs accounted for the largest share of their total healthcare expenditure. …