Harald Nusser, Head, Novartis Social Business, has been actively involved in running the Novartis Access programme for India. He explains how the access programme will add value to the efforts taken by the government to improve healthcare in India
Tell us about the Novartis Access programme and its aim to increase access to healthcare?
We launched Novartis Access in 20151 to curb the growing incidence of non-communicable diseases (NCDs) in lower-income countries. Often, people don’t realise the huge and rising impact chronic conditions like diabetes, respiratory illnesses or cardiovascular diseases have in these countries. Part of the reason is that historically infectious diseases have been the focus of health systems in lower-income countries.
Although the global health community has made tremendous progress in fighting infectious diseases2,3 in the past decade, there’s still a lot of work to be done. And now with chronic diseases, lower-income countries are facing a double disease burden.
Beyond the human suffering they bring, NCDs are colossal obstacles to the long-term sustainability of developing countries – perhaps even more so than infectious diseases. By 2020, NCDs will make up 80 per cent of the global disease burden. Seven out of every ten deaths from NCDs will be in developing countries. Around half of these will be premature4 and this will equate to a massive loss of productivity. It has been estimated that NCDs will cost the world $ 47 trillion by 20305. Much of that cost will be borne by developing countries and their people.
You are planning to launch your programme in 21 countries. What lesson do you bring for India’s healthcare system?
We’re hoping to roll out Novartis Access in 21 countries by 2020, but the programme is actually only being rolled out in Kenya at the moment. Till now, in addition to Kenya, we signed memoranda of understanding with Ethiopia, Rwanda and Pakistan. We are also having discussions with major countries in Africa, Asia and Latin America. In the meantime, we’ve commissioned Boston University to assess the impact of the programme in Kenya6. A team led by Professor Richard Laing will be in charge of the study, looking at how successful the rollout of Novartis Access has been in Kenya. The study will take place over two years, involving a randomised controlled trial and interviews with patients and healthcare workers. The study’s findings, which will be available to the public, will form the crux of our future efforts and the expansion of Novartis Access into other countries in the coming years. Once we have that evaluation, we’ll be able to see what has or hasn’t worked in Kenya and, from there, refine the programme, making sure it’s efficient and cost-effective.
You have an elaborate programme for Kenya, Ethiopia and Rwanda. How different are the healthcare systems of these countries from India?
Healthcare systems have to be different to work in different places. That’s not only true on a country-by-country basis; it’s true within countries. In India, for example, you’ll find what works in an urban setting like Mumbai or New Delhi won’t work in rural communities in Uttar Pradesh. The socio-economic reality being so different from one place to another, people have very different healthcare needs.
In terms of comparing India with the countries you mentioned, there are similarities and there are differences. Kenya and India are similar on the basis that, in both countries, health is managed on a provincial level. In Rwanda, on the other hand, you’ve got quite a centralised system7, with responsibility for healthcare policy and planning at the executive level. This is a contrast with India, where the constitution puts responsibility in the hands of state governments.8
Fundamentally, I would say the main difference between India and the three African countries you’ve mentioned is scale. India has the globe’s second-biggest population, with 1.3 billion people9. By contrast, Ethiopia has a population of 104 million10; Kenya 48 million11; and Rwanda 12 million12.
India is also a far wealthier country – its nominal GDP is the seventh largest in the world; if taken in terms of purchasing power parity, India ranks third13. It also has the world’s highest number of people living below the poverty line in the world14. This is particularly applicable to its rural population, where healthcare accessibility and delivery is lacking. There’s a shortage of doctors and other medical personnel, and people often have to pay out of pocket to fund their healthcare expenditure.
The rising threat of NCDs in India will make this situation even worse, because NCDs are generally chronic conditions requiring treatment over many years. Diabetes is perhaps the best example of this. To combat diabetes, we need reliable access to diagnosis, care and treatment, with often life-long follow-up. But, we also need education – raising awareness among people, in rural and urban India alike, so that they make better lifestyle choices and minimise their risk of becoming diabetic.
How do you conduct your access programme in these countries?
We provide a portfolio of 15 treatments at very low cost – one dollar per treatment per month to public-sector customers15. Novartis Access medicines target the four main types of NCD – breast cancer, cardiovascular diseases, diabetes, and respiratory illness. The treatments include both on-patent and off-patent medications.
Beyond the medicines, we also look toward training community health workers (CHWs). This is important because in many lower-income countries, there are shortages of healthcare professionals. Almost half of WHO member states have less than one doctor for every thousand people16. This has been a long-standing trend, but despite this we’ve seen major progress in reducing the impact of infectious diseases. This can be attributed, at least in part, to the work of CHWs – who thus far have been trained to deal largely with communicable diseases. We believe there is a great potential for these workers to transfer their skill over to chronic disease with the appropriate training. We are already partnering with governments and NGOs to build capacity, and will continue to work with them on it.
A key element of Novartis Access is supply chain improvement. Long-term conditions often require that people take medications on a daily basis. It is thus critical that they get hold of these treatments even in remote rural areas. We also take steps to ensure that middlemen do not mark up the very low prices we have set, to ensure medicines remain affordable to the end user.
And how are these programmes different from your programme in India?
Our focus in India at the moment is Arogya Parivar, which is our Healthy Family initiative. We launched this programme in 2007 to reach out to rural India, where the population is the most underserved in the country in terms of access to healthcare. It’s about improving the quality of life of millions of Indian villagers. And we’ve seen that happen. The outreach work we did in 2015, for example, got seven million villagers in eleven states into more than 125,000 meetings run by health educators trained by Novartis. It also managed to get more than 580,000 people into nearly 10,000 health camps, of whom 60,000 went to a physician afterwards. We have shown that it is possible for those living at the bottom of the pyramid to participate in the health market, if a sustainable market-based approach is customised to their needs. We, ourselves, broke even within 30 months of the programme’s launch, which means Arogya Parivar has long-term sustainability built in at its core.
Now we are exploring ways of integrating Novartis Access products against NCDs into the programme. Already, we’ve managed to cover Indian villagers across, with the provision of 100 products against diseases that are prevalent in rural India.
You say that your access programme brings down the cost of healthcare, can you elaborate on the same?
One of the primary obstacles to treating NCDs in a lower-income country is the perception that healthcare is unaffordable. Our programme reduces the cost of treatment, by making high-quality medications available at low prices, whilst improving supply chains so that the people who need these medications get them when they need them.
We are also able to mobilise individuals to take better care of themselves by educating them at health camps and community meetings run by trained community health workers. A lynchpin of our NCD-targeted programme is taking healthcare systems and treatment models which worked for infectious diseases and adapting them for the NCD threat. This involves the training and supply chain improvements I previously mentioned.
Another important aspect is that most healthcare costs come in the form of staffing, buildings, IT, etc. One thing to clarify is that our work in no way takes away from the requirement for governments and other healthcare providers to invest their personnel and infrastructure. That is why it is so important that we partner effectively with health providers, so that a cohesive approach is undertaken and patient benefit is maximised.
What are the challenges faced by you in the successful execution of this programme in India?
Well, India is a huge country with a very large population. This makes it very difficult to simply implement Novartis Access. As with our other programmes, effective partnerships will be the key. I would not rule out ever working with one of the states.
The main challenge, I would suggest, is that NCDs are not given the priority they should be in India. They account for more than half of India’s disease burden and are potentially building a public health crisis for future generations.
Do you think independent measurement of access programmes can help ensure their success to achieve the SDGs for India?
I think this is absolutely critical. Too many pharmaceutical companies set up access-to-medicine initiatives whilst failing to generate any kind of independent study or insight into how effective these programmes really are. They can be ambitious, they can be innovative, but this means nothing if they are not effective. Novartis wants to be transparent so we can get a complete insight into where we are going right, what we are doing wrong, and what impact our programmes are having on healthcare. We need a clear overview of how well Novartis Access is doing and what we can do to improve it.
Novartis has also set up an evaluation team to measure this success of the programme, right? Any challenges faced in setting up this evaluation?
We discussed the evaluation methodology at length with Boston University and settled on an approach which not only looks at how well we use the program, but also how much of an impact it has on households and availability of medicines. Ultimately, the most important thing is for Novartis Access to work with credible outside evaluators – they must have complete independence in how they measure its impact and publish their results.
How will Novartis Access add value to the efforts taken by the government to improve access to healthcare in India?
At the moment, Arogya Parivar is our focus in India. Novartis Access is not something we have ruled out implementing in India, but there are no plans to do so in the immediate future. However, we would certainly be more than happy to talk with the Indian government, on a federal or state level, if they would like to find out more about our programmes and how they are working on the ground.
References:
1. “Novartis launches ‘Novartis Access’, a portfolio of affordable medicines to treat chronic diseases in lower-income countries” – novartis.com (24/09/15)
2. “Infectious diseases – Achieving extraordinary progress” – David Nabarro, davidnabarro.info (11/01/17)
3. “Remarkable progress made, but long way to go to beating infectious disease” – John Boozman, Devex (29/05/15)
4. “Noncommunicable diseases in developing countries: A symposium report” (Islam et al. 2014)
5. “Chronic disease to cost $47 trillion by 2030: WEF” – Kate Kelland, Reuters (18/09/11)
6. “Novartis invites scrutiny of effort to improve access to medicine” – novartis.com (15/05/17)
7. http://www.afro.who.int/en/ rwanda/country-health-profile/ health-and-development.html
8.“Role of government in public health in India: Current scenario in India and future scope” (Lakshminarayanan 2011)
9. http://www.worldometers.info/ world-population/india-popula
tion/
10.http://www.worldometers.info/world-population/ethiopia-population/
11. http://www.worldometers.info/ world-population/kenya-population/
12. http://www.worldometers.info/ world-population/rwanda-population/
13. http://www.investopedia.com/ articles/investing/022415/worlds-top-10-economies.asp
14. http://www.businesstoday.in/ current/economy-politics/india-has-highest-number-of-people-living-below-poverty-line-world-bank/story/238085.html
15. https://ec.europa.eu/research/ health/pdf/hpforum/novartis_access-factsheet-january_2016.pdf
16. “Community health workers for noncommunicable diseases” (Neupane et al. 2014)