With moves to address the country’s highly fragmented health system, Andy Gray, a senior lecturer in pharmacology at the University of Kwazulu-Natal tells us that voluntary licensing could help tackle challenges of cost and increased access.

By Andy Gray, Senior lecturer in Pharmacology at the University of Kwazulu-Natal

Earlier this century, the number of those over 65 years of age across the world exceeded the number of under-fives for the first time. In South Africa, this landmark will be reached by the mid 2030s. Globally, the population is ageing – but South Africa’s health system, like many others across the continent, is woefully under-prepared for this challenge.

With an ageing population comes a huge increase in non-communicable diseases (NCDs) such as cancer, diabetes, respiratory and cardio-vascular conditions. Yet despite spending around 8.5% of GDP on health care, which should be more than adequate, the fragmented nature of South Africa’s health system limits its ability to deliver the services that its population already needs.

Under-resourced and inefficient government spending on health

Almost 9 million people in South Africa have some form of medical scheme coverage. But this coverage is divided among 75 different medical schemes. Very few of these people go anywhere near a government facility. Those who are not insured – some 52 million people – are almost exclusively dependent on what the state provides, although some do buy goods and services themselves. On the one hand, therefore, the insurance schemes are better resourced but wasteful, whilst on the other, the public health sector is under-resourced and inefficient.

But very soon, South Africa will reach a point at which diabetes and its consequences are more important as causes of death than HIV or tuberculosis. This poses enormous challenges for identifying who is at risk and diagnosing patients early enough. Managing treatment effectively over decades also requires a different organisation of the health system. The current system is predominantly focused on acute events. But a lot more effort needs to be put into the preventative, social determinants of NCDs, be those diet, exercise, cigarette smoking or inappropriate alcohol use.

How to quantify effectiveness of screening

Another major challenge is screening, which has high costs and inadequate facilities. How often, for example, do adults have their blood pressure or blood sugar levels measured? And once treatment is established, it is vital to ensure that the treatment is effective. For instance, statistics suggest that only about half of all patients treated for hypertension actually have controlled blood pressure. In other words, there may be a whole raft of treatments, but collectively they are not resulting in the positive change we need to see.

Another crucial area is the data that underpins South Africa’s public health programmes. There is very poor data on incidence of non-communicable diseases, let alone on treatment coverage or on the outcomes of that treatment. That’s linked to the lack of electronic health records in the country’s public system. The private sector has fantastic data divided amongst 75 different insurers – and 200 variations in coverage – but these data are almost never shared as doing so would lose the companies their competitive edge.

No global financing mechanism for NCDs

Another major factor is that unlike HIV, TB and malaria no global financing mechanism currently exists for NCDs. This means that products used in NCDs don’t have the level of attention that has been granted from civil society and global financing and innovation bodies.

The South African government currently plans to implement a ‘national health insurance’ to help resolve these issues. It is envisaged that this will be a single fund that everyone contributes to either through direct taxation, indirect taxes or workplace taxation or contributions. Efficiency should be improved because that single fund could purchase services much more strategically.

Expansion of MPP’s model

With MPP’s model now expanded to cover all medicines on the essential medicines list, MPP will be able to play a direct and compelling role in this change. The voluntary licensing model needs to be applied much more widely than the three original diseases, HIV, TB and hepatitis. This is especially the case with cancer and other NCDs, where many new drugs and combination products are still patent protected.

The MPP model of voluntary licences could be highly effective in the NCD space. Having licenses for new products that are considered unaffordable by the Essential Medicines List and are still too challenging for many governments to afford could be a real game-changer. With MPP’s first licence for the cancer treatment nilotinib in 2022, I urge other pharmaceutical companies working in the NCD space to follow suit, as this will address one of the key barriers of access: the price of medicines.