WHO has been at the helm of setting up standards in health, pushing for advocacy and awareness in neglected areas. WHO’s Country Head, India, Nata Menabde reveals the organisation’s efforts and her opinion on several key topics, in a conversation with Shalini Gupta
We are still battling with infectious diseases and yet to meet our MDGs on maternal mortality even as the challenge to tackle NCDs rears its head. What kind of approach do we need to tackle this?
| Nata Menabde |
We do not have the luxury to choose between communicable and non communicable diseases. Commitment to reach MDG target and goals is strong, some on which India has done well with difficulty on some targets. There has been several efforts to scale up on maternal and infant mortality. and improvements are clear. That doesn’t mean that the task is accomplished even if the MDGs are achieved. We will need to have a next target which is even more ambitious. However, that said, we also face a growing burden of non-communicable diseases. We live in a transitional society with social inequities and hence there will be different reasons for different disease burden. India’s disease problems can’t be solved by just having vertical diseases programmes for tuberculosis, HIV etc. Rather, a comprehensive approach that establishes the problems, gives proper advice on risk factors and healthy behaviours to reduce them, provide access to healthcare and medications to ensure a healthy recover is needed. Since risk factors are also shared between diseases, so if you tackle one risk factor like tobacco smoking you can have a hold on several diseases. The 12th five year plan as a part of the Universal Health Programme has this aim in mind to integrate healthcare thus making it more equitable and efficient.
Elaborate on NCDs as a priority for WHO globally.
NCDs are a growing problem, not only for India but for the entire world. It is alarming and threatening, contributing to almost half of deaths worldwide (three out of five deaths globally) and 24 per cent of all deaths in India. If nothing is done and the same pattern continues, this number might almost double for India. NCDs have huge human and economic costs, affecting population, taking them out of the economic and productive sector alongwith extensive costs for treatment and access to services and technologies required to sustain. With an increasingly ageing population, India’s cardiovascular disease burden is also set to increase, and this requires collaboration from not only health but other sectors as well. Risk factors include those associated with healthy lifestyle, better conditions at work, opportunities for exercise and access to sufficient amount of fruits and vegetables for people. It requires a comprehensive approach since a solution needs to be worked out in conjunction with both public and private sectors wherein other sectors such as agriculture, distribution, infrastructure, roads and also food habits and economic capacity of people are looked into.
How do you see the whole debate on access to medicines?
When the preventive measures have not been effective and people fall sick, then medicines are the most effective way to treat those conditions provided the diagnosis has been made. Access to medicines is just one dimension towards an effective solution, alongwith resources to ensure proper diagnosis and patient management. However, given the huge proportion of medicines in the overall health expenditure of India- 70 per cent of entire out of pocket expenditure, which in itself is 60 per cent of the total cost, it is not surprising that the government has put Universal Health Coverage and access to essential medicines as the first priority. In Tamil Nadu, logistics and information systems have been put in place to ensure uninterrupted access to public facilities while we have seen great start of the Rajasthan free medicine scheme. So more utilisation of public facilities along with an electronic system for stock and procurement management is needed. Better quality and rational prescribing is also imperative which brings in a whole range of pharma policy issues at stake.
This brings us to the issue of safe medicines. What is WHO doing on this front?
The safety of medicines or that of biologicals and vaccines is an issue of concern. Recently fake antimalarial medicine was found in the distribution channel in Africa which did not have any active ingredient at all. Its a recurrent problem and requires a strong regulatory authority that sets strong regulatory standards, licensing manufacturers who bring these products to the market while also monitoring side effects. This, alongwith the ability to withdraw spurious medicines and sufficient capacity of drug inspectors, to inspect both at the manufacturing as well as distribution channel is needed. WHO has been traditionally strongly engaged with Indian government on this. We have done a lot of work in setting up GMP standards and ensuring that private manufacturers meet them. We are also running pre-qualification of medicines programme since 2001 with an objective to bring consistency into quality standards and reduce cost for regulatory assessment of those medicines. Both manufacturers and regulatory authorities are assessed and those who pass can sell their products through UN supply channels.
What were the points of discussion at the meeting of international pharmacopeias held recently?
DCGI and Indian Pharmacoepia Commission hosted a meeting which saw 20 representatives from different pharmacoepia discuss and draft guidelines on good pharmacoepias including harmonising standards and rules. That is very important in the context of global trade of medicines. It won’t resolve all the issues but its a right move in the right direction. With every country having its own standards that evolved differently from the other, the effort was to focus on setting up as unified standards as possible and ensure best practices in ensuring quality and standards of medicines as well as procedures for assessment.
Has the NRA recognition come late, given India’s domination in vaccine production?
The process of assessment of NRA functionality parameters is not the first one for India. It started in 2001 and every two years there was an assessment which gradually increased the standards. So from assessment to assessment India just did not have to maintain its level but improve it. In 2007, India could not pass this assessment, wherein it could not meet the parameters defined. So even as we had good vaccines from good companies manufactured in the country, they could not be sold through UN channels (UNICEF, GAVI). After that India was given recommendations. Between 2009-12, WHO called an expert committee meeting to review indicators which India then passed last year. It only reflects that India has been regularly investing in strengthening its capacity and has passed assessment of functionality. This helps children worldwide to be at the receiving end of high quality cheap vaccines, as disease preventing interventions. India can continue to be major exporter of those products.