The 4 Ps of sustainable access to healthcare

Our building blocks to battling non-communicable diseases (NCDs)

Overview

Non-communicable diseases (NCDs) are an “invisible epidemic”, and while often preventable, they account for 70 per cent of deaths worldwide.1 According to the World Health Organization (WHO), should this trend continue, it is estimated to cost the global economy $47 trillion by 2030.2 This does not include the emotional toll on individuals, families, communities and nations.

With science at the heart of all we do, providing access to healthcare is where we feel we can make the greatest impact when it comes to tackling NCDs.

At AstraZeneca, we take the threat of NCDs seriously. As part of our sustainability strategy, we work towards sustainable health – aiming to improve lives through access to healthcare, to reduce environmental impacts on human health and the natural world using innovative science and to make decisions for the long term through a focus on ethics and transparency. We are removing barriers for people who lack basic access to healthcare and provide education and awareness of NCD risk factors. It is these building blocks that help us improve lives by expanding NCD prevention, enabling infrastructure capacity, and supporting treatment affordability.

•  Global PARTNERSHIPS that allow us to understand and assess the health challenges and opportunities that exist on a local level.

•  PEOPLE – local professionals and patients who are engaged and benefit directly from our global health access work via trainings or treatment services.

•  Evidence-based POLICY recommendations that support and strengthen on-the-ground efforts.

•  Access PROGRAMMES that span the care continuum – from early detection to treatment – and are improving patient outcomes at almost every stage of their life.

 



01

Partnership

NCDs comprise some of the most complex and challenging diseases. We are working to bring innovative new treatments for cancer, respiratory, and cardiovascular, renal and metabolic diseases while keeping our eyes on the future - on prevention and long-term solutions for sustainable healthcare. Why? Because it is the right thing to do. But we know we can’t do it alone.



“The only way we can achieve this is in three ways,” said Dr. Kibachio Joseph Muiruri Mwangi, head of the Division of NCDs within the Kenyan Ministry of Health. “Number one, partnerships. Number two, partnerships. And number three, partnerships,” he stated in a recent interview.

Earlier this year, during the 71st World Health Assembly (WHA) in Geneva, Switzerland, we were proud to play a role in the NCD discourse leading up to the 3rd United Nations High Level Meeting on Non-Communicable Diseases (NCDs) in September. Dr. Kibachio joined Katarina Ageborg, AstraZeneca’s Chief Compliance Officer, and several of our access-to-health partners, for our first WHA panel: “Driving Novel Partnerships Throughout the NCD Life-Cycle: New Approaches to Preventing and Treating Respiratory and Cardiovascular Diseases in LMICs.”

The panel was a timely topic following the opening remarks of Director-General of the World Health Organization Dr. Tedros Adhanom Ghebreyesus. He was adamant about his three pillars of success, citing partnership as the final key to achieving the goals set in the WHO General Programme of Work.

“The great advantage we have now that we did not have 70 years ago, or even 40 years ago, is that there are so many other actors in global health,” he said. “There are thousands of other organisations all over the world who share our vision, and who have knowledge, skills, resources and networks that we do not.”

His remarks set the scene for our conversation that delved into the importance of impactful partnership models to combat NCDs. Specifically, it focused on public health promotion, the optimisation of existing health interventions, and service integration with an emphasis on how governments can collaborate effectively with the private sector.

In our panel, Dr. Kibachio acknowledged the sensitivity of working with the private sector, but spoke highly of how national administrations, like his, are changing and recognising the “win-win” of public-private partnerships. He emphasised the shared responsibility of government and pharmaceutical companies to identify aligning opportunities. He explained that the typical molecule-meets-the-patient interventions (i.e. just the medicines) can often emphasise the “dollar-faced bottom line” objectives of the pharmaceutical industry. The key takeaway, he noted, is that when there is trust and transparency, there is a “human-faced bottom line” where both sectors can meet in the middle, and where governments, like his, can invest.

He cited AstraZeneca’s Healthy Heart Africa (HHA)* four-year programming as an exemplar (more on this programme in Chapter 4: Programmes)

To date, HHA continues to play a significant role in tackling the “big four” NCDs burdening Kenyans: (1) hypertension and cardiac diseases; (2) diabetes; (3) cancers; and (4) small injuries, that include conditions like sickle cell anaemia and rheumatic heart disease. Conditions, which Kibachio explained, are small in terms of size, but big in terms of burden.

According to Dr. Kibachio, close to 50 per cent of “Kenyans on the street” have very limited knowledge about risk factors and dangers of hypertension. In addition, 60 to 70 per cent of Kenyans have never been screened, which is why the first element for him is creating awareness. The second element links patients to care and control to prevent long-term hypertension complications; and finally, the third element focuses on strategic direction for the Kenyan ministry, developing strategic documents, cardiovascular guidelines and policies that go around addressing the burden of NCDs. 

For Dr. Kibachio, HHA has placed care “on the way” for local Kenyans; enabling an access to healthcare approach that provides patients with the support they need based on where they are in life and in the NCD lifecycle. For a closer look at the importance of policy engagement and the NCD debate, visit Chapter 3.


02

People

In our effort to put patients first, we aim to understand their needs on the ground and equip local professionals with the right tools to facilitate quality care across the NCD spectrum.




Studies show there is a growing and disproportionate impact of the NCD epidemic in Low- and Middle-Income Countries (LMICs) – out of all deaths caused by NCDs worldwide, 80 per cent of them happen in low- and middle-income countries.3

In Indonesia – a country with the largest economy in Southeast Asia and the fourth largest population worldwide4 –   environmental factors including air pollution5 and NCD risk behaviours (starting in adolescence) exacerbate these types of respiratory conditions. Recent statistics show that the prevalence of smoking among Indonesians aged 15 years and above has increased since 2007, and that 36.2 per cent of boys and 4.3 percent of girls currently use tobacco in smoked and/or smokeless form6 – key insights that continue to stimulate the Healthy Lung Asia (HLA) programme.

Among current tobacco users, 18.3% consume cigarettes. Overall, 35.6% smoke one stick per day, whereas more than half of girls (58.3%) smoke less than one cigarette per day. The age at initiation into cigarette smoking of 43.2% of those who have ever smoked a cigarette is 12 to 13 years.

According to estimates from the World Health Organization (WHO), the proportional mortality due to NCDs in Indonesia has increased from 50.7 per cent in 2004 to 71 per cent in 2014.7 At the World Health Assembly, we spoke to Dr. Anung Sugihantono, general director of disease prevention and control from the Indonesian Ministry of Health. He acknowledges the country is in high need of attention when it comes to respiratory health, and he is constantly looking for strategies, activities, and best practices to shape, adapt, and improve his country’s health policies.

According to Joris Silon, Vice President of AstraZeneca Asia, respiratory disease in Asia is not quite recognised at the same level as diabetes or other NCDs. “Care is still centred around emergency care and people go to hospitals to be treated,” Silon explained.

Through Healthy Lung Asia, AstraZeneca works with Indonesia to tackle this health challenge and we are happy to report that our efforts and activities comply with Indonesia’s current National Action Plan (more on this programme on Chapter 4: Programmes). In Indonesia, we are working with the local government to educate healthcare physicians that work in the “Bukezmas” (i.e. local hospitals) to understand what good respiratory treatment looks like.

“Our work with AstraZeneca focuses on public awareness, capacity building for health workers, and support from academia to showcase more lung disease evidence across Indonesia,” said Sugihantono.

Launched in 2017, HLA efforts span nine different countries across the continent with an emphasis on patient awareness and professional education for healthcare workers.

In Vietnam alone, 29 patient clubs were established, benefitting 2,130 patients and improving patient education and awareness of respiratory disease management within the first year of HLA programming. AstraZeneca has outlined additional goals for the country including having 80 per cent of full-time medical staff trained and certified in established respiratory health units, in addition to 150 centres of excellence specialising in asthma and Chronic Obstructive Pulmonary Disease (COPD) outpatient management.

AstraZeneca Taiwan has completed the core training materials for physicians with TSPCCM (Taiwan Society of Pulmonary and Critical Care Medicine) to standardise respiratory health management. Furthermore, partnered with TSPCCM, the Pay for Performance (P4P) programme, looks to improve the management of asthma in Taiwan.


03

Policy

During the World Health Assembly, together with our key international research, NGO, and advocacy partners, another in-depth panel discussion focused on one of the most vulnerable NCD risk groups, and the role effective policy making can play in tackling a growing global health challenge.



The panel discussion, “Turning the Tide on NCDs: Why We Need to Focus on Youth,” highlighted the importance of focusing our attention on youth when it comes to addressing NCD prevention. The ongoing work of AstraZeneca’s Young Health Programme (YHP) – a global non-communicable disease prevention programme –  addresses the primary risk factors of NCDs together with our partners – Plan International UK, NCD Child* through systematic programmatic interventions, community building, as well as research generation and policy engagement.

“You can do a lot of things at the community level,” said Danor Ajwang, Young Health Programme Manager with Plan Kenya. “However, if it is not backed by policy and legislators, it is not backed up. You lose out. We are working with communities, young people, and policy makers to prioritise NCD planning.”

Previous data (2015) from the Kenyan Ministry of Health found that 27 per cent of deaths are being attributed to NCDs.8 50 per cent of hospitalisations are NCD-related, and 40 per cent of hospital deaths can be traced back to NCDs.9

In Kenya, one of the core areas of the Young Health Programme is to lobby and advocate for more effective and responsive policies to some of these issues (more on this programme in Chapter 4: Programmes). Ajwang, a local Kenyan, seeks to ensure that young people understand these policy spaces so that they can voice their concerns.

“When it comes to advocacy, it needs joint efforts,” said Ajwang. “Combined voices to take the work forward. The government has good policies, but they are not implemented because of resources. We can support the government who are willing to actualise.”

According to Liam Sollis, Young Health Programme Advocacy Manager, Plan International UK, there are three key facts that underpin the work of the YHP.

“At the moment, NCDs are by far the largest killer of people all around the world,” said Sollis. “An estimated 70 per cent of deaths around the world are linked to behaviours that are initiated in adolescence. And today, we have the largest adolescent population that the world has ever seen.”



During the panel, research agency RTI International shared additional evidence on the importance of focusing on youth: 90 per cent of adult smokers initiated smoking by the time they turned age 18, with 50 per cent of adolescent smokers continuing to smoke for another 16 to 20 years.10 Additional studies show that two-thirds of premature NCD deaths in adulthood are associated with behaviours initiated during youth.11 These behaviours include tobacco and alcohol use, sedentary lifestyles, and unhealthy diets.

The research summary presented by RTI International during the panel was commissioned by the  AstraZeneca Young Health Programme. The eight-page document, “Investment Case for Reducing Noncommunicable Disease Risk Factors in Adolescents”, looks closely at current policy efforts to curb adolescent (ages 10 to 19 years of age) NCD risk behaviours and where national governments can implement the most cost effective policy interventions to make the biggest impact to tackle the issue. Current global trends are exploring national taxation and fiscal policy overhauls. Sollis stated that many countries have already moved forward with such legislation.

“These types of policy decisions are the direction in which the global NCD conversation is going,” said Sollis in a recent interview. “There is appreciation from governing bodies like the United Nations and WHO.”

The report asserts that with these types of policies in place, around 20 million avoidable premature deaths could occur during the next 50 years – saving on average 500,000 lives and over $6 billion in annual economic benefits.12

A copy of the summary report is available here. Additional findings will be presented at the 3rd United Nations High Level Meeting on Non-communicable Diseases (NCDs) in September.**

*We provide funding to Plan International UK to support the delivery of our Young Health Programme in India, Indonesia, Kenya and Brazil. We also provide funding to support the annual activities of NCD Child which include advocating for the inclusion of children and youth in global health policy and discourse, providing advocacy training to youth-serving practitioners and engaging young people themselves in the process. The Secretariat for NCD Child is currently held by the American Academy of Pediatrics.

** This paper was funded through a charitable grant made by the AstraZeneca Young Health Programme (YHP), in partnership with Plan International UK. Professor Majid Ezzati, Imperial College, London, contributed epidemiological projections on which the calculation of economic benefits was based.


04

Programmes

“It’s no longer about just delivering products to patients,” said AstraZeneca Vice President of Sustainability Jim Massey. “Our strategy spans the lifecycle of the people we serve; whether it’s prevention, or building infrastructure to support the appropriate diagnosis, or improving the accessibility and affordability of the actual treatment that people need.”




At AstraZeneca, we are responding to the call to invest in the prevention of non-communicable diseases (NCDs) and support the long-term, sustainable growth of healthy nations. As part of the Sustainable Development Goal (SDG) 3 – good health and well-being  – when we talk about sustainability, our focus is access to healthcare and transforming the lives of patients around the world for the long-term.

We are committed to supporting access to healthcare on a continuum – from education and awareness, to prevention, screening, and treatment – reaching people across the lifecourse, from adolescence through adulthood.

Access in Action

Through the support of our diverse programmes, we cover the whole NCD lifecycle from prevention to early detection and where appropriate, treatment.

Health promotion, training and education lie at the core of our disease prevention programmes.  A significant portion of our work is focused on youth. We work to educate on and prevent exposure to NCD risk behaviours beginning as early as age 10, through our Young Health Programme (YHP). What began as a collaboration with Johns Hopkins Bloomberg School of Public Health and Plan International* in 2010, has evolved into a network of 30 global health partners and more than 50,000 trained NCD peer educators.

From smoking awareness and social empowerment to building healthy eating habits, YHP has one goal: reduce the uptake of unhealthy behaviours in young people to improve their health outcomes as adults. To date, the programme has reached 2.25 million young people across 21 markets and five continents with healthy lifestyle information.

Early detection is a crucial element that many of our access programmes focus on, providing complete care by working to strengthen healthcare frameworks and capabilities. As an example, the Healthy Heart Africa (HHA) programme, launched in Kenya in 2014, tested different intervention models across the public, private and faith-based sectors. The close collaboration provided identification of a working sustainable model, allowing for county scale up in Kenya and further country expansion.

To date, HHA has activated over 680 healthcare facilities to provide hypertension services and secure supply chains for low cost, high-quality antihypertensive medicines. The programme has conducted over 6.6 million blood pressure screenings, identified over 1.2 million people living with high blood pressure; and trained over 5,800 healthcare workers.

Our work in Africa continues to span the NCD spectrum and the growing needs of its diverse nations with an emphasis on early detection.

In South Africa particularly, we’ve worked to “uplift” local communities when it comes to identifying chronic conditions and NCDs that impact men and women alike and can strike at any point in adulthood. In collaboration with South Africa’s Foundation for Professional Development, we provide accredited courses for healthcare professionals in early detection, cancer diagnosis, treatment and care.

The term “Phakamisa” means ‘uplift or ‘elevate’ in Zulu and Xhosa and is the name of our NCD programme – established in 2011 – dedicated to reducing the burden of breast cancer, prostate cancer and respiratory disease on the national health system in South Africa. Through Phakamisa, we have reached over 1.75 million women, trained more than 600 healthcare professionals and trained 400 people as Phakamisa “Navigators” in cancer diagnosis, who in 2017 alone, identified 5,300 malignant lumps, again providing early detection for patients.

In an effort to broaden our impact across the continent, we are piloting a new programme in Kenya: Dunga Beach. For the first time, we will be bridging two of our key sustainability pillars – access to healthcare and environmental protection – to improve health outcomes throughout local Kenyan communities.

The programme works to process waste into valuable clean energy and reduce (indoor) air pollution and respiratory illness in Sub-Saharan Africa; an area where around 80 per cent of households are in rural areas13 and rely on burning solid fuels on a naked wick – a major driver of respiratory ill-health. Through this initiative, we aim to reduce the time needed for individuals, particularly women and children, to collect firewood, allowing opportunities to spend greater time on schooling or entrepreneurial activities.

Finally, we understand the burden of treatment costs and accessibility, which is why we are determined complete the NCD lifecycle through our three main therapy areas; oncology, respiratory, and cardiovascular and metabolic diseases.

Indonesia, and its citizens, sit at the intersection of two colliding forces: high smoking rates14 and environmental pollution.5 Together, they result in a high rate of respiratory conditions.15 In 2017, our Healthy Lung Asia (HLA) programme was established across nine key geographies including Indonesia, India, Malaysia, the Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam to combat rising respiratory conditions.

To date, this programme has established 14 partnerships, trained more than 5,500 healthcare professionals and reached 134,000 people with education, diagnosis and treatment of COPD or asthma. By focusing on raising the profile of respiratory disease with policymakers and building health-system capacity, we aim to provide improved healthcare to those patients in need of treatment while driving a healthy and sustainable business in this fast-developing region.

“AstraZeneca is a company that is meeting our patients’ needs,” said Massey. “We are doing it ethically and transparently, and we’re also doing it not just for this quarter, but for patients 10, 15, 20 years from now.”

To learn more about Sustainability at AstraZeneca visit; https://www.astrazeneca.com/sustainability.html.

 

*We provided funding to Johns Hopkins Bloomberg School of Public Health to support the delivery of the Wellbeing of Adolescents in Vulnerable Environments (WAVE) research, a first-of-its-kind study that looked at comparable health profiles of 15- to 19- year olds in similarly impoverished communities around the world.


References:

1. The Partnership. The Defeat-NCD Partnership. (2018). Accessible at: https://defeat-ncd.org/.

2. Resource Mobilization Orientation: Facilitator’s Manual. World Health Organization. (2016).

3. Regional High-level Consultation in the Eastern Mediterranean Region on the Prevention and Control of Non-communicable Diseases in Low- and Middle-Income Countries. World Health Organization. (2010). Accessible at: http://www.who.int/nmh/events/2010/Tehran_Background_Paper.pdf

4. Overview Indonesia. The World Bank. (2018). Accessible at: http://www.worldbank.org/en/country/indonesia/overview.

5. Widya Yudha S. Air Pollution in Indonesia. The National Bureau of Asian Research. (2016). Accessible at: http://nbr.org/research/activity.aspx?id=665

6. World Health Organization, Regional Office for South-East Asia. Global Youth Tobacco Survey (GYTS): Indonesia report, 2014. New Delhi: WHO-SEARO, 2015

7. Bloom, D. E., Chen S., McGovern M., Prettner K., Candeias V., Bernaert A. and Cristin S. The Economics of Non-Communicable Diseases in Indonesia report. World Economic Forum & Harvard T.H. Chan School of Public Health. (2015). Accessible at: http://www3.weforum.org/docs/WEF_The_Economics_of_non_Disease_Indonesia_2015.pdf  

8. Ministry of Health. Kenya STEPwise survey for Non Communicable Diseases Risk Factors 2015 Report. Ministry of Health, Division of Non-Communicable Diseases. (2015) Pg. 4.

9. Ministry of Health. Kenya STEPwise survey for Non Communicable Diseases Risk Factors 2015 Report. Ministry of Health, Division of Non-Communicable Diseases. (2015) Pg. 2.

10. Nugent R, Hale J, Hutchinson B, Watkins D. Investment Case for Reducing Noncommunicable Disease Risk Factors in Adolescents. RTI International. (2018) Pg. 3.

11. Fact sheet on adolescent health. World Health Organization Western Pacific Region. (2015). Accessible at: http://www.wpro.who.int/mediacentre/factsheets/docs/fs_201202_adolescent_health/en/#

12. Nugent R, Hale J, Hutchinson B, Watkins D. Investment Case for Reducing Noncommunicable Disease Risk Factors in Adolescents. RTI International. (2018) Pg. 5.

13. De Magalhaes L, Santaeulalia-Llopic R. The Consumption, Income, and Wealth of the Poorest. Cross-Sectional Facts of Rural and Urban Sub-Saharan Africa for Macroeconomists. World Bank Group. (2015). Pg. 2

14. The Tobacco Atlas. Indonesia.  2018 American Cancer Society, Inc. and Vital Strategies. (2015). Accessible at: https://tobaccoatlas.org/country/indonesia/

15. Schröders J, Wall S, Hakimi M, et al. How is Indonesia coping with its epidemic of chronic noncommunicable diseases? A systematic review with meta-analysis. Renzaho AMN, ed. PLoS ONE. 2017;12(6):e0179186. doi:10.1371/journal.pone.0179186. Accessible at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478110/