University of Toronto
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Reducing the Economic Burden
of Non-communicable Diseases in the BRICS:
Lessons from Brazil

Julia Kulik,
Lead, BRICS Health Policy Project
BRICS Research Group University of Toronto
January 25, 2013

Non-communicable diseases (NCDs), defined to include mainly cancer, diabetes, cardiovascular disease, and chronic respiratory illness, are a great and growing health challenge for all countries. In fact, they present the greatest threat health to low- and middle-income countries (LMICs). NCDs account for 65 per cent of all global deaths, 80 per cent of which occur in LMICs, yet only 1 per cent of official development assistance is allocated to addressing them (Hotez and Daar 2008). The preoccupation of the donor community with diseases such as HIV/AIDS, tuberculosis, malaria, and neglected tropical diseases, which are communicable and thus a direct threat to their citizens at home, has meant that NCDs have received very little attention (Kirton, Guebert, and Kulik forthcoming). This is arguably an unsustainable course of action, as the economic and social costs of these diseases are remarkably high. Recent studies have shown that over the next 20 years, NCDs will cost the world economy $47 trillion in direct healthcare costs, loss of productivity, and premature death (NCD Alliance 2010).

Policy makers are now more widely recognizing that maintaining a person's health is a necessary component to economic development. Failing to address non-communicable diseases in LMICs will prove to be a major impediment to this economic development. Therefore, national and international strategies to prevent and control these diseases are an absolute necessity. One of the major barriers in preventing and controlling these diseases, particularly in LMICs, is the lack of access to essential medicines and care. However, Brazil has a well-known, successful universal access to HIV/AIDS treatment program that can serve as a lesson for addressing NCDs both within Brazil and other low- and middle-income countries (Berkman et al. 2005). While there are distinct differences between NCDs and HIV/AIDS, they share a similar property in that they are both chronic. In dealing with the onset and spread of HIV/AIDS, many LMICs have had to scale up their health systems in a manner that may prove to be helpful in addressing NCDs (Rabkin and El-Sadr 2011).

This paper argues that maintaining health is an essential component of economic development but, because of the increasing burden of non-communicable diseases in low- and middle-income countries, this economic development is threatened. The solution draws on Brazil's struggle with HIV/AIDS and the country's subsequent introduction of a successful program for universal access to treatment to show how population health can lead to economic growth. Linkages are drawn between the scaling up of health systems in response to HIV/AIDs in LMICs and the future scale-up needs for NCDs. By identifying the successes and limitations of both the lessons and linkages, this paper makes recommendations to address the increasing burden of these diseases as a means of promoting economic development.

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LMICs and NCDs

This discussion of this policy strategy focuses on five particular LMICs — Brazil, Russia, India, China, and South Africa. These five countries share several key qualities: they are all emerging economies whose recent economic growth is threatened by NCDs; they have all struggled with the onset and spread of HIV/AIDS in recent years, and they are the founding members of the summit-level international political BRICS, which has increasingly addressed both development and health. In Brazil, 72 per cent of all deaths are caused by NCDs, the largest contributor being neuropsychiatric disorders (Schmidt et al. 2011). Russia faces increasing rates of cardiovascular disease, a disease that accounts for roughly 1.3 million deaths each year (Eberstadt 2011). Due to high rates of tobacco use in India, there are 800,000 new cases of cancer diagnosed every year (Reddy et al. 2005). In China, 85 per cent of all deaths are due to NCDs and the country now has the largest population of people living with diabetes (Huang 2011). Although the disease burden in South Africa is still largely from communicable diseases, increasing rates of physical inactivity and tobacco use suggest that NCDs will present a major challenge in coming years (World Heath Organization 2005).

These diseases thus present and will continue to present major impediments to the BRICS countries' economic growth, compounded by the fact they are also still burdened with communicable diseases. The economic impacts of NCDs are felt at the individual, workplace, societal, and state levels. At the individual and workplace levels, poor health and wellbeing lead to significant decreases is productivity. In addition, due to their chronic nature, NCDs require costly medicine and treatment over a number of years, which can lead to substantial declines in household income and savings (Abegunde and Stanciole 2006, 2). At the state level, unhealthy populations and premature mortality decrease the quality and quantity of the country's productivity and production, thus reducing its gross domestic product (GDP). By contrast, improved health and wellbeing can increase the quality of human capital, subsequently increasing productivity and GDP by eliminating the costs associated with sick days and disability and redirecting the resources for treatment and medicines to other areas such as improving education and reducing poverty (Abegunde and Stanciole 2006, 4).

There are two approaches to estimating the economic impact of NCDs: a cost-perspective approach that highlights the price of non-intervention and a benefit approach that highlights the advantages of intervention. There are three main categories to the cost perspective approach: cost of illness models, growth accounting models, and full-income models (Abegunde and Stanciole 2006, 5). In a World Health Organization report, Dele Abegunde and Anderson Stanciole (2006, 7) apply the Solow-Swan growth accounting model using human capital and labour output data and projected 2015 GDP data to measure the impacts of NCDs on economic development in Brazil, Russia, India, and China.

The result indicates that Brazil, Russia, India, and China along with numerous other countries will experience a significant decline in national income due to the strain on labour supply and household savings from NCDs. The estimated loss of national income in 2005 due to cardiovascular diseases, stroke, and diabetes in Brazil, Russia, India, and China respectively were $3 billion, $11 billion, $9 billion, and $18 billion. Abegunde and Stanciole (2006, 11) estimate that in 2015 the economic losses will be three to seven times those amounts. Their study also indicates how these economic losses will affect GDP. In 2005, Brazil, Russia, India, and China likely experience reductions in GDP of 0.5 to 1 percent. In 2015, reductions in GDP due to these diseases will likely amount to almost 5 per cent (12). These forecasts exclude the costs associated with cancer and chronic respiratory disease — two of the most burdensome diseases.

Without policy intervention, these countries are more likely to be disproportionately affected by the rising burden of NCDs, because of rapidly aging and declining populations and low-quality public healthcare systems in these countries, particularly Russia and China. In order to estimate the benefits of intervention to prevent and control these diseases, Abegunde and Stanciole (2006, 15) propose a goal of a 2 per cent reduction in NCD death rates, corresponding to the prevention of 36 million deaths over the next 10 years. They compared the figures estimating the economic losses without intervention and those with intervention, to project that the respective gains in national income in Russia, India, and China would be $20 billion, $15 billion and $36 billion respectively (15). Furthermore, gains in GDP with intervention to reach the proposed 2 per cent goal would translate into 0.19 per cent in Russia, 0.05 per cent in India, and 0.04 per cent in China (16).

Thus intervention for the prevention and control of NCDs will inevitably lead to higher levels of economic growth. In turn this type of economic growth should improve other social objectives, including poverty reduction, increased levels of education, and reduction in social inequity.

Brazil, Russia, India, China, and South Africa have produced innovative solutions and strategies for their domestic health systems in recent years. These have led to decreased morbidity and mortality from HIV/AIDS and other infectious diseases. Such success can serve as lessons for the type of intervention needed to prevent and control NCDs.

Each of the BRICS countries has displayed leadership within major global health governance institutions and through initiatives at home. Russia did so as host of the 2006 G8 St. Petersburg Summit, which produced a substantial report on the fight against infectious diseases, and as host of the 2011 Moscow Ministerial Conference on Healthy Lifestyles and NCDs in the lead-up to the UN High-Level Meeting in New York (Guebert 2011). India has continued to strengthen its pharmaceutical industry so that it is able to provide low-cost access to vaccines (Chan 2011). India advanced health at the third BRICS summit, which it hosted in Delhi in March 2012. China, the host of the 2011 BRICS summit, has invested significant resources in disease monitoring and reporting mechanisms since the shocking outbreak of severe acute respiratory syndrome (SARS) exposed weaknesses in its public healthcare system (Blumenthal and Hsiao 2005). South Africa, which will host the fifth BRICS summit in Durban in March 2013, has successfully battled the pharmaceutical industry in order to provide its population with access to low-cost essential medicines. South Africa will likely lead Africa in research and development, epidemiology, and pharmaceutical production (Barnard 2002). Among the five countries, Brazil's program for universal access to treatment for HIV/AIDS provides the leading example of an effective approach to disease control and prevention by a low- to middle-income country.

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Brazil's Response to HIV/AIDS Through Universal Access to Treatment

In 1996, the Brazilian government passed a law through congress that guaranteed universal access to free HIV/AIDS treatment for its infected population. Brazil's public drug companies produced generic AIDS medicines, allowing the country to battle the private pharmaceutical companies that dominated the market with high-cost medicines. By domestically producing medicine, it avoided the cost of importing pharmaceuticals. All antiretroviral drugs (ARVs) produced in Brazil were introduced before Brazil became a signatory to the World Trade Organization's Trade-Related Aspects of Property Rights (TRIPS) agreement. Because drugs introduced after the implementation of TRIPS enjoy patent protection, they cost significantly more to purchase. Brazil's strategy has allowed access to essential, life-saving medicines for thousands of people (Nunn et al. 2009).

The onset of HIV/AIDs in Brazil began in the 1980s and spread rapidly by way of sexual transmission. At the beginning of the country's HIV/AIDS epidemic, the disease afflicted mainly urban men, but then spread to women and individuals with low incomes and low levels of education (Le Loup et al. 2009). In 1990, international institutions estimated that unless Brazil adopted an effective disease control strategy, just over one million people would become infected with HIV within the next 10 years (Berkman et al. 2005). In 1997 Brazil implemented the National AIDS Program (NAP) for universal access to ARV therapy, which led to significant decreases in the prevalence of the disease. Within seven years, AIDS mortality had dropped by 50 per cent and hospitalizations had declined by 70 per cent. By spending $232 million on the formulation and implementation of a national strategy for HIV/AIDS, Brazil saved just over $1 billion in direct and indirect costs (Berkman et al. 2005).

During the 1980s, notions of citizenship and solidarity fuelled a movement for the pursuit of democracy by the Brazilian people. The dialogue between civil society, political parties, and trade unions resulted in democratic elections and the creation of a democratic constitution and one in which health had an important place. This set the pace for a number of movements in which the Brazilian people sought out the security of human rights, including in the face of HIV/AIDS. The first component was the sanitary reform movement, led by healthcare workers, political parties, and religious institutions. Together they sought the creation of a public health system that would be controlled by the public and built on the foundation of health as a fundamental human right. The sanitary reform movement had a strong base in the city of Sao Paulo, which eventually led the response to the first reported case of AIDS in Brazil (Berkman et al. 2005).

Another essential movement in the pursuit of human rights was the emergence of civil society actors dedicated to removing the stigmatization of people living with HIV/AIDS. In many regions around the world, discrimination against men, women, and children with the disease has not been properly mitigated. In Brazil, however, demand for the rights of people living with HIV/AIDS emerged as early as the 1980s and continued into the 1990s. Civil society groups, human rights activists, and individuals affected by AIDS pressured the government to implement both the first governmental AIDS program and nongovernmental AIDS service organization in the country. This civil society movement would be a fundamental catalyst in the development of a national AIDS strategy (Berkman et al. 2005).

The pursuit of a comprehensive prevention, care, and treatment program for people living with HIV/AIDS was made possible by the recognition of health as a human right in the Brazilian constitution. This lead to the implementation of the NAP.

Brazil's NAP contains four essential elements: universal access, integral care, social control, and public funding (Berkman et al. 2005). These elements are important concepts for moving forward on a strategy to combat NCDs.

Integral care recognizes the need for health strategies to maintain a balance between both prevention and care. A health strategy that is limited to prevention withholds the right to health from people already living with illnesses and diseases. Combining prevention with care and treatment provides equal care to both those at risk of contracting HIV/AIDS and those already living with it (Berkman et al. 2005).

Social control recognizes the contributions that civil society has made in the strengthening of health systems and strategies. It acknowledges its fundamental role moving forward. Brazil's national AIDS strategy was formulated from the bottom up, diverging from the bureaucratic nature of public health systems elsewhere. Civil society, nongovernmental organizations, and activists were instrumental in removing the stigma from people living with HIV/AIDS. They continue to be a fundamental component of the policy development and implementation process of Brazil's public health system (Berkman et al. 2005).

Successful reductions in morbidity and mortality from HIV/AIDS have also resulted from civil society advocacy for a publicly funded healthcare system. The recognition of health as a human right led to the recognition by the state of its responsibility to deliver national health care at no cost to its people. The Sistema Universal da Saude (SUS) is considered to be one of the largest public healthcare systems in the world, providing access to care for roughly 190 million people. Coupled with Brazil's access to medicines campaign, its public health system avoided the 1.2 million deaths that the international community had projected would occur by 2004. However, inequities within this system still exist. While the urban populations in southern Brazil maintain a high degree of quality and care, those living in the rural north typically suffer from much lower quality services. The social inequalities that have plagued Brazil for several years continue to do so, particularly at the expense of children under five, as Brazil still registers high levels of child mortality (Bliss 2010, 3).

Nonetheless, Brazil's forward thinking and innovative approach to public health care and access to medicines has prevented large-scale premature deaths and resulted in a much healthier population. These innovations have also contributed to economic growth, the kind of economic growth that has labelled Brazil one of the world's emerging economies.

The Brazilian government recognized that research and development in health strategies could be an important driver for economic growth. By developing a program for universal access to health care and medicine, it recognized that it not only would prevent unnecessary deaths but also that such a program was the only course of action to prevent the economic costs associated with illness and mortality. Until very recently Brazil experienced vibrant economic growth, which had led to reductions in social inequality, an expansion of the middle class, and reductions in poverty. Its healthier population, coupled with increasing industrialization and commodity prices for its exports, has led to higher levels of economic growth (Bliss 2010, 2). This growth has enabled Brazil to become a full and founding member of the BRICS summit-centred institution, partnering with the other emerging economies of Russia, India, China, and South Africa and hosting the second BRICS summit in 2010. Brazil's successful access to medicines campaign and public healthcare system provide lessons for all members in addressing NCDs.

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Policy Lessons from Brazil

There are fundamental differences between HIV/AIDS and the major NCDs of cancer, diabetes, cardiovascular disease, and chronic respiratory disease. However, since the introduction of life-saving antiretroviral medicines, HIV/AIDS, now shares a similar property with NCDs, in that it is now considered a chronic illness. As a result, the strategies used to combat HIV/AIDS, particularly in Brazil but also in Russia, China, India, and South Africa, can be used to form a strategy for the prevention and control of NCDs.

In April 2011 the leaders of Brazil, Russia, India, China, and South Africa met in Sanya, China, at their annual BRICS summit, a forum that arose in 2009 for emerging economies to become more involved in global governance. In Sanya, the leaders committed to hosting the first meeting of BRICS health ministers, which took place in Beijing a few months later. Here they acknowledged the challenge faced by all members due to increasing rates of NCDs (BRICS Health Ministers 2011). The Sanya Summit, paired with the Russian-hosted Ministerial Conference on NCDs in April 2011, solidified these countries' desire to combat these diseases both domestically and internationally.

In order to act effectively against NCDs, the BRICS countries can draw on lessons from Brazil to formulate a strategy.

The first policy lesson is to emphasize health education and prevention. In the 1980s, Brazil used education and prevention campaigns, which included condom distribution and HIV testing as well as informational sessions for vulnerable groups, to stop the spread of HIV/AIDS (Nunn 2009, 1,103). Health prevention and education are among the most cost-effective ways of preventing NCDs. By informing people early on about the dangers of tobacco and alcohol use, physical inactivity, and poor diet, a large number of these diseases can be prevented, especially among children and youth (Bailey, Caulfield, and Ries 2008, 375).

The second lesson is to engage civil society and conduct advocacy. Within Brazil this proved to be an effective means to understanding the needs of communities, prompting government action, and reducing the stigmatization of people living with HIV/AIDS. Such involvement can serve as an important lesson as both domestic and international action on these diseases has been limited. Engagement with civil society and stakeholders will be increasingly important in formulating a strategy for NCDs, as new and powerful players in health such as the Bill and Melinda Gates Foundation and the NCD Alliance have emerged. The increasing number of people with neuropsychiatric disorders, particularly in Brazil, can benefit by this approach, as they have consistently been stigmatized (Rabkin and El-Sadr 2011).

A third lesson is to emphasize integral and continuous care in addressing NCDs. Like HIV/AIDS, NCDs require the coordination of services and a continuous relationship between patients and healthcare professionals over a number of years. These chronic diseases require testing and diagnosis, disease surveillance and treatment, and palliative care. The costs associated with these types of continuous services are high. However, this type of care can also lead to fewer unnecessary deaths and hospitalizations by identifying problems and promoting healthy lifestyle choices early in life (Rabkin and El-Sadr 2011). Recent scaling up health systems to address the now chronic nature of HIV/AIDS could mean that these LMICs are more prepared to deal with NCDs.

A fourth lesson for addressing NCDs in LMICs is to address the need for access to essential medicines. Again, due to the chronic nature of these diseases, they often require medication that reduce symptoms, stop metastasis, and reduce risk factors. The costs of these drugs over a long period can present a major burden to the individual's and state's income. During the 1990s Brazil sought ways to obtain access to low-cost generic medicines, despite having signed onto the TRIPS agreement. The result was thousands of lives saved. While Brazil's approach to medicines cannot be replicated all over the world, similar innovative strategies to produce and obtain access to NCD medicines are required to prevent and treat these diseases.

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Policy Limitations

There are, however, significant limitations on the applicability of these lessons. First and foremost are the resource-limited settings in which LMICs operate. Brazil's approach to HIV/AIDS provides a leading example of a resource-limited country successfully battling an epidemic, but does not factor in the double burden of disease that such countries are now facing. In recent years, Brazil, Russia, India, China, and South Africa have produced innovative solutions for HIV/AIDS, through technological innovation and pharmaceutical production. But their populations are still vulnerable. Furthermore, the price of AIDS treatment has been rising rapidly over the last few years. From 2004 to 2005 alone, the cost of ARVs doubled, with per patient costs reaching US$2,577 (Nunn et al. 2008, 1,109). Therefore, it will be difficult for BRICS members and other LMICs to divert their limited resources away from HIV/AIDS to the new burden of NCDs.

In addition, there are still fundamental differences between HIV/AIDS and NCDs. Although ARVs are more expensive than the drugs and medicines that treat diseases and illnesses such as diabetes and hypertension, ARVs have been shown to be more cost effective. This is because the degree of improvement for people on ARVs is much higher than its counterpart for NCD treatments. Slight differences in service delivery between the two types of diseases mean that the scaling up of health systems in the face of HIV/AIDS still leaves gaps in the services needed for NCDs. The major gap will come in the form of the tertiary services that are often needed to treat certain types of cancers and cardiovascular disease (Rabkin and El-Sadr 2011).

Another major limitation of these strategies is the shortage and migration of healthcare workers, particularly in South Africa. LMICs have limited resources. And since these countries have already committed significant resources to treating HIV/AIDS, it is likely that healthcare professionals specializing in NCDs will be few. Because countries like the United States and the United Kingdom can offer healthcare professionals higher wages and better facilities, research budgets, and professional environments, many workers often leave their country of origin once they have received their training (Stilwell et al. 2004, 596). Without skilled healthcare professionals, a strategy to address NCDs will be ineffective.

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Brazil's pursuit of an HIV/AIDS strategy, with a foundation in recognizing health as a human right, offers many lessons for formulating a strategy for scaling up health systems to face non-communicable diseases. Yet there remain limitations to the applicability of these policy lessons. One of the major challenges the countries of Brazil, Russia, India, China, and South Africa face is the limited-resource setting in which they operate, especially since they are still vulnerable to the threat from communicable diseases. And since a significant amount of resources have already been invested in addressing HIV/AIDS, it is unlikely that there is much left to invest in an NCD strategy. However, these countries have an advantage in that they now play a greater role in global summitry.

The BRICS partners have an opportunity as host of the group's annual summit over the next few years to help the international community recognize the threat that NCDs pose to every country in the world. As a full and equal member of the economic forum of the G20, each BRICS country can also assist other members in recognizing the economic impact of these diseases. Engaging with the existing international institutions as well as the other major global health players such as the Bill and Melinda Gates Foundation, the BRICS countries can use their emerging leadership to promote and produce global commitments to address NCDs. The international Framework Convention on Tobacco Control (FCTC) is an example of such a commitment. The FCTC has contributed to global reductions in tobacco use, one of the major risk factors contributing to NCD prevalence.

Building on the UN High-Level Meeting on Non-Communicable Disease in New York in September 2011, the BRICS countries have an opportunity to further the commitments made on marketing foods high in fats, sugars, and salt to children, increasing access to vaccinations and disease screening, and promoting healthy workplaces. While no firm targets or timelines were produced at that meeting, the BRICS countries can use their role as host of a series of summits in the next few years to advocate for them.

Limited resources will prevent Brazil, Russia, India, China, and South Africa from investing in a substantial NCD prevention and control program in the coming years. However, using the lessons learned from Brazil's approach to HIV/AIDS along with the BRICS's newfound leadership in the international community, they have an opportunity to engage with government and nongovernment actors to recognize the social and economic impact of these diseases. Such international recognition of the burden of these diseases can lead to global commitments, which all countries can benefit from.

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