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How can we improve access and get more value from drug expenditures in Africa?

Patricio V. Marquez's picture

Medicines are key inputs for quality medical care and the prevention of disease, and when administered appropriately, as evidence from Sub-Saharan African countries shows, they can contribute significantly to reducing death rates due to conditions such as HIV/AIDS, tuberculosis, and malaria.
 
But it is also obvious that not everybody in these countries, particularly the poor, enjoys this benefit, since limited access to essential drugs remains a key challenge in most health systems.  High out-of-pocket expenditures, typically more than 40% of total health expenditures in some countries (a large portion for outpatient drugs), also place a heavy burden on poor families with chronically ill members who require daily drug intake. 

Facilitating effective access to essential medicines at an affordable price has been a long-standing aspiration of governments across the world.  This challenge has become more acute nowadays given the negative impact of the global economic downturn on public budgets that constrain health spending and development aid. 

I think that to effectively deal with this challenge, countries need to reinforce the adoption of an essential drugs benefit for the most prevalent diseases, ensuring that decisions about what drugs are included on essential drugs lists and likely volumes are costed, and that the full implications of listing every new drug are taken into account. 

But where should additional resources come from to finance this benefit?

An obvious option is to redirect public expenditures toward long-term needs of social sectors such as health, and away from less productive categories of public expenditures (for example, general administration expenditures, or untargeted subsidies and transfers). Another promising option is to increase excise taxes on cigarettes to pay for the drug benefit and improvements in the supply chain for drugs. This option is not only consistent with the Framework Convention on Tobacco Control, which most countries in Sub-Saharan Africa have ratified, but also would have the effect of raising prices to make cigarettes less affordable, encouraging tobacco users to quit and contributing to a reduction in the high cost of treating tobacco-related chronic diseases in the future.
 
The adoption and implementation of stronger tobacco taxation policies in Sub-Saharan Africa to generate additional funds for health programs is indeed feasible, since 30 out of 46 African nations have a tobacco taxation rate lower than 40% as compared to only 5 out of 53 European countries, or to some Latin American countries, where the rates range from 56% in Costa Rica, 65% in Mexico, and 76% in Chile. A good international example of the application of this option is the decision in February 2009 by the US Government to renew and extend the Children’s Health Insurance Program (CHIPRA) for low-income uninsured children, financed by a 62-cent per-pack increase in the federal cigarette taxes and other tobacco tax increases.

Some people may argue that this type of proposal will only aggravate an already bleak situation given significant evidence that government-provided drugs are stolen (usually by health workers) and sold on the open market, which makes it even harder for poor people to get access to them.  Yes, that happens, and the problem is part of institutional weaknesses in the health sector in many countries.  But at the same time, there is significant evidence of success stories in other countries.
 
So, besides adequate funding, it is imperative that ongoing efforts be supported to build resilient institutions and systems to facilitate access to and promote the rational use of medicines. 

For example, in Nigeria, as recently reported in The Economist, the government has adopted measures such as a scratch-off label system that have reduced the flow of counterfeit medicines from around half to a tenth in five years. Stronger supply chains for lifesaving drugs—including hiring district-level planners to help manage orders and deliver drugs more efficiently—have proved very effective in Zambia, where pediatric malaria drugs, essential to save children’s lives, have become available in 88% of public health centers in pilot districts, nearly doubling the 51% availability rate in control districts. 

Results presented at the 2012 Clinton Global Initiative, showed that in Tanzania, the Medical Stores Department (MSD), leveraging Coca-Cola's expansive distribution system and supply chain expertise, has reduced the delivery times for anti-AIDS drugs and vaccines in 10 rural regions from 30 days to five. Now, the initiative is going to be expanded to cover 75% of Tanzania and include Ghana and Mozambique.

Given the ever-growing number of drug therapies, the lack of access of many physicians to scientific information or enough technical knowledge for making a critical appraisal of new medicines, the adoption of clinical guidelines for specific diseases as done in Botswana is helping improve prescription patterns of physicians avoiding tendencies to overmedicate with little or no benefit for the patient. Equally important are methods to ensure adherence of patients to the prescribed drug regime, such as the directly observed treatment for tuberculosis, that helps prevent the development of drug resistance.

As the implementation of the universal health coverage agenda evolves across African countries, proper attention needs to be placed to ensure timely access to essential medicines taking into account international experiences and ongoing innovative efforts in the countries.  The policy decisions that could be adopted in this area will be of crucial importance to improve resource utilization and generate better health outcomes.

RELATED LINKS:
A Practical Approach to Pharmaceutical Policy: 
http://issuu.com/world.bank.publications/docs/9780821383865/1?zoomed=&zoomPercent=&zoomX=&zoomY=&noteText=&noteX=&noteY=&viewMode=magazine
http://go.worldbank.org/SZPAB6CMN1

Zambia Study Shows Stronger Supply Chains for Key Drugs can Reduce Child Mortality:
http://go.worldbank.org/V61HKWLUQ1

Bad medicine.  The world’s drug supply is global. Governments have failed to keep up
http://www.economist.com/node/21564546

Shanta Devarajan's response to this blog post
http://blogs.worldbank.org/africacan/improving-access-to-drugs-fitting-the-solution-to-the-problem

Comments

Submitted by Andreas Seiter on
Covering essential medicines should be part of any plan to provide health coverage for the population, but the implementation is tricky. The example from Ghana suggests that, without a good system to monitor prescriptions and usage, drug expenditure in third party financed systems tends to outgrow revenues within a few years. What can be done to avoid that? First, a drug benefit can be defined in a restricted way, for example offering only a limited number of treatments with high public health relevance, restricting patient eligibility and setting a cap on how much each patient can receive per given period of time. Second, if patients are required to register with a primary care provider, the provider can be given a hard budget cap that is based on average cost of the benefit package times number of patients. A more advanced solution would be to develop smart phone apps (in places with mobile internet coverage and assuming that health workers use internet enabled phones already) that guide the transaction, verify patient identity with a photo and may even send the payment directly to the provider once the transaction has been recorded and verified. In any case, a functioning supply chain that keeps stock levels within defined upper and lower limits is prerequisite. In places with pre-historic annual planning, procurement and top-down distribution systems, universal coverage will remain an empty promise for those who need it most.

Submitted by Kalipso Chalkidou on
Given the pharmaceuticals budget is proportionately one of the largest items (if not the largest) in health expenditure for most developing countries, boosting the institutional, informational and human resource capacity of payers, hence strengthening the demand side, is a condition for countries reaching and sustaining Universal Coverage. As Dr Marquez sets out in his timely blog, current weaknesses in the way pharmaceuticals are selected, procured, priced, listed/reimbursed and used in routine practice, in the public sector, is hardly an argument for doing away with an attempt to strengthen the ability of public payers better to perform these functions. As countries such as India, China and Turkey spend more public money on buying healthcare for their populations, the role of accountable, scientific, transparent and defensible processes is becoming more (not less) important. The role of Thailand's Health Technology Assessment agency (HITAP) in helping select essential drugs and vaccines for their Universal Coverage package, is a case in point. Similar work in enhancing the allocative efficiency of decisions is taking place at central and local levels in India (through its insurance and tax-funded schemes) and rural China. Colombia through IETS is also on the same track. And the British National Health Service is a case in point too with the work of NICE with regard to the adoption and diffusion of new and also existing technologies.

Thank you for sharing your ideas. From my point of view, one important question is how medicines are really used. Part of the efforts to facilitate access to medicines are wasted efforts simplu because medicines are not appropriately prescribed and/or are not appropriately used. Weekly or monthly, a number ofscientific publications are showing us that medicines are not used following the therapeutic guidelines, that adherence to treatments is far from the ideal, that some medicines are prescribed to patients that probably need anotherdrug, and so on. And this happen among patients that have real access to medicines, but the result of the collective (or individual) effort to have access is not an efficient one. So, efforts to ensure the appropriate use of medicines would probably revert in a real increase of access. Local educative actions can help to improve how medicines are prescribed and/or used.

Many thanks Andreas, Kalipso and Albert for your comments, which tend to reinforce the importance of the topic for improving health care delivery and achieve good health outcomes on the basis of evidence. Given the complexity of the pharmaceutical sector, that is compounded by the information asymmetries that characterize the patient/physician or prescribed relationship and the influence played by interest groups on what is prescribed and consumed, it is imperative for those involved in health sector reforms to carefully study and develop knowledge about the required pharmaceutical policies, systems, institutions,rules and processes (including a careful understanding of positive and perverse incentives at play) that need to be in place to generate the intended benefits. For those interested on the topic, I would like to suggest, besides the above references, a recent World Bank publication funded by the DFID and authored by two distinguished experts, Marc Roberts (U of Pennsylvania) and Michael Reich (Harvard U). The interactive version of the book, "Pharmaceutical Reform. A guide to Improving Performance and Equity", can be accessed at: http://www.worldbank.org/pdt

As noted in the press release, a recent 2012 study by the IMS Institute for Healthcare Informatics has identified six levers that can be applied to improve medicine use worldwide and empower public and private stakeholders to realize nearly a half-trillion dollar avoidable cost opportunity. The levers are: --Increase medicine adherence by addressing patient beliefs and behaviors at the point of prescription and during medicine intake. --Ensure timely medicine use that prevents avoidable and costly consequences among patients with highly prevalent diseases that increase in severity if diagnosis and treatment are delayed. --Optimize antibiotic use to turn the tide on rising antimicrobial resistance worldwide due to the misuse and overuse of antibiotics. --Prevent medication errors throughout the medicine provision pathway, from prescription to administration. --Use low-cost and safe generic drugs where available to leverage the under-exploited opportunity in post-patent expiry markets. --Manage polypharmacy where the concurrent use of multiple medicines, particularly among the elderly, risks costly complications and adverse events. --Improvements in patient adherence make up more than half – $269 billion – of the $500 billion annual opportunity in avoidable healthcare costs. The study also focuses on two key factors critical to driving improvement across the six levers: multi-stakeholder engagement, and the power of information. Prescribers, dispensers, the pharmaceutical industry and patients can all play a role in aligning the health system to drive improvement. The study, "Advancing the Responsible Use of Medicines: Applying Levers for Change, " released in October 2012, can be downloaded from: http://www.responsibleuseofmedicines.org/press-release-october-23-2012/

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