Improving accessible and affordable pharmacotherapy for chronic conditions: a framework applied to low and middle income countries Presented by: Veronika Wirtz Co-authors: Warren Kaplan, Yared Santa Ana-Tellez, Ruy Lopez-Ridaura Work funded by Alliance for Health Policy and Systems Research, WHO Geneva

Overview of the presentation Rationale for talking about chronic conditions and a framework for care Aim of the project Barriers to access to routine care and pharmacotherapy for chronic conditions Previous models of care for chronic Proposal of a framework for chronic conditions with particular focus on pharmacotherapy Policy implications

UN high level meeting positioned NCDs as a health & development priority Emphasis on preventative strategies for all countries. Placed new focus on the importance for research and international cooperation. Highlighted need for a comprehensive global monitoring framework. Recommended only voluntary goal targets for each country

The NDC gap: People in LMIC develop NCDs at younger ages, suffer more – often with preventable complications – and die sooner than those in high- income countries 29% of deaths from NCD in LMC occur in people < 60 years versus 13% in high income countries

Health systems in many countries are not designed to deliver long-term and complex care for a large population DimensionsCare for acute careCare for chronic care InteractionShortLong-term (including life-long) Treatment goalReturn to normal lifeMaintaining independent and acceptable quality of life Patient rolePassiveManagement not entirely by the patients themselves but crucial for successful therapy Health provider (HCP) role Diagnosis and instructions how to treat On-going monitoring of treatment management and outcomes, retention of patients over time Communication between HCP and patient Often one-way (instructions)Requirement for two-way and continuous communication ProviderSingleMultiple, multi-disciplinary often includes referral between different levels of care CommunityLimited roleContinuous support and active role MedicationIn most cases less costly as expenses are not continuous High cost burden as continuous expenditure, administration of medication should facilitate adherence Information in table adapted from Holman and Lorig, BMJ, 2000

In contrast to many acute diseases, access to medicines without access to quality care may not make the difference in the management of chronic conditions Global efforts to improve access to medicines have focused mainly on HIV, tuberculosis and malaria –Illustrated by ICIUM abstract #300 by Men: “I Wish I Had AIDS: Qualitative Study on Access to Health Care Services for HIV/AIDS and Diabetic Patients in Cambodia” An important opportunity to learn from access scale up for HIV Preventative strategies alone with not be sufficient to control NCD in LMIC

Aim of the project To propose a framework to improve access to pharmacotherapy and routine care for patients with chronic conditions in LMIC Objectives To analyze access barriers to pharmacotherapy in LMIC taking diabetes, asthma and depression as an example To review models and interventions which have been designed to re-structure or deliver innovative care for chronic conditions in LMIC To propose a new framework for access to pharmacotheray and routine care for chronic conditions based on overcoming the barriers

The good, the bad and the “back story” about medicines and chronic conditions Good story: Cost-effective pharmacotherapeutic options exist for many chronic conditions in LMIC –e.g. pharmacotherapy for hypertension: 35-40% reduction in stroke and 50% heart attack (Neal et al, 2000) Bad story: –Availability of medicines is low Low, particularly in the public sector (Cameron et al, Lancet 2009) Lower for chronic than for acute conditions in the public as well as the in the private sector (14.3 and 5.6% difference of the mean) (Cameron et al, Bulletin WHO 2011) –Affordability of medicines is low: Particularly low for medicines such as insulin (Beran et al, Diabetes Care 2005; HAI, 2010) “Back story”: Affordability and availability are only two of many other barriers to pharmacotherapy and routine care for chronic conditions

Each country is likely to encounter different combinations of barriers, with different types and varying extents of problems Large gap between optimal and received quality of care Lack of patient adherence to pharmacotherapy (non specific for either acute or chronic conditions but highly relevant for chronic conditions) Lack of community support (particularly important for LMIC due to lack of institutional support) Lack of leadership, organization and continuity (particularly relevant for LMIC) An integrated approach is necessary to overcome barriers.

Most care models lack details on pharmacotherapy The Innovative Care for Chronic Conditions Framework, Epping and Jordan, 2002 Chronic Care Model (CCM), Wagner et al, 2001 Limitations of traditional chronic care models when applied to LMIC: Developed for high income countries primarily Lack on specific description of how to optimize pharmacotherapy, including monitoring Role of the community in relation to pharmacotherapy not well developed: little published evidence in comparison to other CCM elements

Proposed framework for improving pharmacotherapy and routine care for chronic conditions: key elements Community 1.Behavioral and educational programs 2.Peer to peer support/ care partner 3.Social mobilization Patient 1.Encourage/incentivize health seeking behavior 2.Receive adequate and acceptable care 3.Motivate/support a primarily self-managed environment Innovation, financing and other policy initiatives 1.Governance and leadership 2.Innovation and development of cost-effective medicines 3.Financing of medicines 4.Private-public sector partnership and collaboration with other sectors Health care organizations 1.Medical and related products (including diagnostics, monitoring and administration devices) 2.Service delivery fostering affordable, high quality pharmacothearpy and adherence 3.Information and communication technology 4.Primary mental health care 5.Training, incentives and performance evaluation of human resources

Framework emphasizes a patient and community centered approach for LMIC Routine monitoring of adherence –e.g. ICIUM abstract 505 by Obua et al: “Improving Adherence to Antiretroviral Treatment in Uganda: Facility-Based Minimal-Input Intervention” Incentives for patients to monitor and optimize pharmacotherapy Role of the community, particularly in context of very weak government support –Peer support: creating evidence on their effectiveness and efficiency will be important (e.g. ICIUM abstract #333 by Vanpelts “Managing a continuum-of-care with Revolving Drug Fund for People with Diabetes (DM) and Hypertension (HBP) through a Peer Educator Network in rural Cambodia) –Social Mobilization: Important element for structural change (e.g. UN High level meeting in Moscow: “Global attention was only focused on these issues as a result of sustained and coordinated action by civil society, both within countries and internationally”)

Monitoring and evaluation of improving pharmacotherapy and routine care for chronic conditions is critical WHAT IS NEEDED IS: –Development of common indicators to monitor progress in access to medicines for chronic conditions. including indicators related to quality of care in particular pharmacotherapy –Linkage of access to medicines with access to services – medicines/service evaluation should integrated (Beran et al, 2008) –Awarding high quality of care and creating incentives for good practice Strengthening organizations and institutions (Holloway et al, World Medicines Report 2011)

Conclusions Proposed Framework is first step to identify key elements which should be in place to promote pharmacotherapy for chronic conditions Integrated strategies are needed –access to pharmacotherapy needs to be successfully linked to access to quality care and services Identification of priority interventions to improve the integration of pharmacotherapy and routine care for chronic conditions in LMIC is necessary –ICIUM can make an important contribution

Acknowledgements We would like to thank the following people for their comments on an earlier draft of the project report: Maryam Bigdeli Sauwakon Ratanawijitrasin Anita Wagner Win van Damme David Beran Annemiek van Bolhuis Conflict of interests We declare no conflict of interests.