Coordination is paramount to achieving desired societal impact

Equitable access to medicines is one of six buildings blocks of health system strengthening. That means they must eventually be available and affordable to households.

On a recent panel of the Africa Health Business Symposium, I was sharing some of my insights, this time related to Sub-Saharan Africa, on why listed private companies engage with governments in Public Private Partnerships, how their engagement might be perceived and the issues both parties might face and how they could be prevented or overcome.

Why do companies engage? Often still because of bolstering their reputation or to improve their scores in certain indices. Others do because they understand access to affordable medicines is a material matter to them, as determined by a regular materiality assessment. What materiality really means is worth a separate discussion. Additional benefits might be employee attraction and retention and gradual knowledge generation about future market places.

Countries might engage in order to attract foreign direct investment along with technology transfer, in order to associate themselves with SDG 17 or simply because they anticipate fit with their universal health coverage (UHC) roadmap (cf. SDG 3.8).

For a UHC roadmap, three questions are paramount to find answers to:

(1) Which services (including medicines) to include first / next?

(2) Which people to include first / next? and

(3) How to shift from out-of-pocket payments to prepayment?

That in principle means, an access to medicine program can just aim at making a medicine available for a low price and that potentially nicely fits into such a roadmap. Sounds simple, but it isn’t.

In a private company questions could surface like: Shall the intervention be run as a business or be rather philanthropic? In which countries shall we move with such a program, which countries are politically stable enough? How do we make sure our approach doesn’t go contrary to other objectives we have? What are we willing to invest, for what, for how long and with whom do we want to partner?

Similarly, a public concern, that I have just recently heard again in a webinar, might be: How do we know that this program is not solely to superimpose a single medicine or therapeutic area priority onto our UHC agenda? Should we really be confident that our standard treatment guidelines will not be manipulated? How can we make sure we will not be associated with undue business practices?

Assuming those questions were positively answered and a signed MoU signals a Public Private Partnership along with an associated announcement, there soon is a need to show transactions are happening for both parties, displaying activity. Usually a sound situational analysis is not (yet) standard prior to discussing the MoU, i.e. local policy or roadmap implementation might not be transparent, even prevalence data not understood on sub-national levels, an overview of already available interventions by facility (level) or even household expenditure data stratified by wealth quintile not known to either side. Thus, where to go and how and with whom, in order to increase the odds for real societal success, is not known at all.

By that time, stakeholders start to ask questions on the progress and success …

Here are some insights I have gained in previous years:

1.     Subnational noncommunicable diseaase (NCD) prevalence can be more than 15% points different to what is common country knowledge

2.     NCD medicines are less frequently available in lower level facilities, but they generally are in households, in which people with a NCD diagnosis live

3.     Consistently people in the poorest wealth quintile pay the most for their medicines (in absolute terms)

4.     Local essential medicines lists are very often not coinciding with the WHO (global) essential medicines list and are updated irregularly and with delay. Standard treatment guidelines do not coincide with local essential medicine lists and with national procurement lists for medicines. Referral hospitals may even operate another (different) list for their hospital pharmacies

5.     NCD medicines are rarely expected to be available in lower level public facilities

“The drugs that we can’t get from our hospital … are [those for] asthma, high blood pressure, diabetes … and maybe the other ones for these “big” diseases. Like cancer. You can’t get [those medicines]. Maybe you find pain killers.”

(Patient from Makueni county, Kenya)

6.     “First in first out” rules are not adhered to in most instances

7.     Health insurance does not guarantee access to NCD medicines.

“[Y]ou are disappointed, you just see how you have wasted money and then there is no drug, you will be forced again to buy it which is a double cost.”

(Cardiovascular patient from Kakamega, Kenya)

8.     Patients regularly go to private outlets, though diagnosed in the public setting, to obtain their medicines. This poses an internal alignment challenge to companies, as often times access interventions run in parallel to business operations. Only in social business models, or special setups, this can be different, but it takes time and stamina to get there. – Besides, and even more importantly, patients, who need the medicines, might not be able to chose or compare, as medicine outlets are scarce in rural areas.

“I have to sell the chicken cheaply so that I can get medicines, rearing chicken you can only do that if you are not sick and are focused, if you have the chicken you will sell it so you can buy a goat but if I am sick I am not able to buy the goat but buy the medicines.”

(Patient from Embu, lowest wealth quintile, Kenya)

9.     Once patients are diagnosed for an NCD, routine monitoring of blood pressure, weight, glucose are not done, only when patients feel sick and have money

While it can take time to adapt the approach to include distribution to the private sector as well and to then calculate backwards to help ensure a maximum resale price will not be exceeded, it is also important to acknowledge that the most recent high-end innovation is not the optimal contribution in every case, but rather working towards regular availability of a quality assured and affordable, say, salbutamol inhaler. Affordable meaning less than 2 USD per inhaler to the lowest wealth quintile household for this medicine. 

Access initiatives or social business models therefore need to go far beyond deriving patient numbers from boxes shipped. Patient numbers need to be derived from the facility level as a minimum. How have those patients been reached, via a functioning health system? Have prescriptions been made according to standard treatment guidelines or according to what was on stock at the nearest pharmacy? Has the access program increased population coverage or just substituted existing medicines in households? Could out of pocket spend really been cut down? Has consumption data in the analysis been linked with income data? Answering those types of questions requires companies and their partners in collaboration with the government to leave their comfort zones and go the extra mile. But this extra mile will generate societal insights and helps steer interventions to become more favorable to all stakeholders involved. Ultimately, only with these questions in mind should societal intent be claimed.

Have prescriptions been made according to standard treatment guidelines or according to what was on stock at the nearest pharmacy?

Going forward situational analyses need to be made prior to interventions. Each stakeholder will also benefit from adapting from a “we know” to a “we learn”, from a “we own” to a “we share”, from a “we lead” to a “we help convene” mindset and sharing what’s in for them openly, as this accelerates mutual understanding during the process of co-creation. I find the “WHO Checklist” and the related paper https://joppp.biomedcentral.com/articles/10.1186/s40545-020-0204-z very helpful in identifying information needs to comply with transparency requests in this regard. Let me quote (from the above paper) three examples from that list for illustration:

 1.     The program does not divert resources away from other public health priorities.

So, here information on how the additional resources that might be required from government will not adversely affect other public health priorities is needed.

 2.     A clear transition plan for when the program ends has been developed.              

So, here a description of how the program will transition to the local community/government or made self-sustaining when the funding has ended meets this requirement. For example, having training participants pay a training fee to sustain the program.

 3.     The process for monitoring and evaluation has been established.            

So, here a description of the process for monitoring and evaluation of the program. This may include a description of the performance indicators and data collection and processing strategies.

Information around these requests will subsequently also enable more meaningful co-creation and coordination.

Source: Quotes in this article were taken from presentations of colleagues from Boston University School of Public Health in webinars and link back to the evaluation of the Novartis Access Program