Reflections on access to antimicrobials in a time of increasing global attention to antimicrobial resistance
David L. Heymann, M.D.
London, UK. David is a Professor of Infectious Disease Epidemiology at the London School of Hygiene and Tropical Medicine. He is also Head and Senior Fellow at the Centre on Global Health Security at Chatham House in London.
In the 1980s when I was on assignment from the US Centers for Disease Control and Prevention (CDC) in Malawi, I worked for five years with the ministry of health to better understand how to develop a more effective malaria control programme in view of the challenge caused by chloroquine resistance. One of the lessons I learned at that time is that there is a fine line to walk between rapid access to life-saving antimicrobials, and the need to use them responsibly by confirming diagnosis before treatment. Children with high fevers caused by plasmodium falciparum die if treatment is delayed while awaiting a diagnostic test result from a distant laboratory.
This lesson remains valid today as antimicrobial resistance continues to erode the effectiveness of medicines to cure malaria, and also the effectiveness of the medicines used to cure other parasitic, bacterial, and viral infections. Easy access to life-saving antimicrobials must be a part of the agenda to control antimicrobial resistance, and it cannot be compromised or delayed.
Recently I spoke with a developing country colleague who told me that he is aware that some governments are considering legislation to require laboratory diagnosis prior to treatment of any suspect infection, a national interpretation of the WHO Action Plan on Antimicrobial Resistance. Any clinician faced with infectious diseases day in and day out knows the harm that would come if such legislation were developed and enforced in a country where access to diagnostics is limited because of lack of laboratory infrastructure and/or cost or of point of care diagnostics that are already on the market.
The need for rapid, inexpensive and stable point-of-care diagnostics to guide treatment and slow the evolution of antimicrobial resistance has never been greater. Medicines For Africa must advocate for their development, and ensure that as they become available countries have access to them as well.
Geneva, Switzerland. Lenias is passionate about improving access to quality affordable treatments.
An estimated 18 million people die each year from treatable and preventable disease mainly because they lack access to medicines. Huge efforts to reduce rates of infection and death from infectious diseases such as HIV and malaria have brought significant gains and improvements though more still needs to be done. However, African countries face additional challenges that urgently require effective solutions that are sustainable. Chronic diseases such as cancer, diabetes and cardiovascular diseases are expected to become the leading cause of disability by 2030 and will contribute significantly to lost productivity and higher healthcare costs for Africans.
Better availability of quality affordable treatments for these problems will be part of the solutions needed to prevent and treat these illnesses. Whilst many countries around the world are confronting the challenge of the rising cost of medicines, in the African context, the problem is exacerbated by weak infrastructure, which prevents the good results that are possible. Countries are not using their purchasing power and the African medicines market is dominated by suppliers who dictate the terms and influence the greater use of more expensive treatments that are not cost-effective. This is part of the reason why African countries are paying some of the highest prices for medicines outside of the areas supported by donors. Medicines for Africa is working to correct the anomaly that within areas not supported by donors, most medicines used within African countries are bought by governments themselves, quite inefficiently and at very high cost.
We believe that the challenges contributing to the excessive cost of medicines in African countries are not insurmountable and can be solved if we commit ourselves to doing so. To address them, African countries require resources that are far beyond what is available to them. Making making better use of the resources that are available to countries will go a long way towards bringing the change that is possible. Medicines for Africa's vision is to work with countries to achieve this by making sure that available resources are used more efficiently and countries avoid paying excessively in some areas to the detriment of others. We believe that African countries could make system wide improvements that strengthens their ability to provide treatments for the health needs of entire national populations.
It is a huge challenge that no single country has the capacity to tackle alone. However, countries can work together to achieve it. They can make significant improvements over time with very modest investments. Ensuring the health of African populations health is one of the most pressing challenges facing African nations. Failure to make the necessary changes and investments will undermine the productivity of individual citizens which in turn will retard the economic growth of countries throughout the region. All of us Africans should be concerned about how we are going to meet the growing health needs of our people in a way that is sustainable. Medicines for Africa has a sustainable solution that improves infrastructure for delivering treatments needs of entire national populations.
A cardinal point for Medicines for Africa that we keep in mind at all times, the north star that keeps us on course in our search for adequate solutions is that breakthrough will not likely result from individual effort. Navigating the healthcare landscape towards improving the strength of health systems to make them more resilient and responsive to the needs of entire populations is a complex task. It will require a collective effort, and all the best minds available. Medicines for Africa has benefited enormously from the collective effort of many professionals and experts from across the globe who have contributed their knowhow and experience in various ways in support of the vision of Medicines for Africa. This has propelled us to come so far, with so little. The biggest lesson from all of this is that people are our best resource.
This has remained true even as differences on the best path towards our destination have risen. Constructive debate serves a very important purpose in any organisation. It can lead to stronger, more confident teams with a better focus on the implementation of the organisation's vision. This unwavering focus on our vision has been our basic guiding principle. It keeps us on course as we continue to explore and iterate to find the the best approach. We owe it to ourselves and to the future of our children to stay the course and give our very best in searching for credible sustainable answers to the biggest problems facing our nations during our time. Our people's health is our nations' wealth.
Session on Leveraging donor procurement and commodity donations for market development. L- R. Lenias Hwenda- Chairperson, Mariatou (Tala) Jallow Head of sourcing and procurement of health products - The Global Fund, Edwin de Voodg- Managing Director IDA; Jantine Jacobi - UNAIDS Representative and Country Director for Kenya; Atieno Ojoo - UNICEF Supply Division President of Leadership Development Programme; René Berger USAID Kenya.
Nairobi, Kenya (2016) Lenias is passionate about improving access to quality affordable treatments.
Reflecting back on some of our discussions in Nairobi at the Africa Pharmaceutical Summit in 2016, Dr Muraguri, the Kenyan Principal Secretary of Health in the Ministry of Health highlighted medicines as the biggest driver of healthcare costs in Kenya. Unless Kenya addressed the spiraling cost of accessing medicines by its population, achieving affordable healthcare would be impossible. I have heard different versions of this statement from many African Ministry of Health officials.
We had all gathered to swap ideas on how to mitigate against the high prices of medicines and the poor sustainability of many solutions today. The CEO of Kemsa, Dr John Munyu, outlined a host of challenges facing medicines procurement across the continent, not just in Kenya. They included lack of data, lack of professional experts and weak infrastructure.
The old approaches were not producing the good results that we all sought. The ultimate solution eluded us, but we agreed on one thing. Our current paradigm needed to change. The problem, everyone agreed, was too large for any individual organization to solve alone. We discussed the merits of many solutions. From health systems leap-frogging development to avoid the lengthy path to salvation, to local production and effective market development.
Accra, Ghana Lenias is passionate about improving access to quality affordable treatments.
Lack of access to medicines is not just an African problem. It is a problem that affects health systems all over the world. All around the world, countries have only so much money. They are increasingly forced to decide what to spend it on. In this respect, African countries face the same budgetary problems as the rest of the world. What is different is that we have a higher burden of disease. Our infrastructure is inadequately prepared to meet current health care needs let alone serve the needs of our burgeoning youthful population. We need to find a viable path towards sustainable health development in countries.
In this respect, the challenges that we face in African countries are greater. That is why we need to invest in developing national infrastructure needed to serve the growing health care needs of a young population with their entire lives ahead of them. Only then can we be prepared to face the challenges facing our countries in the coming decades from changing disease patterns from the dominance of infectious diseases to the dominance of NCDs.
The resilient infrastructure that we need to strengthen African health systems in any meaningful and sustainable way will take time to develop. It is an enormous task, overwhelming to contemplate. We should take comfort in the knowledge that others have walked this path before, with success, but that success is not a given. We must roll our sleeves and get to work. Just because our problems are hard, does not mean we should not attempt to solve them.
Toronto, Canada Peter Evans is the former Chief of Procurement at WHO and UNFPA and Chief of Medical Procurement at UNICEF
Why Medicines for Africa and why now?
Because Medicines for Africa represents a sustainable approach in the long term, building on what is in place, leading to the best comprehensive health care that the countries can afford, with the least dependence on donors.
“Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.” Currently, the “teaching” is often limited to learning how to advance each Agency’s objective and the provided “fish” are dumped in ways that cause long term collateral harm.
Donors more and more insist on almost immediate confirmation of success and choose target disease reduction, as a validation of success. The effectiveness, of investments in health systems, is difficult to measure and therefore difficult to fund. Over the past few decades, the transfer away from financial and technical support for health infrastructure, towards targeted support limited to specific diseases, has been significant. Indicators of success usually concentrate on dollars spent in a given time period, how many health units provided, then how many health units used and finally how much health was achieved. However, as far as I have seen, no one measures how much other health care was displaced.
The health gains from attention to the targeted diseases are significant and to be applauded but while all major international health programmes pay lip service to providing support to the basic health infrastructure of each country, the reality is that support is mostly given to the elements that require the vertical programme (disease-specific) to achieve success and not to the horizontal support (population-specific) required for all other health improvements.
Geneva Switzerland. Lenias is passionate about improving access to quality affordable treatments.
The WEF in identified health inequality as a major issue that will shape global development in the coming years. According to the WHO Director General, Dr Margaret Chan, health inequalities are often aggravated by high prices of medicines. Prices for medicines would be substantially lower if procurement and distribution processes were more efficient with reasonable mark-ups and free of corruption. Limited financial resources and the growing trade in counterfeited medicines, a huge proportion of which are sold in African countries are major consequences of corruption world wide. Corruption constrains growth and development of countries. We need to address it in order to promote health as major driver of economic growth and sustainable development.
The enormous scale of the global medicines market makes it an attractive target of corruption. At an estimated $30 billion in 2016 with projections to grow to $65 billion by 2020, the African medicines market is not immune to this problem. Corruption remains a major obstacle to strengthening the supply chains of medicines in African countries. It reduces the availability of affordable quality medicines.
A social enterprise like Medicines for Africa with a mission to improve the availability of low cost, quality treatments for African people must reflect upon the complex problems of corruption, its multiple facets and create measure to counter it. This is important because corruption or the perception of corruption erodes trust which undermines supply chain efficiencies which raises the cost of medicines. Medicines being one of the largest components of health expenditure, it is important for African countries to ensure efficiency in their procurement processes in order to be able to achieve better value for money.
On the way to patients, the supply chain of medicines involves many steps with many participants that include agencies, ministries, service providers, manufacturers and patient representatives. Their respective roles and responsibilities, accountability and relationships are often not clearly defined. This complexity increases the supply chain’s vulnerability to corruption by providing numerous opportunities for it. Corruption in the medicines supply chain can take many forms.
These include the falsification of evidence, bribery or special influence on the selection of medicines and suppliers by countries, international agencies and development partners. Asymmetries in the availability of information’s to decision-makers along the supply chain, pharmaceutical companies, regulators, healthcare providers and patients add to the problem.
In Davos with Bill Gates and Matthew Bishop of The Economist discussing the launch of CEPI.
Davos Switzerland. Trevor is the President of Global Health at the Bill and Melinda Gates Foundation. He is passionate about science.
Greetings from Davos, Switzerland. I’m here this week to talk about what governments and the private sector can do to tackle the world’s biggest health challenges.
Yesterday, I attended the launch of the Coalition for Epidemic Preparedness Innovations (CEPI), a global initiative designed to accelerate the development of vaccines for emerging infectious diseases with the aim of preventing future pandemics. Here’s a fascinating interactive visualizationthat we produced to explain what CEPI is and why we need to take action now against a host of emerging infectious diseases.
But we also need to stay focused on existing epidemics. While the Ebola outbreak of 2014–15 and the Zika outbreak of 2016 have raised justifiable alarm, HIV, tuberculosis and malaria remain massive public health emergencies that claim millions of lives each year. One of the best ways to fight these diseases is to ensure that we make new tools designed to fight them available to the people who need them as quickly as possible. And so I also have been meeting in Davos with colleagues from sub-Saharan Africa to discuss how we can accelerate the discovery, development, and regulatory licensing of a range of life-saving interventions.
Innovation transforms lives. From the light bulb to penicillin to the personal computer, clever ideas turned into real products through painstaking research and development have radically changed the way we live. Innovative breakthroughs have also led to a major shift in how long we live. Vaccines, drugs and other medical technologies eradicated smallpox, turned diabetes and HIV from death sentences into a manageable conditions, and have made us healthier in countless other ways.
But good ideas and powerful products can’t change lives if people can’t access them. Many roadblocks keep lifesaving innovations out of reach for the people who need them most. Perhaps the most frequently debated are the cost of medicines and challenges in delivering them to remote communities. Less prominent is the preliminary milestone in making health products accessible: regulatory approval.
David Nabarro, MD
New York, USA. David Nabarro is the UN Secretary General's Special Advisor on Sustainable Development and Climate Change and he is running for Election as the next Director General of the World Health Organization.
Governments and health insurers find that increasing numbers of people need care for their NCDs and seek ways to cope with this rising demand. They wonder how best to reduce the numbers of their people with NCDs, and how to make reductions happen in practice. People, their societies, and their governments turn to different organizations for help. The World Health Organization sets the standards for what needs to be done and suggests how the standards can be achieved. There are big challenges with making this happen because the underlying causes of NCDs are woven into people’s lifestyles and are not easily reduced. It is not at all like removing the bacteria that cause an infectious disease. The consequences of this NCD epidemic are on the rise and affect individuals, their societies and economies of their nations. How can the principles and practice of public health best be used to reduce these consequences?
First – prevent people getting an NCD. Have them work out why they are at risk and then encourage them to remove the risk factor from their lives. Make sure the people most at risk are heard when risk reduction efforts are being planned. Bring them together with different organizations that have an interest in NCD Movements. Encourage joint action that is based on the best evidence of what’s wrong, and of what works. A shared purpose, agreed frameworks for action and partnering are needed for impact at scale. Second – make sure that people with NCDs are diagnosed early and get the best possible treatment so as to slow the progress of the disease (and, ideally, stop it).
Geneva Switzerland. Lenias is passionate about improving access to quality affordable treatments.
The first priority for public health is to protect populations from harm. In their duty to protect, governments use the law to promote and protect public health. There are also instances where the law is used in ways harmful to health. A new report launched by the WHO and its partners outlines how countries use the law for better or worse. Protecting health using the law requires the commitment of lawmakers who are often confronted with competing economic and social interests both at international level and domestically amongst citizens.
In line with their fiscal responsibility, governments often use the law to shape the environments in which their people live and influence the choices people make about their lives. When laws help people to live longer and healthier lives, they enable economies to become more resilient. People require access to quality prevention, treatment and care in order to maintain good health and lead economically productive lives.
This is why the role that the law plays in improving access to treatments is important. The law promotes and incentivises innovation of treatments needed to keep people healthy. In this case, it attempts to balance the rights of patients and those of innovators to ensure the common goal that treatment are available at affordable cost to those who need them. With affordability and access having become a mainstream concern, even in high-income countries, balancing the common and the competing interests of business is a constant source of tension between policy makers and businesses.
Delighted to have joined Lenias Hwenda of Medicines for Africa and Dan Rosen of IMS Health on a panel at the recent PharmaAfrica conference in London. We enjoyed a lively discussion on ‘Trust’ and how to encourage the Public and Private sectors to work together in delivering essential medicines to communities across Africa.
In the broader context, the PharmaAfrica event seeks to bring together private sector manufacturers and distributors with academics and government agencies to network and explore the challenges of the Pharma industry across the continent of Africa.
It was good to hear from African manufacturers and distributors, and to compare and contrast this with my knowledge of 'Big Pharma' from the European and US perspectives, and the Governmental, Public Sector and International Donor/Aid perspectives.
Health access requires the combination of quality, service and price to be right - quality products, available to the patient, at an affordable price. Local industry has an important role to play in this - one that I feel has been historically under-estimated and potentially neglected by international organisations.
In order to move the health agenda forward, African nations have to start to break-away from their dependence on others. Progressive graduation from aid is already occurring. As part of this, Africa needs to develop, grow and sustain a vibrant health industry - in manufacturing, in distribution, in retail pharmacies and in public and private health clinics where patients can access treatments. This work needs to be done in collaboration – working supportively towards joint objectives between the private sector, local industry, national governments and regulators, international donors and aid organisations.
To succeed, quality of medicines is a given, it must be there and the investment needed to achieve this has to be made. Price and affordability matters, and the gap with Indian generic producers and the mark-ups and inefficiencies in the local distribution chains have to be addressed. But this is not enough to succeed.
Local businesses have to differentiate - they must offer something valuable, that their larger international competitors cannot easily bring to the table - a connectivity to their local markets that is unique and can become a key differentiator. I refer to this as ‘Service Response - or Agility’ - the ability to rapidly tailor products and services to your local market, to be driven and respond to commercial opportunity and demand much faster than any of your competitors. There is an immense value here from being local - one that should be recognised and valued by all.
Support may be needed to create and foster a vibrant, profitable and therefore sustainable local industry. International organisations have an important role to play here, to encourage the development and support to a platform for local businesses and in strengthening the position and purpose of regional associations.
If I had one thought to come out of the recent conference for the leaders of these African industries – “it’s time to lift your voices, shout louder and be heard”.