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 highincome 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
Dimensions
Care for acute care
Care for chronic care
Interaction
Short
Long-term (including life-long)
Treatment goal
Return to normal life
Maintaining independent and acceptable quality of life
Patient role
Passive
Management 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
Provider
Single
Multiple, multi-disciplinary often includes referral
between different levels of care
Community
Limited role
Continuous support and active role
Medication
In 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
Chronic Care Model (CCM), Wagner et al, 2001
The Innovative Care for Chronic Conditions Framework, Epping
and Jordan, 2002
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
Innovation, financing and other policy initiatives
1.
2.
3.
4.
Governance and leadership
Innovation and development of cost-effective medicines
Financing of medicines
Private-public sector partnership and collaboration with other sectors
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
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.