Medicines as Emerging Technologies: Unprecedented Opportunities

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Medicines as Emerging Technologies Unprecedented
Opportunities Continuing Disparity

• Chitr Sitthi-amorn, MD PhD
• Institute of Health Research
• Chulalongkorn University

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International Technology Development
Unprecedented Opportunities

• Late 1890s aspirin was the only drug
  manufactured on a large scale.
• Since 1940s
• Vaccines full range of magic drugs
• Chronic diseases DM, HT, CRF, ESRD, gene
  therapy
• Lifestyle drugs Viagra
• People, even the poor, can expect to live longer
  than Kings and Emperor of the past

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Medicine Development Continuing Inequity

• RD of new medicines has favored the problems of
  the rich (Of the 220 new chemical compounds
  developed in the last 20 years, only 10 have
  been targeted for problems of tropical diseases
  WHO EBM)
• Dengue vaccine
• MDR strains complicate RD Effective drugs more
  expensive more inequity.

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Inequities of Disease Burden
Source Global Forum for Health Research (2000)
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Inequities Inverse Care Laws

• 1.Health care resources the rich consume more
  hospital and PH care than the poor, despite less
  need (Hart 1971)
• 2. PH and preventive care immunization coverage
  is strongly correlated with socioeconomic status
  (Gwatkin, 1999)
• 3. Financial risk the poor that access drugs and
  services risk medical impoverishment ( Liu and
  Hsiao, 1997).
• 4. Poor people still live without medicine.
  Poor health status parallels poverty.

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Inverse Care Law Multifactorial

• Private sector growth
• Growth of Doctors in private hospitals
• Growth of MOPH budget for investment
• Increase in Specialists
• Increase in Big Ticket equipments
• Increase in Imported Drugs Profits
• State responsibility gtgt Ability to pay

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Spending on Drug by PeopleOut of Pocket Payment
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Key Challenges

• Value of Health Systems and Health Research
  System
• Equity vs. ability to pay
• The focus
• The Strategies

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1. Value Equity Ability to Pay
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2. The Focus

• Settings or Areas where problems are
• Country, areas or settings, Inter-country
• Actors
• Government, NGOs, Academic, Intended
  Beneficiaries, Donors Development agencies
• INRUD (MOH, NGOs, etc) vs. DAP
• Issues Need based equitable access

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The Strategy Modified Equity Gauge
Pillars
Interventions
Empower Social Processes
Research and monitoring
Empower Political Process
Existing tools New tools and methodology Evidenc
e Based aimed at inequity Capacity

• Drug Development Import
• Country ED Registration De-registration
• Facilities
• Provider Consumers Behavior
• Illnesses Pattern

• Informing stakeholders
• Shaping Public Debate
• influencing decision-makers

• Raising awareness
• Engaging communities
• Training skill development for change agents

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First Pillar Some R M Examples

• The National International Level
• NDP formulation Implementation
• The EDL, Registration and Deregistration
• The Facility Levels
• Indicators for assessing RUD
• STG DUE
• Providers and Consumers Levels
• ADR, drug interactions, access to IT
• New Indicators Needed

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Guidelines A Strategy to Influence Technology at
Health System Practice Levels
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Research MonitoringExample from India..1

• List of ED published by EBM Committee
• Two envelop pooled procurement system by a
  standing Special Purchase Committee
• Quality assurance system for drug products.
• Training on Rational Use
• All Hospitals procure 90 of drugs from ED
  Physicians asked to prescribed ED
• STG developed and disseminated
• Parliament approval of Magic Remedy Act
• Regular updates to doctors on quality etc

Roy Chaudhury 2002
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Research MonitoringExample from India..2

• Fall in drug price from 20-60
• of available drugs actually dispensed to
  patients improved from less than 22 to more than
  70 in all hospitals.
• Availability of key drugs improved from less than
  50 before PP to more than 90 after PP.
• Generic prescription improved from less than
  40 in 1995 to more than 80 in 2000.

Roy Chaudhury 2002
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Second Pillar Intervention

• Existing tools
• PRDU, NDP, Mgt Supply, Store Mgt, PTC
• New tools and methodology
• Effectiveness of EB Interventions aimed at
  INEQUITY, including PPP franchising
• ARV use (DOTS?), Hospital RUD indicators
• Capacity
• Supply Demand side
• Institution Individual
• Development and Retention

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Cochrane Collaboration www.Cochrane.org

• To help people make well informed
  decisions by preparing, maintaining and promoting
  access to systematic reviews of studies on the
  effects of health and health care practices and
  policies.

Campbell Collaboration C2 www.Campbell.org
To help people make well informed decisions by
preparing, maintaining and promoting access to
systematic reviews of studies on the effects of
educational, legal and social interventions upon
health.
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Cochrane and Campbell collaboration proposed
Methods Group

• Cochrane Campbell To identify interventions
  that improve the health status of the poor and
  reduce health inequities
• Series of systematic reviews on effective
  interventions
• Role of WHO, MSH, INRUD countries in
  development and refinement of new tools
• New inter-country cooperation vs. parent-children
  relationship

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Capacity Supply Side

• Knowledge Individual Institution
• Generation, Access, Collation, translation,
  application, monitoring evaluation
• System leadership management
• Stewardship Management Leadership
• Partnership Negotiations teamwork IEC
• Resource mobilization allocation based on
  society values (funding based on local plan)
• Understanding upholding ethics EQUITY
• Renewal of HR New younger generation

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Capacity Demand Side

• Knowledge Users
• Policy makers Practitioners Public
  Communities
• Potential Research funder
• Development Agencies (ICIUM recommendation)
• Investors Pharmaceuticals Private Hospitals.
• Corporates, Media, Other Programs.

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Capacity Example Situation of Testing for Drug
Quality

• Most drugs are imported, multiple ports of entry
  inadequate inspection
• Unregistered drugs are available.
• Local pharmaceutical production is typically not
  GMP compliant
• Resources for marketplace surveillance are
  extremely limited.
• Drug problem reporting is limited
• Counterfeit products General concerns about
  drug quality.

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Capacity Example Access to Information

• While patients in developed countries can enjoy
  Consultation On-line
• A second opinion
• Many resources are available convenient on
  internet
• Privacy when seeking information on embarrassing
  issues
• People in developing countries are
  disadvantageous.

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Third Pillar Empower Political Process

• Secure evidences
• Informing stakeholders
• Shaping Public Debate
• Influencing decision-makers resource
  allocation use politics to support policies gtgt
  upscaling
• A full range of intervention

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Fourth Pillar Empower Society

• Raising awareness Public Advocacy
• Engaging communities societies
• Training and skill development for change agents
  or prime movers
• A full range of intervention

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Example Empower Politics Society
EB Guide, Comply, Stock, Refer Technical, Admin,
Financial
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Empower Politics Society The Range of
Intervention
Target High Risk Behavior
National Policies Tax Incentives Social Norms
Health Promotion Programs
Vaccine Medicine Combination Complication Adherenc
e
Target Society Behavior Values
Biological marker Individual Screening Rx
Public Health Community Infrastructure
DOWNSTREAM Prevention and Curative Focus
UPSTREAM Healthy Public Policy
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Conclusion

• The EQUITY approach to health recognizes that
  health is a capacity or resource for everyday
  living, not just a state,
• This broader notion of EQUITY recognizes the
  range of social, economic and physical
  environmental factors that contribute to health,
  will need values, focus 4 pillars.
• RUD is a link in the chain of health. A chain
  has never been proven stronger than its weakest
  link RUD incentive structures