Making health markets work - Virology...
Transcript of Making health markets work - Virology...
Making health markets workKickstarting sustainable HCV treatment models in Africa
3rd International Viral Hepatitis Elimination meeting
December 3rd, 2016 - Amsterdam
Agenda
1. PharmAccess background
2. The daunting complexity of health
3. Facts on Health in developing countries
4. HCV in developing countries - challenges and
opportunities
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PharmAccess Group History: Starting private, growing public (I)
THE START 1995-2000
• HIV-AIDS research: Joep Lange publishing mother - child transmissions studies in Africa and developing and testing a new combination therapy to treat HIV-infected patients
• With the mother – child transmissions studies Lange changed the perspective that HIV/AIDS is not only a disease related to sexual life style in the West but also linked to poverty in Africa
• Treatment was only introduced in developed countries, not in Africa.
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“WHY IS IT THAT WE ARE ALWAYS
TALKING ABOUT THE PROBLEM OF
DRUG DISTRIBUTION, WHEN THERE
IS VIRTUALLY NO PLACE IN AFRICA
WHERE ONE CANNOT GET A COLD
BEER OR A COCA-COLA.”
JOEP LANGE
2001 PharmAccessAccess to HIV treatment in the absence of funding
PharmAccess: in absence of public funding work through private
sector (“going private to grow public”)
Sufficient financial means, infrastructure and human capacity at the
Heineken breweries
Well-defined group of beneficiaries (workers + families: 35,000 people)
PharmAccess represents a trusted HIV-specialist for a multinational
company
Guaranteed confidentiality and privacy through separate databases and
management structures
PharmAccess is liaison with pharmaceutical companies to procure and
distribute ARVs
Coordinated international database provides real-time patient data
demonstrating clinical success
Data analyses lead to good publications in peer-reviewed journals,
contributing to reputation and motivating other workplace initiatives3
PharmAccess Group History: Starting private, growing public (II)
KICKSTARTING FIRST HIV TREATMENTS IN AFRICA
• By convincing private companies to act (Heineken, Unilever, CelTel) and make treatment available for their labourers and families, he proved that starting private can positively influence public services
• Public initiatives like PEPFAR and Global Fund started subsequently to support the public health sector with grants, crowding out private sector delivery and private investments. Every solution comes with a price
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“WHY IS IT THAT WE ARE ALWAYS
TALKING ABOUT THE PROBLEM OF
DRUG DISTRIBUTION, WHEN THERE
IS VIRTUALLY NO PLACE IN AFRICA
WHERE ONE CANNOT GET A COLD
BEER OR A COCA-COLA.”
JOEP LANGE
Agenda
1. PharmAccess background
2. The daunting complexity of health
3. Facts on Health in developing countries
4. HCV in developing countries - challenges and
opportunites
5
The daunting complexity of health
Increase health spending=
Stimulate economic development& crowding in
Decrease out-of-pocket costs=
Stimulate risk pooling
Pro
ble
mSo
luti
on
First law of health economics Second law of health economics
Poor countries spend little on healthcareWhen GDP per capita is known, health expenditures per capita can be predicted with more than 95 percent accuracy
Poor countries have a high share of out-of-pocket costsWhen you are poor, you are on your own
In general, economic development is the only way to increase healthcare spending
Otherwise, create situation where private investment increases as well as government spending
Reduce individual risk for users by (subsidized) risk pooling through insurance schemes
Source: A new paradigm for increased access to healthcare in Africa, 2007 – Onno Schellekens et al – FT/IFC Award; WHO NHA data 2009/2010
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Agenda
1. PharmAccess background
2. The daunting complexity of health
3. Facts on Health in developing countries
4. HCV in developing countries - challenges and
opportunites
7
High burden of disease, lack of investments
> 15%of the world’s
population
25%of the total global
burden of diseases
(47% of communicable diseases)
< 2%of global total health
expenditure
660
2.083
Africa Rest of the world
98.118
6.354.308
Africa Rest of the world
1.136
6.102
Africa Rest of the world
Burden diseases
(Million DALYS)
Total health expenditure
(Million USD)
Population
(Millions)
WHO Global Health Estimates 2014 WHO Global Health Expenditure Database 2010World Population Data Sheet 2014
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Health funding in developing countries
In most countries most funding of health is private
48 4951 51
48
52 5149 49
52
0
10
20
30
40
50
poorest poorer middle richer richest
Source of health care by wealth quintiles in sub-Saharan Africa
public
private
50% in lowest income quintile receive healthcare from private or non-state providers
0%
25%
50%
75%
100%
Uga
nd
a
Nig
eria
Ken
ya
Zim
bab
we
Tan
zan
ia
Mo
zam
biq
ue
Gh
ana
Rw
and
a
Nam
ibia
Zam
bia
Mal
awi
publicsector
private sector
Source: National Health Accounts 2012 (Zimbabwe 2001), PharmAccess analysis
Analysis of DHS surveys, latest available year included, Montagu, 2010
Source: World Bank/IFC (2011), Healthy Partnerships, How governments can engage the private sector to improve health in Africa
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Lack of investment in the health sector
In one decade World Bank Group only invested $ 12M in Sub-Saharan Africa out of $ 12.8B
WBG spending on health.
266
10998 95
12
Asia Lat Am Eur Middle E SSAfrica
Improving effectiveness and outcomes for the poor in health, nutrition & population, World Bank 2009
Size of IFC’s investments in health by region (loans and equity 1997-2007)(million USD)
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Low share of insurance coverage
WHO Global Health Expenditure Database 2013
Only 5.5% of total health expenditure in Africa is financed through health insurance
Percent of total health expenditure
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Sou
th A
fric
a
Bo
tsw
ana
Nam
ibia
Cab
o V
erd
e R
ep.
Gab
on
Gh
ana
Sen
egal
Ken
ya
Mo
zam
biq
ue
Rw
and
a
Mau
rita
nia
Djib
ou
ti
Togo
Cô
te d
'Ivo
ire
Ben
in
Swaz
ilan
d
Mad
agas
car
Lib
eria
Sou
th S
ud
an
Gam
bia
Sud
an
Tan
zan
ia
Gu
inea
Mal
awi
Nig
eria
Zam
bia
Dem
. Rep
. of
the…
Bu
rkin
a Fa
so
Nig
er
Cen
tr. A
fric
an R
ep.
Cam
ero
on
Co
ngo
Bu
run
di
Eth
iop
ia
Social security funds as % of THE
Private insurance as % of THE
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Our analysis: the vicious cycle of health
African health systems are stuck in a vicious circle of low demand, poor supply, and limited investments, because trust in the system is low and risks are (seen as) high.
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• Health is a (semi) public good, requiring large government
intervention
• Developping countries are in different stages of development
• State capabilities are often limited. They have a lack of
enforcement, a weak tax collection system and large informal
sector
• In such environments, the private sector is by default the main
actor, also for the poor, but often neglected in development
policies
• Institutional failures result in high transaction costs
• Low solidarity is a result: the rich are not paying for the poor
Without sufficient supply there is limited demand
Without pre-payment there is no willingness to invest
Without investments there is no health infrastructure
development
The challenges
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How to turn a vicious cycle of health in Africa into a virtuous one?
Demand SupplyHigherTrust
Patients
HigherQuality
standards
Access to treatment
Research andAdvocacy
mHealth
Health insuranceand savings
Loans
mHealth
Government and Institutions
Fin
anci
ng
Del
iver
y
Higher
Higher
Equity
Vision: Digitalization will transform global
health, poverty and development
Mission: Making Inclusive Health Markets Work
Addressing market failures in health
• Redistribution of income through trust, identification and enforcement
• Address asymmetry of information and transparency of claims and data
• Real time connecting demand and supply with zero marginal cost
leading to reduced risk, increased investments and financial inclusion
And today it is possible to include everybody at zero marginal cost
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Towards a virtuous cycle in a digital space connecting demand and supply real time
Demand SupplyHigherTrust
Patients
HigherQuality
standards
Access to treatment
Research andAdvocacy
mHealth
Health insuranceand savings
Loans
mHealth
Government and Institutions
Fin
anci
ng
Del
iver
y
Higher
Higher
Equity
Agenda
1. PharmAccess background
2. The daunting complexity of health
3. Facts on Health in developing countries
4. Kickstarting HCV Treatment
Facts, challenges & step by step approach towards
sustainability
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Epidemiology
• 60-80 million Hepatitis C patients worldwide (est.)
Estimates are still very unreliable
• Leading cause of liver diseases
• Mortality burden: 350,000 people die yearly of liver
cirrhosis or liver cancer due to Hepatitis C
• Highest prevalence top 3: Egypt, Cameroon, Burundi (est.)
Facts on hepatitis C*similarities and differences with HIV-AIDS
Transmission mostly through blood / contaminated
(hospital) equipment
• Inadequate sterilized medical equipment
• Unsafe injection practices
• Transfusion of blood and blood products
Pattern
• Infection mostly asymptomatic until decades
• 10 -30% cures spontaneous
http://www.nature.com/nm/journal/v19/n7/full/nm.3184.html
SOURCES: DR. M van der Valk (Internal medicine and infectious disease specialist AMC), WHOPanAfr Med J. 2013; 14:44, Lavanchy, Clinical Microbiology and Infection 2011 17, 107-115
Prevalence
• High prevalence linked to historical events/circumstances
Mass treatment programs (e.g. Egypt, Cameroon)
Intravenous drug use (e.g. USA)
• Prevalence is dynamic with age group re time of infection
Dynamic course of HCV infection in the US
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Opportunities
• New DAA drugs have become available with
exceptionally high cure rates (>95%)
• In 2000 HIV Aids treatment >10,000 USD/Yr
Now differential pricing mechanism of DAAs has
been established for >100 LMIC’s
HCV LIMC treatment prices are 900-1,200 USD
• Generic versions of DAAs for LIMCs are rapidly
being developed – increased affordability of
treatment
• New pan-genotyping HCV drugs are being
developed, precluding expensive diagnostics
HCV cure: opportunities & challenges in developing countries
Challenges
• Slow registration of DAAs in LMICs, e.g. Africa
• Slow SRA quality approvals/WHO pre-qualification of
generic DAAs
• Limited access to diagnostics; need for genotyping,
leading to high costs – differential pricing for diagnostics
is still not available
• No funding mechanisms in place
• HCV prevalence data scarce, e.g Cameroon• Prevalence of 13.8 % but confidence interval between 0 and
40% (Pan Afr Med J. 2013; 14: 44)
• Experts say figures may be lower than initially thought; 1%
among young adults rising to 10% among 55-59 years (National
Demographic Survey)
• Where to find the patients?• Long asymptomatic period of patients
• Risk groups are mostly historic (patients infected 15-25 years
ago – age specific cohorts are dominant)
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HCV treatment challenges in a glance
Demand- No financing
mechanisms in place
- Historic dependence on
multi-lateral grants
Supply+ New DAA drugs at
affordable prices- Diagnostics: low access / high cost
LowRisk
Patients
low QualityStandards
Low or absent
No tested, standardized protocols for LIMC’sFinding patients is a challenge
Research andAdvocacy
- Prevalence data is unreliable
- LIMC treatment results still scarce
Mainly OOP or state driven
Limited Loans
Government and Institutions- Slow registration and SRA / Pre Q procedures
Fin
anci
ng
Del
iver
y
Low
Low
No Equity
1. Create common standards and data platform
A. Hep-C protocol development for resource poor settings
B. Design and implement a digital platform for doctors, patients and payers
2. Catalyze treatment: Create public-private partnerships
A. Treatment partnership: Contract leading clinics, labs and researchers
B. Access Partnership: Make available and procure drugs & diagnostics
3. Implement in an evidence based program
A. Find and target patients: start with F3/F4 – discuss policy on F0-F2
B. Costing of the treatment: agree on treatment costs, co-payment and
reimbursement
4. Financing
A. State of health financing: current policy, political will to engage, what is
the economic effect to cure HCV?
B. Select start up financing and provider payment model:
public good approach, performance based or insurance?
HCV treatment – step by step towards a solution
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Activities started since Addis meeting in June
• Global network of specialists mobilized, e.g.
• Leading hepatologists from Nigeria, Kenya,
Ethiopia, Senegal, Cameroon, Uganda
• Duke University, AMC, AIGHD, CHAI
• Chair: Roel Coutinho supported by
Andrew Muir, Susanna Naggie, Tobias
Rinke de Wit, Marc van der Valk, Janke
Schinkel
• First site to test protocol in Cameroon with
Prof Njoya, Faculty of Medicine and
Biomedical Sciences
1. Create common standards and data platformCoordinated clinical protocol for Hep C in LMIC
Clinical Protocol (draft)
Pre-treatment screen
Pre-treatment information
Pre-treatment assessment
Assessment after 4 weeks therapy
Therapy
• Adherence support
• Physical exam• Complete Blood Count• Hepatic functional panel• Creatinine/Calculated
glomerular filtration rate (GFR)• HCV RNA nucleic acid test (NAT)• HCV Genotype• Test for hepatitis B & HIV• Pregnancy test
• Hepatitis C antibody
• Patient information collection
• HCV RNA nucleic acid test (NAT)
• Adherence support
• END OF TREATMENT
Assessment after 8 weeks therapy
Assessment after 12 weeks therapy
Assessment 12 weeks post treatment
• HCV RNA nucleic acid test (NAT)• Counselling
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1. Create common standards and data platformReal-time mobile platform for patients, providers, and payers
Some characteristics of the treatment, research &
payment platform
• Evidence-based mobile platform for low-resource
settings
• Gain transparency into on the ground activities
with health worker monitoring reports and linked
supervisory apps
• Register and track individual patients and access
patient data online or via external database
• Enable real-time payments ― performance- /
outcome-based
• Reach patients with targeted SMS tools that
supports case management
• Gain visibility into on-the-ground activities with
real-time data & analytics
• Online & offline, Android & Nokia Series 40,
Integrates with web & SMS
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Prof Oudou NjoyaFaculty of Medicine and Biomedical Sciences
Professor of Gastroenterology
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2. Catalyze treatment: Create public-private partnershipsA first example - Cameroon
MINISTÈRE DE LA SANTÉ PUBLIQUE
Prof Roel CoutinhoProfessor of Epidemiology
Chair Medical Board PharmAccess
Local partners
Operational
partners
Implementing
organisations & funders1st 1000 treatments at a discount
Investor
Impact Bond
Patients
>500 patients ready for immediate treatment
Drugs
Harvoni , generic sofosbuvir (Mylan),
ribavirin
Doctor
6 clinics/doctors willing to join forces
Financing
PharmAccess and JLIOutcome payer (TBC)
Diagnostics
Institute Pasteur ready for all lab work
Protocol
submitted by Prof Njoyabased on PharmAccess
standard
Regulatory
Government signed MOU, committed to national approach
Quality
WHO pre-qualification generic sofosbuvir
expected by Q4
Essential elements in place to start by December 2016
3. Implement in an evidence based programExample of Cameroon
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4. FinancingState of HCV health financing: current policy, political will to engage, what is the economic effect to cure HCV?
Characteristics of treatment cost and financing of
elimination strategies
Some financing options
• Public good financing models focus on
centralized purchasing and reducing
transaction cost
• Insurance models cater for pre-payment and
risk sharing in the population reducing risks
and enabling investments
• Performance based options can catalyze
treatment by taking out the execution risk as
payers only pay for outcome
• Impact bonds pre-fund treatment costs and
are repaid based on outcomes / cures
• Suppliers for drugs and diagnostics in future
to be reimbursed on outcomes?
Financing risk of execution and treatment cost is at the
payer / patient – benefits follow later
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4. Kick-starting a sustainable approachExample: the HCV impact bond
Administrator
Implementing
OrganizationOutcome Payer
Service
provider
Service
provider
Service
provider
Target population
Investor
Evaluator
Funds Conditional
payment
Data Service
Attractive intervention:
• Straight forward intervention (treatment
protocol) with potential for scale
• Causal relationship between intervention
and outcome
Attractive outcome:
• Simple outcome metric: SVR sustained
virological response
• Causal relationship between outcome and
future government savings
Attractive Investment
• Short intervention cycle (12+12 weeks)
• High cure rates (>95%)
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AdministratorAdministrator
4. Kick-starting a sustainable approachStepwise approach: test and scale in Cameroon
PAI + local
partner
IO
DEF
Outcome Payer
Service
provider
Service
provider
Service
provider
150 HCV patients
Target population
JLI
Investor
PAI
Donor
Phase 1: Test (pending final approvals) Set up operational, administrative and
contractual structure for first HCV impact bond Proof and fine-tune concept and structure Collect input/data to structure for roll out Advocate to attract players for roll out
Phase 2: roll out Government (potentially in combination with donors)
join as outcome payers Outcome investors provide short/medium term capital
for roll out International Fin. Institutions provide long term
capital to secure outcome payments
Dr. Njoya
CPC
Evaluator
Funds Conditional
payment
Data Service
IOMoH, Donors
Outcome Payer
Service
provider
Service
provider
Service
provider
[#] HCV patients
Target population
Outcome
Investors e.g.
Dr. Njoya
CPC
Evaluator
International Fin Institutions
Hep C Fund, DFIs?
4. Kick-starting a sustainable approachPhase out grants, reduce prevalence
Minus 91.4%
0,00%
0,10%
0,20%
0,30%
0,40%
0,50%
0,60%
0,70%
0,80%
0,90%
-
2.000.000
4.000.000
6.000.000
8.000.000
10.000.000
12.000.000
0 1 2 3 4 5 6 7 8 9 10
Bond model
Grants
Investment
Outcome payment
Prevalence Rate without Intervention
Prevalence Rate with Intervention
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