Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary (2014)

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C Workshop Agenda Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: A Workshop January 13-14, 2014 Addis Ababa, Ethiopia Background: Sub-Saharan Africa (SSA) has one of the largest treatment gaps for men- tal, neurological, and substance use (MNS) disorders in the world. In 2011 the Grand Challenges in Global Mental Health initiative identified priorities that will make a significant impact on the lives of people living with MNS disorders. The reduction of cost and improvement of the sup- ply of effective medications was highlighted as one of the top five chal- lenges. Critical to the success of any effort to reduce the treatment gap is a demonstration that ignoring MNS disorders is not only devastating for overall population health but that it also undermines efforts to prevent and treat other causes of disease burden. Efforts in this area should not try to complete for resources used to combat infectious diseases, but should, instead, try to leverage those ongoing activities with initiatives targeted to MNS disorders. For low- and middle-income countries im- proving access to essential medicines can be a tremendous challenge and a critical barrier to scaling-up care for MNS disorders. Given the im- portance of access to essential medicines this workshop will bring to- 115 

116 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA gether key stakeholders to discuss opportunities for achieving long-term affordable access of medicines for MNS disorders. Meeting Objectives: Participants will be invited to: • Identify critical barriers that impact the procurement of essential medicines for MNS disorders. o Explore challenges and opportunities for improving access to essential medicines in four critical areas: demand, selection, supply chains, and financing and pricing • Examine successful activities that increase access to essential medicines both within SSA and in other developing countries. o Identify critical components of these models that might be features in SSA programs focused on MNS disorders. • Consider the role of governments, nongovernmental organiza- tions, and private groups in procurement of essential medicines for MNS disorders. o Examine current funding and payment practices at each lev- el. o Explore the impact of prescription practices on determining priority setting for acquiring essential medicines. • Identify the key components of a distribution framework that may serve as a demonstration project focused on increasing ac- cess for these essential medicines. DAY ONE 8:30 a.m. Welcome H. E. DR. KESETEBIRHAN ADMASU Minister of Health, Ethiopia 8:35 a.m. Opening Remarks STEVEN HYMAN, Chair Director, Stanley Center for Psychiatric Research The Broad Institute 

APPENDIX C 117 8:40 a.m. Access to essential medicines for MNS disorders with the greatest burden: Focus on depression, psychosis, and epilepsy ATALAY ALEM Professor of Psychiatry Addis Ababa University 9:00 a.m. Current look at the supply of essential medicines for MNS disorders versus other disease areas (e.g., HIV/AIDS, malaria, tuberculosis) PRASHANT YADAV Director, Healthcare Research William Davidson Institute, University of Michigan 9:20 a.m. Exploring successful access to medicine frameworks HANS HOGERZEIL Professor of Global Health Groningen University 9:40 a.m. Charge to participants: workshop objectives and deliverables TEDLA GIORGIS Advisor, Officer of the Minister Ministry of Health, Ethiopia SESSION I: CHALLENGES AND OPPORTUNITIES FOR IMPROVING ACCESS TO ESSENTIAL MEDICINES Session Objectives: Explore feasible opportunities for improving access to essential medicines in four challenge areas: de- mand, selection, supply chains, and financing/ pricing. Examine how progress in one of these are- as can impact the others. Consider current govern- ment, nongovernmental organizations, and private group decision-making strategies. 

118 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA 9:50 a.m. Overview and Session Objectives DAVID MICHELSON, Session Chair Vice President, Clinical Neuroscience and Ophthalmology Merck Research Laboratories 10:00 a.m. Challenge 1: Insufficient Demand How is patient demand adversely affected by: • The prevailing standard of care for MNS disorders? • Provider training, prescribing ability, and prescribing knowledge? • Ability of providers to monitor drug adherence and ef- ficacy? • Low awareness about availability of common medi- cines? • Concerns around cost of both medicines and health care system use? • Public stigma around MNS disorders? OYE GUREJE, Professor Department of Psychiatry University of Ibadan 10:25 a.m. Challenge 2: Appropriate Selection How is appropriate selection of medicines adversely affected by: • Low and/or variable availability? • Regulatory and procurement procedures? • Prescription practices and patient demand? • Prioritizations based on disease area, cost, generation? HANS HOGERZEIL, Professor of Global Health Groningen University 10:50 a.m. BREAK 

APPENDIX C 119 11:05 a.m. Challenge 3: Ineffective Supply Chains How are supply chains for medicines adversely affected by: • Absence of or delays in registration of drugs? • Absence of monitoring of drug supplies? • Transportation deficiencies? PRASHANT YADAV Director, Healthcare Research William Davidson Institute University of Michigan 11:30 a.m. Challenge 4: High Pricing/Poor Financing How are pricing and financing of medicines adversely affected by: • Tariffs and taxes placed on supply prices? • High mark ups by suppliers and wholesalers? • Inadequate financial price off-setting by distributers? MARGARET EWEN (PRICING) Pharmacist Health Action International DAN CHISHOLM (FINANCING) Health Economist World Health Organization 12:10 p.m. Response Panel • Is there one area that could be considered the greatest barrier to improvement or are all four areas equal in burden? Government Perspective ATALAY ALEM Professor of Psychiatry Addis Ababa University 

120 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA Nongovernmental Organization Perspective CHRISTINA NTULO Basic Needs Uganda Private-Sector Perspective ISMET SAMJI, Director Portfolio Expansion GlaxoSmithKline 12:40 p.m. Panel discussion with session speakers and participants • How would changes in one area impact the other are- as? For example, would increases in demand positive- ly boost willingness of groups to finance essential medicines for MNS disorders? DAVID MICHELSON, Session Chair Vice President, Clinical Neuroscience and Ophthalmology Merck Research Laboratories 1:10 p.m. LUNCH SESSION II: SUCCESSFUL PROCUREMENT OF ESSENTIAL MEDICINES Session Objectives: Examine successful activities that have in- creased access to essential medicines both with- in SSA and in other developing countries. Explore acquisition and distribution models for other disease areas (e.g., diabetes, HIV/AIDS). Identify critical components that might be fea- tured in programs focused on MNS disorders. 2:10 p.m. Overview and Session Objectives EVA OMBAKA, Session Chair Senior Lecturer St. John’s University of Tanzania 

APPENDIX C 121 Speakers will focus on the following questions: • What were the challenges in developing and executing the project? • What partnerships were critical to the success of the project? • How were issues around demand, selection, supply chains, and pricing/financing addressed? • Are there specific lessons learned that could be ap- plied to efforts around MNS medicines? 2:20 p.m. Set One—Country Programs Example I—National Health Insurance ALBERT AKPALU, Neurologist, Ghana Example II—Government Storage with Private Groups JAFARY LIANA, Accredited Drug Dispensing Outlets (ADDO), Tanzania 3:00 p.m. Set Two—Infectious Disease Programs Example III—MDR-TB PAUL ZINTL Senior Advisor for Planning and Finance Program in Infectious Disease and Social Change Harvard Medical School 3:20 p.m. BREAK 

122 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA 3:40 p.m. Set Three—Noncommunicable Disease Programs Example IV—Diabetes MAPOKO MBELENGE ILONDO, Senior Advisor Corporate Stakeholder Engagement Novo Nordisk A/S, Denmark Example V—Schizophrenia FRANCOIS BOMPART, Medical Director Access to Medicines Sanofi 4:20 p.m. Lessons Learned—Discussion with Speakers and Participants • What components of the examples presented might translate well into a project around MNS medicines? • What common challenges and opportunities would a demonstration project need to address early on? EVA OMBAKA, Session Chair Senior Lecturer St. John’s University of Tanzania 5:15 p.m. WRAP-UP AND ADJOURN DAY TWO 8:15 a.m. Day Two Welcome STEVEN HYMAN, Chair Director Stanley Center for Psychiatric Research The Broad Institute 

APPENDIX C 123 8:20 a.m. Day One Panel Review: Defining the Challenges, Understanding the Lessons PAMELA COLLINS Director Office for Research on Disparities & Global Mental Health, National Institute of Mental Health ATUL PANDE Senior Vice President, Neurosciences Neurosciences Medicines Development Centre GlaxoSmithKline TEDLA GIORGIS Advisor Officer of the Minister Ministry of Health, Ethiopia DAN CHISHOLM Health Economist World Health Organization SESSION III: A ROADMAP FORWARD—ADDRESSING THE CHALLENGES Session Objectives: Identify a roadmap forward to address the four challenge areas: demand, selection, supply chains, and pricing/financing. Consider country income levels (e.g., low, middle, and high) and MNS disorders (e.g., depression, psychosis, epi- lepsy) when discussing potential solutions. 8:50 a.m. Session Objectives and Goals FRANCES JENSEN, Session Chair Professor and Chair, Department of Neurology University of Pennsylvania Health System 

124 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA 9:00 a.m. Challenge Area Discussions • Identify components of a roadmap to address the chal- lenge area. Discuss barriers and opportunities at the level of country income and MNS disorder. Challenge Area 1: Demand PAMELA COLLINS, Challenge Facilitator Challenge Area 2: Selection ATUL PANDE, Challenge Facilitator Challenge Area 3: Supply Chains TEDLA GIORGIS, Challenge Facilitator Challenge Area 4: Pricing/Financing DAN CHISHOLM, Challenge Facilitator 12:30 p.m. LUNCH 1:30 p.m. Building a Roadmap Forward—Within and Across Challenge Areas Challenge Facilitators PAMELA COLLINS, Challenge Facilitator—Demand ATUL PANDE, Challenge Facilitator—Selection TEDLA GIORGIS, Challenge Facilitator—Supply Chains DAN CHISHOLM, Challenge Facilitator—Pricing/Financing 3:00 p.m. Discussion with Leaders and Participants • Identify potential obstacles and opportunities to im- plementation FRANCES JENSEN, Session Chair Professor and Chair, Department of Neurology University of Pennsylvania Health System 3:30 p.m. BREAK 

APPENDIX C 125 SESSION IV: NEXT STEPS–IMPLEMENTING THE ROADMAP FORWARD Session Objectives: Explore available resources that could support a demonstration project. Identify tangible next steps for launching a demonstration project for MNS disorders. 3:45 p.m. Overview STEVEN HYMAN, Chair Director Stanley Center for Psychiatric Research The Broad Institute 3:50 p.m. Discussion with workshop session chairs, facilitators, and participants • Identify potential next steps for launching a demon- stration project • Who would be critical partners to facilitate such a project? 4:30 p.m. Closing Remarks 4:45 p.m. ADJOURN