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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Page 28
Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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Page 29
Suggested Citation:"2 Challenge: Insufficient Demand." Institute of Medicine. 2014. Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18380.
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2 Challenge: Insufficient Demand Opportunities to Address Insufficient Demand as Identified by Individual Participants • Implementation of the World Health Organization Mental Health Gap Action Programme (mhGAP) intervention guide and training modules to increase detection, diagnosis, and treatment. • Development of national task forces composed of government officials and key stakeholders to advocate for and develop training and education plans for mental, neurological, and substance use (MNS) disorders. • Integration of patient- and family-oriented training into existing community-based programs to develop an informed population about MNS disorders and treatment outcomes. • Reduction or removal of policy limitations on which levels of health care providers can prescribe medications and which medications they can prescribe, leading to an increased number of available prescribing providers. NOTE: The items in this list were addressed by individual par- ticipants and were identified and summarized for this report by the rapporteurs. This list is not meant to reflect a consensus among workshop participants. For additional attribution information, please refer to the table at the end of this chapter. 15

16 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA Increasing patient and provider demand for appropriate essential medicines for MNS disorders is a critical first step to improving access, noted Oye Gureje, professor in the department of psychiatry at the University of Ibadan in Nigeria. If patients do not seek out treatments and health care providers do not properly diagnose and prescribe appropriate medicines, the result is a health system with low demand and continued patient suffering. Gureje noted there are associated challenges related to low demand, including perceived quality of care; acceptability of seeking care (i.e., negative attitudes toward those with MNS disorders); cost of care and affordability of medicines; and overall awareness of the need for care by patients, families, and health care providers. THE CONTEXT OF MNS CARE IN SSA As previously noted, SSA has one of the largest treatment gaps for MNS disorders. Gureje gave the example that in many SSA countries, as little as 5 to 10 percent of epilepsy patients receive any form of treatment (Chin, 2012; WHO, 2012). He added that among the few who do receive treatment for MNS disorders, there is often a delay in accessing treatment (Wang et al., 2007). Challenges associated with services, continuity of care, treatment, and medication costs can lead to non- adherence—withdrawal from formal treatment—resulting in reduced demand for MNS medications, Gureje said. Challenges to Seeking and Receiving Treatment for MNS Disorders Perceived Quality of Care Having access to properly trained health care providers is important for patients with MNS disorders to be diagnosed and properly treated, said Gureje. However, in SSA countries, human resources for treating these disorders are scarce (WHO, 2011a). For example, there is less than 1 psychiatrist per 100,000 population in SSA, compared to about 10 per 100,000 in Europe. In many SSA countries, the ratio is 1 psychiatrist to more than 1 million people (WHO, 2011a). Several countries have only one psychiatrist, Gureje said, and some do not have any (WHO, 2011).

CHALLENGE: INSUFFICIENT DEMAND 17 There are roughly 20,000 mental health workers across all SSA countries, with a staff-to-population ratio of about 1 mental health worker for 40,000 people, or 2.5 mental health workers or full-time equivalents (FTEs)1 per 100,000 population (WHO, 2011a). WHO estimates the minimum number of health workers across all specialties required in order to deliver on the health-related commitments of the Millennium Development Goals2 (MDGs) is 2.5 health workers per 1,000 population, indicating that current levels are 100 times below what is needed to fulfill the MDGs. Given these limited numbers, Gureje noted that when patients do receive care it is usually in a primary or general health care setting from providers who may not be adequately trained to recognize, diagnosis, and treat MNS disorders (Gureje et al., 1995a,b). A large portion of medical school programs in SSA only provide 2 to 4 weeks of psychiatric training, at most. Gureje went on to explain that many physicians have little to no training in the treatment of common MNS disorders such as depression or anxiety. Non-specialized, non- prescribing providers, such as community health officers, may only have 15 hours of instruction over a 2-year general training program and likely will not see a clinical case during training. A WHO survey found that few countries had a majority of providers receiving in-service training on MNS disorders within a 5-year period (WHO, 2011a). In addition, provider knowledge about prescribing medications for MNS disorders can be limited, Gureje said. Guidelines or manuals about the management and treatment of MNS disorders are only available in about 25 percent of SSA countries and can often be unclear about treatment recommendations (WHO, 2011a). Gureje noted that many times treatments are either inappropriate or inadequate (e.g., suboptimal dose) when patients are seen by primary care health providers. Several participants noted that increasing the number of providers might not be sufficient to address the issues of quality of care. They stressed the importance of increasing capabilities of providers around identification, diagnosis and treatment of MNS disorders. Providers in urban and rural settings that might be targeted for increased training included psychologists, medical doctors, nurses, and community health care workers. Many participants noted that the development of core 1 Full-time equivalent is the number of working hours corresponding to one full-time employee during a fixed year. 2 See http://www.un.org/millenniumgoals.

18 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA competencies, such as those discussed in the previous IOM workshop,3 might be a robust mechanism for improving patient outcomes through improved provider knowledge. Acceptability of Care Even when services are available, patients may not seek access to care because of poor knowledge about and persistent stigma associated with MNS disorders, noted Gureje. A study of 2,040 people in Nigeria found that more than 40 percent believe that some MNS disorders are due to supernatural causes and 30 percent believe in faith or spiritual treatments rather than medical treatments (Gureje et al., 2005). During the open discussion, a few participants pointed out that the negative attitude of the public toward individuals with MNS disorders and associated stigma can discourage individuals and their families and relatives from seeking out treatment. For example, 78 percent of Nigerians said they would be upset working with someone with an MNS disorder and 83 percent would be ashamed if people knew they had an MNS disorder (Gureje et al., 2005). This means, Gureje said, that immediate family members might discourage a relative to seek treatment because of the perceived shame associated with MNS disorders. Several participants suggested that the first step to changing individual and community behavior is to educate the public that MNS disorders are medical conditions. Many participants discussed the roles of local and international champions in helping to raise awareness and push for quality medications. A participant pointed out the parallels with epilepsy in the United States, where there is limited patient and public awareness and a lack of training of primary care providers in recognition and treatment (IOM, 2012). In this case, public service announcements were key to increasing awareness and reducing stigma. Ismet Samji, director of Portfolio Expansion at GlaxoSmithKline, suggested taking lessons from the successful awareness campaigns in the field of oncology. She noted that nearly everyone knows someone who has cancer and many governments rally behind oncology; a similar approach could be used for MNS disorders. A participant suggested that another effective approach to raising political awareness and garnering support from leadership and 3 See http://www.iom.edu/reports/2013/Strengthening-Human-Resources-Through- Development-of-Candidate-Core-Competencies-for-Mental-Neurological-and-Substance- Use-Disorders-in-Sub-Saharan-Africa.aspx.

CHALLENGE: INSUFFICIENT DEMAND 19 ministers might be to refine the message and focus on a few specific disorders rather than on MNS disorders broadly. Many participants emphasized that there is a need to demonstrate to politicians and private employers the economic impact of lost work days due to MNS disorders. One participant suggested that this might bolster both financial and service commitments toward treatment and care of patients with MNS disorders. Finally, several participants suggested focusing first on dem- onstrating that training can be provided to develop the clinical capacity to diagnose and treat patients and that quality medicines can be accessible at affordable prices for these few disorders, and in time, efforts can be expanded to a much wider range of conditions. Cost and Affordability of Treatment The cost of care for MNS disorders directly influences the demand for medicines, said Gureje. Given the lack of universal health insurance coverage in most SSA countries, patients must pay out-of-pocket for health care expenses, even though 70 percent live below the poverty line in some countries (World Bank, 2014). The cost of care not only includes the fees for services and medicines, said Gureje, but also transportation costs to see a health care provider. For illustration purposes, Gureje noted that in Nigeria, risperidone, an antidepressant, costs 6,000 naira (~37 USD) for a 1-month supply and carbamazepine, an antiepileptic, about 10,000 naira (~62 USD), while the minimum wage in public service in 9,000 naira (~55 USD) per month. The affordability of health services and treatment is an important consideration when patients consider seeking out care, said Gureje. Low Demand Perpetuates Low Access Challenges associated with the perceived quality, acceptability, and affordability of care for MNS disorders can lead to reduced demand for medicines. This lack of demand is directly correlated with the avail- ability of essential medicines. Overall procurement of MNS medications in SSA countries is low, with a median $2,300 spent per 100,000 population compared with a global median of $680,800 (WHO, 2011a). As a result of low demand, pharmacies and local dispensaries are not incentivized to procure and store medicines that have low sales and,

20 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA therefore, are not profitable. Newer medications are often most affected due to their relatively high cost compared to generics, Gureje said. The health system in SSA that cares for patients with MNS disorders is characterized by inefficient coordination and limited availability of specialists, Gureje said. Primary health care providers, who constitute the bulk of the service providers, lack the supervision and support needed to give attention to MNS disorders in the context of other competing priorities. Some health care providers lack the confidence to prescribe MNS medications, and become less familiar with their use over time without continual training. Improving Access to MNS Medicines Through Increased Demand To begin to address the challenges of demand and access, Gureje explained that Nigeria has been using the mhGAP4 to scale-up services for MNS disorders. The program includes engagement with policy makers, training of primary care providers, and public education through facility-based programs and media interviews. Results thus far show a dramatic increase in access to care for MNS disorders, Gureje said. There has also been an increase in health care provider competence, resulting in increased detection and treatment, as well as adherence to intervention guidelines. Prescription of MNS medications has increased, as has procurement. Based on his experience, Gureje offered the following thoughts on how to improve access through increased demand. First, improve help- seeking through public education; enhance detection and treatment through provider training focused on improving skills and reduce negative attitudes toward MNS conditions; and reform the health system so that the few specialists available can spend more time providing supervision and support to first-line providers. Gureje stressed the importance of engaging policy makers to improve procurement. Finally, the ability to pay for medicines needs to be addressed, he said. A participant suggested that the development of national treatment guidelines and algorithms by key stakeholders (e.g., Ministry of Health and professional associations) might be beneficial. Several participants indicated a potential role for technology to improve training and support continuing education among health care providers. 4 See http://www.who.int/mental_health/mhgap/en.

CHALLENGE: INSUFFICIENT DEMAND 21 LESSONS LEARNED FOR ADDRESSING INSUFFICIENT DEMAND As previously mentioned, five example programs addressing access to medicines were presented during the workshop to facilitate ex- ploration of best practices and lessons learned from other programs. The examples were selected by planning committee members and included two country-level programs, an infectious disease project, and two noncommunicable disease programs. Highlights from the presentations of the lessons learned for addressing insufficient demand are provided in Box 2-1. A full description of the examples as presented can be found in Appendix A. BOX 2-1 Highlights of Lessons Learned from Example Programs: Insufficient Demand Country Programs National Health Insurance Scheme (NHIS), Ghana • The establishment of the NHIS provided access and basic financial coverage to health care services for residents of Ghana. This led to reduced out-of-pocket costs and increased inpatient and outpatient use of the health care system. • Mental, neurological, and substance use (MNS) disorders have been recently integrated into the health insurance scheme, including premium exemptions for persons with MNS disorders. The Accredited Drug Dispensing Outlets (ADDO) Program, Tanzania • Local drug dispensaries, given their close proximity to the majority of the patient population, provided a critical opportunity for increasing patient and consumer awareness about the importance of treatment adherence and use of quality medicines. • Local drug dispensaries offered more privacy to patients and flexible payment modalities compared to public-sector facilities.

22 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA Infectious Disease Program Multidrug-resistant Tuberculosis (MDR-TB) • Attitudes toward treating MDR-TB had a significant role in implementing successful programs, scaling-up programs, and increasing demand. • Beyond a need to demonstrate the ramifications of inaction, successful programs for MDR-TB have demonstrated that an increase in access to medicines improves health outcomes. • Development of guidelines for the management of treatment improved clinical expertise and diagnostic capacity. Noncommunicable Disease Programs Diabetes • Coordinated approaches with multiple stakeholders were needed to provide accessible and affordable diabetes med- icines to patients. • Specific allocations dedicated to diabetes treatment with- in government budgets helped to reduce out-of-pocket expenditures from patients, resulting in increased demand. • Country-level prevalence data were needed to help accurately determine the demand for diabetes care and treatment. Schizophrenia • The simultaneous launch of awareness initiatives aimed at patients and families and training of primary health care providers increased demand. • Non-promotional education and information programs for professionals, as well as for patients and communities, led to reduced stigma and acceptability of seeking treatment. • Training primary care providers in basic diagnostic pro- cedures and treatments about MNS disorders boosted demand for medicines. • Preferential pricing policies for MNS medicines for governmental and other nonprofit procurement stakeholders ensured access to affordable, adapted, and quality medicines. SOURCE: Presentations by Akpalu, Liana, Zintl, Ilondo, and Bompart. See Appendix A for full discussion and references.

CHALLENGE: INSUFFICIENT DEMAND 23 CHALLENGES AND OPPORTUNITIES FOR ADDRESSING INSUFFICIENT DEMAND In preparation for the focused discussions on insufficient demand, Pamela Collins, director of the Office for Research on Disparities and Global Mental Health at the National Institute of Mental Health (NIMH), summarized the challenges for increasing demand that were discussed in the overview presentation and example programs. Access-related barriers that can influence demand at the health care service delivery level include adequate human resources for MNS disorders and perceived quality of care; in particular, whether providers have the necessary skills to recognize, diagnose, and treat. Poor provider education can increase demand for incorrect medications. Additional barriers include the acceptability of care, affordability of care, and awareness of a need for care. Collins noted that participants discussed the presence of policies that might restrict the ability for certain providers to prescribe medications in some countries, which could also influence demand. The dynamics of supply also influence demand, she said. Insufficient demand can lead to low supply as manufacturers perceive a small market, which ultimately leads to higher costs, which in turn negatively influences demand. Forecasting demand is also a challenge, and requires timely and accurate feedback. Following the focused discussion, Collins reported that three priority constraints and/or barriers were identified by various participants relative to demand for MNS medicines: (1) inadequate training and education of health care providers and managers; (2) low perceived need for medical care by individuals and families with MNS disorders; and (3) access to prescribers. All constraints and/or barriers and potential opportunities noted by participants are included in Table 2-1. To address the need for increased and improved training and education of providers and managers about MNS disorders, several participants suggested that implementation of the mhGAP intervention guide and training modules might be a strong first step in addressing this challenge. A few participants suggested that national task forces composed of government officials and key stakeholders might be able to develop training and education plans aimed at addressing treatment gaps in care of patients with MNS disorders. Collins noted that during the focused discussions, many participants supported the cultivation of champions from within government agencies and across society to increase the perceived need for MNS-specific

24 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA medical care by patients and families. This low perceived need might also be addressed through integration of patient- and family-oriented training into general health care facility and community-based programs. The third barrier, limited access to prescribers by patients, was directly linked to low demand for essential medicines, according to many discussion participants. Collins indicated that a key opportunity identified by some participants was the reduction or removal of policies that limit the types of health care providers who can prescribe medicines and which medications they can prescribe. In particular, a participant highlighted a need for policies aimed at increasing the number of potential nurse prescribers through improved training, know- ledge, monitoring and capacity building via the mhGAP tool. Several participants noted that these changes might result in an overall increase in the number of certified prescribers, which in turn might boost demand.

TABLE 2-1 Opportunities to Address Insufficient Demand for Essential Medicines as Identified by Individual Workshop Participants1 Constraint Potential Relevant Potential Suggested Secondary and/or Barrier Opportunity Outcome(s) Metric(s) of Partnership(s) Consideration(s) Success Inadequate Implementation of Increased Increased number Specialized MNS Use of health training and the mhGAP detection, of health care disorder trainers; information education of intervention guide diagnosis, and providers trained. primary care systems with health care and training intervention of Increased case providers; consideration providers and modules across MNS identification of pharmacists; based on funding managers about SSA countries.b,c,e disorders.b,c,g MNS disorders. facility managers; availability.b,c,e,g MNS Increased use of other disorders.b,c,d,e,f,g,h,i evidence-based administrators.b,c,d, e,g,h,i interventions based on mhGAP guidelines as demonstrated by increased number of prescriptions.b,c,d, e,g 1 This table presents challenges and opportunities discussed by one or more workshop participants. During the workshop, individual participants engaged in active discussions. In some cases, participants expressed unique ideas and/or differing opinions. However, because this is a summary of workshop comments and does not provide consensus recommendations, workshop rapporteurs endeavored to include all workshop participant comments. This table and its content should be attributed to the rapporteurs of this summary as informed by the 25 workshop.

26 Constraint Potential Relevant Potential Suggested Secondary and/or Barrier Opportunity Outcome(s) Metric(s) of Partnership(s) Consideration(s) Success Inadequate Cultivation of Development of a Active Policy makers; Consider need for training and champions within sustainable group participation by primary care articulating education of both government of government members of the providers; priority conditions health care and society to officials and key task force (e.g., community based on country providers and identify gaps in stakeholders to attendance at members; supply conditions and managers about addressing MNS comprise a meetings with chain evidence-based MNS disorders and train national task diverse representatives; medication needs. disorders.b,c,d,e,f,g,h,i health care force. A national representation). other government Incorporate providers and taskforce could Concrete action agencies; education and managers.b,c advocate for and plans leading to nongovernmental training on MNS develop training detailed training organizations; disorders in and education and education faith-based medical schools plans that include plans.b,c,g organizations; and across all monitoring and nonprofit health care evaluation.b,d,g organizations; professional academia; programs.b,c,e,g research community; pharmaceutical industry.b,c,d,e,g,h,i

Constraint Potential Relevant Potential Suggested Secondary and/or Barrier Opportunity Outcome(s) Metric(s) of Partnership(s) Consideration(s) Success A low perceived Integration of Increased number Increased demand Facility-based Consider the need for MNS- patient- and of patient for care and providers; impact on primary specific medical family-oriented education sessions treatment in health Ministry of health care care by patients training about per month focused care facilities. Health; advocacy providers due to and MNS disorders in on MNS Reduced groups; increased families.a,b,c,d,e,f,g,h,i health care disorders. An community use of nongovernmental demand.b,c facilities.b,c,d,e,f informed non-evidence- organizations; community about based treatments Ministry of MNS disorders (e.g., punishment, Education.b,c,e,g and treatment shackling). outcomes.b,g Increased dialogue about health care needs between patients and providers. Decreases in time to treatment and care.b,c,d,e,f,g 27

28 Constraint Potential Relevant Potential Suggested Secondary and/or Barrier Opportunity Outcome(s) Metric(s) of Partnership(s) Consideration(s) Success A low perceived Integration of Increased Increased Community-based Consider country need for MNS- training about education on MNS identification of organizations; differences in specific medical MNS disorders disorders for faith cases. Increased faith-based levels of care by patients into existing leaders, referrals to a organizations; literacy.b,d and community-based complementary health care facility Ministry of families.a,b,c,d,e,f,g, programs.b,c,d,e,g and alternative for treatment and Health; advocacy h,i health care care. Decreases in groups; providers, and time to treatment nongovernmental other community and care.b,e,g organizations; leaders. Improved Ministry of accuracy of Education.b,c,d,e,g information delivered about MNS disorders.b,c,d,g

Constraint Potential Relevant Potential Suggested Secondary and/or Barrier Opportunity Outcome(s) Metric(s) of Partnership(s) Consideration(s) Success Limited access to Reduce or remove Increased number Increased Ministry of Country-based prescribers by policy limitations of providers able to number of Health; Ministry regulations on patients.a,b,c,d,e,g on which types of prescribe certified of Finance; patient prescribing health care medications. prescribers. and family groups; practices by providers can Establish parity in Adequate prescriber different provider prescribe prescription of distribution of representatives; levels.b,e medications and psychiatric and providers. training and which medications non-psychiatric Increased credentialing they can prescribe. medications. evidence-based organizations.b,c,d,e, f,g Changes to be Ability to prescribe prescribing of based on human MNS-specific medications.b,g resource needs medications is and recognizing incorporated into limitations roles, associated with responsibilities, and controlled qualification substances.c,d,g requirements for adequately trained providers.b,e,g a f Alemu Asgedom Eric Amin Jeje b g Pamela Collins Thomas Kresina c h Oye Gureje Adesola Ogunniyi d i Charlotte Hanlon Eva Ombaka e 29 Steven Hyman

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In 2011 the Grand Challenges in Global Mental Health initiative identified priorities that have the potential to make a significant impact on the lives of people with mental, neurological, and substance use disorders. Reduction of the cost and improvement of the supply of effective medicines was highlighted as one of the top five challenges. For low- and middle-income countries, improving access to appropriate essential medicines can be a tremendous challenge and a critical barrier to scaling up quality care for mental, neurological, and substance use disorders. Reduction of cost and improvement of the supply of effective medicines has the potential to significantly impact the lives of patients with these disorders.

Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa is the summary of a workshop convened by the Institute of Medicine Neuroscience Forum in January 2014 in Addis Ababa, Ethiopia to discuss opportunities for achieving long-term affordable access to medicines for these disorders. This report examines challenges and opportunities for improving access to essential medicines in four critical areas: demand, selection, supply chains, and financing and pricing. The report also discusses successful activities that increase access to essential medicines both within Sub-Saharan Africa and in other developing countries, and considers the role of governments, nongovernmental organizations, and private groups in procurement of essential medicines for mental, neurological, and substance use disorders.

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