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6 Perspectives on Next Steps Potential Opportunities for Addressing the Four Challenge Areas as Presented by Individual Participants Insufficient Demand ⢠Implementation of the 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. Inappropriate Selection ⢠Development of a coherent and comprehensive national strat- egy, based on mhGAP, for the treatment and care of MNS disorders that receives widespread support and resources by key stakeholders. ⢠Development of national medicine lists and treatment guide- lines for each level of provider based on agreed-upon task- shifting practices. 87
88 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA ⢠Establishment of a learning health system to include review, revision, and periodic updates. ⢠Increased inclusion of medicines that promote adherence and greater accommodation of a reasonable range of provider and patient medication preferences. ⢠Promotion of evidence-based selection of medicines through the development of training programs. Ineffective Supply Chains ⢠Development of an information network systems approach for improved communication among tiers leading to streamlined and continuous flow of data. ⢠Training on data collection and analysis, leading to improved forecasting and reduced stock-outs and overstocking. ⢠Learning and leveraging information systems of other vertical supply chain programs. ⢠Increased training of supply chain staff on logistic manage- ment information systems and all levels of health care pro- viders about supply chains and logistics. ⢠Increased allocation of human resources for supply chains and inclusion of supply chain workers in determining needs for health care systems. ⢠The use of mobile technology across tiers and/or facilities. ⢠Establishment of therapeutic committees at health institutions to conduct coordination efforts and consider information on needs, stocks, and supply chain logistics. ⢠Reduction of the number of tiers between central warehouses and patient distribution points. ⢠Improved transportation between central warehouses and local distribution points to decrease time and costs for medicines to arrive. ⢠Increased working capital funds for national medicine supply agencies. High Pricing and Poor Financing ⢠Evidence-based policies can impact pricing and financing of medicines. ⢠Increase in evidence-based prioritization of funds for MNS disorders by governments, not-for-profit, and for-profit partners. ⢠Increased competition and lower barriers for entry into the market leading to an increased number of stakeholders and affordable medicine options.
PERSPECTIVES ON NEXT STEPS 89 ⢠Implementation of simpler and clearer regulations, require- ments, and procedures. ⢠Streamlined procurement of medicines at efficient prices and passing along of low procurement prices to patients, leading to a decrease in the overall unit cost of medicines. NOTE: The items in this list were addressed by individual part- icipants and were identified and summarized for this report by the rapporteurs, not workshop participants. This list is not meant to reflect a consensus among workshop participants. SOURCE: Adapted from chapter tables and presentations by Collins, Pande, Dua, Chisholm, and Jensen. For additional attribution information, please refer to individual tables for each challenge area. CONSIDERATIONS FOR MOVING FORWARD In the final session, individual workshop participants discussed the practicalities of drawing attention to and beginning to take action on the four challenge areas of insufficient demand, inappropriate selection, ineffective supply chains, and high pricing and poor financing. Hans Hogerzeil reiterated that SSA is made up of regions, countries, and people of many different languages and cultures, and there is no one- size-fits-all approach for access to essential medicines for MNS disorders. He emphasized country-based solutions based on the unique challenges in each country. Daniel Chisholm noted that the strategies discussed throughout the workshop are really a menu of potential options for countries to consider based on their current systems and situation. A participant noted that countries might be able to better strategize potential solutions if best practices and examples of successful access to medicines programs were disseminated widely. In particular, many participants noted that efforts to increase access to antiretroviral therapy (ART) for HIV/AIDS might be an additional program to explore, one not discussed in detail at the workshop. It was noted that rapid scale-up of access to ART was the result of advocacy efforts, political commitments, reductions in the cost of medicines, and increases in foreign assistance (IOM, 2013a). For low-income countries, scale-up was also successful due to an increased recognition among a range of stakeholders of the growing impact of HIV/AIDS on health, economics, and development along with growing evidence that it was possible to treat HIV/AIDS
90 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA (IOM, 2013a). Beyond infectious diseases, several participants pointed out that similar efforts are under way to address access to essential medicines for noncommunicable diseases in SSA and that concepts and strategies from these efforts could be applied to MNS disorders (Hogerzeil et al., 2013a). Although the focus of the workshop was improving access to medicines to treat MNS disorders, individual workshop participants discussed the broader challenge of increasing access to MNS treatment and care. Several participants discussed national MNS programs that address access to treatment and care, as well as social and cultural issues such as stigma. The general lack of attention to MNS disorders was a central barrier across all four challenge areas and the need to encourage countries to address MNS disorders in the context of their overall health needs and national programs was emphasized by many participants. They stressed that access to medicines to treat MNS disorders can be integrated into existing activities and health care systems. In resource- limited environments, a few participants noted the importance of high- lighting the return on investment for health in general, not just mental and neurological health. Addressing supply chain issues, for example, can impact access to medicines for many conditions. According to several participants, challenges associated with access to medicines are not specific to MNS disorders, but working to address MNS disorders could be positioned in policy discussions as an entry point for making changes in the country to address broader system issues. As an example, it was noted that programs such as the Emerging mental health systems in low- and middle-income countries (EMERALD) project1 are trying to include improvement of MNS disorder outcomes as a component of overall health-systems strengthening initiatives. In addition, several participants discussed demonstration projects that could be developed in partnership with government agencies to access the feasibility of improving access to medicines. These demonstration projects could be implemented at the local level to achieve tangible results and provide evidence to support scale-up efforts. To be most effective, several participants suggested a need to focus on a few medicines or disorders for these demonstration projects. The evidence collected could empower champions to drive demand and push for systemic change, a participant noted. Champions can be public figures that draw attention to MNS disorders and help reduce stigma, clinicians 1 For further information see http://www.emerald-project.eu.
PERSPECTIVES ON NEXT STEPS 91 in the field who have first-hand experience with the needs of patients and the treatment gap, or others in the country or community engaged in the demonstration projects. Several participants reiterated that continuous monitoring of such projects is important for sustainability to assure officials that investments have been spent wisely and resulted in reduced costs, improved health outcomes, and/or reduced burden of disease. Lastly, many participants discussed how partnerships with key stakeholders are essential to help foster action. Key stakeholders may include ⢠Government agencies (ministries of health, finance, and trade); ⢠Pharmaceutical manufacturers (generic and non-generic); ⢠Supply chain management professionals; ⢠Global and local nongovernmental organizations (e.g., WHO, the World Bank); ⢠Health care providers; ⢠Professional associations; ⢠Patient groups; ⢠Health educators; and ⢠Donors and foundations. Multiple roles for WHO and other key stakeholders were suggested, such as creating consortia for guidelines and best practices; education and credentialing aligned with the use of guidelines; and incorporating tools and strategies from workshop proceedings into mhGAP programs. It was suggested that the annual mhGAP forum, which brings together governments, international NGOs, researchers and other stakeholders, could be one venue to reach out to the target audience for many of the concepts discussed during the workshop. Individual participants were also eager to see MNS disorder outcomes linked to the MDGs. CLOSING COMMENTS Although it was acknowledged that the challenges associated with improving access to essential medicines for MNS disorders have been discussed for decades, many participants believe there is an opportunity now to conduct an all-inclusive exploration and develop system-wide solutions to the barriers impacting access to MNS medicines. The strategies discussed by many workshop participants may help
92 ESSENTIAL MEDICINES FOR MNS DISORDERS IN SSA countries conduct individual assessments of their needs. The potential opportunities and strategies to improve demand, selection, supply chains, and pricing and finance, rely heavily on increasing public and political awareness of, and provider training in MNS disorders. Lastly, applying global knowledge from other chronic disease areas, sharing best practices that can be adapted to a countryâs policies, and leveraging existing systems may offer additional insights on potential solutions. As potential next steps, a few participants discussed the value of developing a toolkit that countries could use to assess their individual country needs and inform their decisions and system improvements. Several participants also reiterated the role and potential value of small, focused demonstration projects in developing the evidence base to support incremental and sustainable systemic change at a national level.
