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Challenge: Insufficient Demand

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).

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

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¹Full-time equivalent is the number of working hours corresponding to one full-time employee during a fixed year.

²See http://www.un.org/millenniumgoals.

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

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³See 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.

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 demonstrating 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 availability 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,

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.

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⁴See http://www.who.int/mental_health/mhgap/en.

LESSONS LEARNED FOR ADDRESSING INSUFFICIENT DEMAND

As previously mentioned, five example programs addressing access to medicines were presented during the workshop to facilitate exploration 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.

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

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, knowledge, 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

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¹This 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 workshop.

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^aAlemu Asgedom

^bPamela Collins

^cOye Gureje

^dCharlotte Hanlon

^eSteven Hyman

^fEric Amin Jeje

^gThomas Kresina

^hAdesola Ogunniyi

ⁱEva Ombaka

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