Making health markets work Kickstarting 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 1 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. “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 2 2001 PharmAccess Access 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 initiatives 3 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 “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 4 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 First law of health economics Second law of health economics Poor countries spend little on Poor countries have a high healthcare share of out-of-pocket costs When GDP per capita is known, When you are poor, you are health expenditures per capita on your own Problem can be predicted with more than 95 percent accuracy Increase health spending Decrease out-of-pocket costs = = Stimulate economic development Stimulate risk pooling & crowding in . In general, economic development is the only way to increase . Reduce individual risk for users by (subsidized) risk pooling Solution healthcare spending through insurance schemes . Otherwise, create situation where private investment increases as well as government spending Source: A new paradigm for increased access to healthcare in Africa, 2007 – Onno Schellekens et al – FT/IFC Award; WHO NHA data 2009/2010 6 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% 25% < 2% of the world’s of the total global of global total health population burden of diseases expenditure (47% of communicable diseases) Population Burden diseases Total health expenditure (Millions) (Million DALYS) (Million USD) 98.11 1.136 8 660 6.102 2.083 6.354. 308 Africa Rest of the world Africa Rest of the world Africa Rest of the world World Population Data Sheet 2014 WHO Global Health Estimates 2014 WHO Global Health Expenditure Database 2010 8 Health funding in developing countries In most countries most funding of health is private 50% in lowest income quintile receive healthcare from private or non-state providers Source of health care by wealth quintiles in sub-Saharan Africa 52 51 51 51 52 100% 49 49 49 50 48 48 private sector 40 75% public 30 50% public 20 private sector 25% 10 0% 0 poorest poorer middle richer richest Kenya Ghana Nigeria Zambia Malawi Uganda Rwanda Namibia Tanzania Zimbabwe Mozambique 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 9 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. Size of IFC’s investments in health by region (loans and equity 1997-2007) (million USD) 266 109 98 95 12 Asia Lat Am Eur Middle E SSAfrica Improving effectiveness and outcomes for the poor in health, nutrition & population, World Bank 2009 10 Low share of insurance coverage of insurance share Low Only 5.5% of total health expenditure in Africa is financed through health insurance health through financed is Africa in expenditure health of 5.5% total Only WHO Global Health Expenditure Database 2013 Database Expenditure Health Global WHO 10% 15% 20% 25% 30% 35% 40% 45% 50% 0% 5% Percent of total health expenditure health expenditure total of Percent South Africa Botswana Namibia Cabo Verde Rep. Gabon Ghana Senegal Kenya Mozambique Rwanda Mauritania Djibouti Togo Côte d'Ivoire Benin Swaziland Madagascar Liberia South Sudan Gambia Sudan Tanzania Guinea Malawi THE as %of insurance Private THE of % as funds security Social Nigeria Zambia Dem. Rep. of the… Burkina Faso Niger Centr. African Rep. Cameroon Congo Burundi 11 Ethiopia 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. 12 The challenges • 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 13 How to turn a vicious cycle of health in Africa into a virtuous one? Health insurance Research and Government and Institutions Loans Equity and savings Advocacy Higher Financing Demand Higher Trust Higher Supply Quality standards Higher Delivery Patients mHealth Access to treatment mHealth 14 And today it is possible to include everybody at zero marginal cost 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 15 Towards a virtuous cycle in a digital space connecting demand and supply real time Health insurance Research and Government and Institutions Loans Equity and savings Advocacy Higher Financing Demand Higher Trust Higher Supply Quality standards Higher Delivery Patients mHealth Access to treatment mHealth 16 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 17 Facts on hepatitis C* similarities and differences with HIV-AIDS Epidemiology Transmission mostly through blood / contaminated • 60-80 million Hepatitis C patients worldwide (est.) (hospital) equipment Estimates are still very unreliable • Inadequate sterilized medical equipment • Leading cause of liver diseases • Unsafe injection practices • Mortality burden: 350,000 people die yearly of liver • Transfusion of blood and blood products cirrhosis or liver cancer due to Hepatitis C • Highest prevalence top 3: Egypt, Cameroon, Burundi (est.) Pattern Prevalence • Infection mostly asymptomatic until decades • High prevalence linked to historical events/circumstances • 10 -30% cures spontaneous 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 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), WHO PanAfr Med J. 2013;