making health markets work - virology...

Making health markets workKickstarting 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.

2

“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

2001 PharmAccessAccess 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 initiatives3

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

4

“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

Agenda





opportunites

5

The daunting complexity of health

Increase health spending=

Stimulate economic development& crowding in

Decrease out-of-pocket costs=

Stimulate risk pooling

Pro

ble

mSo

luti

on

First law of health economics Second law of health economics

Poor countries spend little on healthcareWhen GDP per capita is known, health expenditures per capita can be predicted with more than 95 percent accuracy

Poor countries have a high share of out-of-pocket costsWhen you are poor, you are on your own

In general, economic development is the only way to increase healthcare spending

Otherwise, create situation where private investment increases as well as government spending

Reduce individual risk for users by (subsidized) risk pooling through insurance schemes

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





opportunites

7

High burden of disease, lack of investments

> 15%of the world’s

population

25%of the total global

burden of diseases

(47% of communicable diseases)

< 2%of global total health

expenditure

660

2.083

Africa Rest of the world

98.118

6.354.308


1.136

6.102


Burden diseases

(Million DALYS)

Total health expenditure

(Million USD)

Population

(Millions)

WHO Global Health Estimates 2014 WHO Global Health Expenditure Database 2010World Population Data Sheet 2014

8

Health funding in developing countries

In most countries most funding of health is private

48 4951 51

48

52 5149 49

52

0

10

20

30

40

50

poorest poorer middle richer richest

Source of health care by wealth quintiles in sub-Saharan Africa

public

private

50% in lowest income quintile receive healthcare from private or non-state providers

0%

25%

50%

75%

100%

Uga

nd

a

Nig

eria

Ken

ya

Zim

bab

we

Tan

zan

ia

Mo

zam

biq

ue

Gh

ana

Rw

and

a

Nam

ibia

Zam

bia

Mal

awi

publicsector

private sector

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.

266

10998 95

12

Asia Lat Am Eur Middle E SSAfrica

Improving effectiveness and outcomes for the poor in health, nutrition & population, World Bank 2009

Size of IFC’s investments in health by region (loans and equity 1997-2007)(million USD)

10

Low share of insurance coverage

WHO Global Health Expenditure Database 2013

Only 5.5% of total health expenditure in Africa is financed through health insurance

Percent of total health expenditure

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Sou

th A

fric

a

Bo

tsw

ana

Nam

ibia

Cab

o V

erd

e R

ep.

Gab

on

Gh

ana

Sen

egal

Ken

ya

Mo

zam

biq

ue

Rw

and

a

Mau

rita

nia

Djib

ou

ti

Togo

Cô

te d

'Ivo

ire

Ben

in

Swaz

ilan

d

Mad

agas

car

Lib

eria

Sou

th S

ud

an

Gam

bia

Sud

an

Tan

zan

ia

Gu

inea

Mal

awi

Nig

eria

Zam

bia

Dem

. Rep

. of

the…

Bu

rkin

a Fa

so

Nig

er

Cen

tr. A

fric

an R

ep.

Cam

ero

on

Co

ngo

Bu

run

di

Eth

iop

ia

Social security funds as % of THE

Private insurance as % of THE

11

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

• 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

The challenges

13

14

How to turn a vicious cycle of health in Africa into a virtuous one?

Demand SupplyHigherTrust

Patients

HigherQuality

standards

Access to treatment

Research andAdvocacy

mHealth

Health insuranceand savings

Loans

mHealth

Government and Institutions

Fin

anci

ng

Del

iver

y

Higher

Higher

Equity

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

And today it is possible to include everybody at zero marginal cost

15

16

Towards a virtuous cycle in a digital space connecting demand and supply real time

Demand SupplyHigherTrust

Patients

HigherQuality

standards

Access to treatment


mHealth

Health insuranceand savings

Loans

mHealth

Government and Institutions

Fin

anci

ng

Del

iver

y

Higher

Higher

Equity

Agenda




4. Kickstarting HCV Treatment

Facts, challenges & step by step approach towards

sustainability

17

Epidemiology

• 60-80 million Hepatitis C patients worldwide (est.)

Estimates are still very unreliable

• Leading cause of liver diseases

• Mortality burden: 350,000 people die yearly of liver

cirrhosis or liver cancer due to Hepatitis C

• Highest prevalence top 3: Egypt, Cameroon, Burundi (est.)

Facts on hepatitis C*similarities and differences with HIV-AIDS

Transmission mostly through blood / contaminated

(hospital) equipment

• Inadequate sterilized medical equipment

• Unsafe injection practices

• Transfusion of blood and blood products

Pattern

• Infection mostly asymptomatic until decades

• 10 -30% cures spontaneous

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), WHOPanAfr Med J. 2013; 14:44, Lavanchy, Clinical Microbiology and Infection 2011 17, 107-115

Prevalence

• High prevalence linked to historical events/circumstances

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

18

http://www.nature.com/nm/journal/v19/n7/full/nm.3184.html

Opportunities

• New DAA drugs have become available with

exceptionally high cure rates (>95%)

• In 2000 HIV Aids treatment >10,000 USD/Yr

Now differential pricing mechanism of DAAs has

been established for >100 LMIC’s

HCV LIMC treatment prices are 900-1,200 USD

• Generic versions of DAAs for LIMCs are rapidly

being developed – increased affordability of

treatment

• New pan-genotyping HCV drugs are being

developed, precluding expensive diagnostics

HCV cure: opportunities & challenges in developing countries

Challenges

• Slow registration of DAAs in LMICs, e.g. Africa

• Slow SRA quality approvals/WHO pre-qualification of

generic DAAs

• Limited access to diagnostics; need for genotyping,

leading to high costs – differential pricing for diagnostics

is still not available

• No funding mechanisms in place

• HCV prevalence data scarce, e.g Cameroon• Prevalence of 13.8 % but confidence interval between 0 and

40% (Pan Afr Med J. 2013; 14: 44)

• Experts say figures may be lower than initially thought; 1%

among young adults rising to 10% among 55-59 years (National

Demographic Survey)

• Where to find the patients?• Long asymptomatic period of patients

• Risk groups are mostly historic (patients infected 15-25 years

ago – age specific cohorts are dominant)

19

20

HCV treatment challenges in a glance

Demand- No financing

mechanisms in place

- Historic dependence on

multi-lateral grants

Supply+ New DAA drugs at

affordable prices- Diagnostics: low access / high cost

LowRisk

Patients

low QualityStandards

Low or absent

No tested, standardized protocols for LIMC’sFinding patients is a challenge


- Prevalence data is unreliable

- LIMC treatment results still scarce

Mainly OOP or state driven

Limited Loans

Government and Institutions- Slow registration and SRA / Pre Q procedures

Fin

anci

ng

Del

iver

y

Low

Low

No Equity

1. Create common standards and data platform

A. Hep-C protocol development for resource poor settings

B. Design and implement a digital platform for doctors, patients and payers

2. Catalyze treatment: Create public-private partnerships

A. Treatment partnership: Contract leading clinics, labs and researchers

B. Access Partnership: Make available and procure drugs & diagnostics

3. Implement in an evidence based program

A. Find and target patients: start with F3/F4 – discuss policy on F0-F2

B. Costing of the treatment: agree on treatment costs, co-payment and

reimbursement

4. Financing

A. State of health financing: current policy, political will to engage, what is

the economic effect to cure HCV?

B. Select start up financing and provider payment model:

public good approach, performance based or insurance?

HCV treatment – step by step towards a solution

21

Activities started since Addis meeting in June

• Global network of specialists mobilized, e.g.

• Leading hepatologists from Nigeria, Kenya,

Ethiopia, Senegal, Cameroon, Uganda

• Duke University, AMC, AIGHD, CHAI

• Chair: Roel Coutinho supported by

Andrew Muir, Susanna Naggie, Tobias

Rinke de Wit, Marc van der Valk, Janke

Schinkel

• First site to test protocol in Cameroon with

Prof Njoya, Faculty of Medicine and

Biomedical Sciences

1. Create common standards and data platformCoordinated clinical protocol for Hep C in LMIC

Clinical Protocol (draft)

Pre-treatment screen

Pre-treatment information

Pre-treatment assessment

Assessment after 4 weeks therapy

Therapy

• Adherence support

• Physical exam• Complete Blood Count• Hepatic functional panel• Creatinine/Calculated

glomerular filtration rate (GFR)• HCV RNA nucleic acid test (NAT)• HCV Genotype• Test for hepatitis B & HIV• Pregnancy test

• Hepatitis C antibody

• Patient information collection

• HCV RNA nucleic acid test (NAT)

• Adherence support

• END OF TREATMENT



Assessment 12 weeks post treatment

• HCV RNA nucleic acid test (NAT)• Counselling

22

1. Create common standards and data platformReal-time mobile platform for patients, providers, and payers

Some characteristics of the treatment, research &

payment platform

• Evidence-based mobile platform for low-resource

settings

• Gain transparency into on the ground activities

with health worker monitoring reports and linked

supervisory apps

• Register and track individual patients and access

patient data online or via external database

• Enable real-time payments ― performance- /

outcome-based

• Reach patients with targeted SMS tools that

supports case management

• Gain visibility into on-the-ground activities with

real-time data & analytics

• Online & offline, Android & Nokia Series 40,

Integrates with web & SMS

23

Prof Oudou NjoyaFaculty of Medicine and Biomedical Sciences

Professor of Gastroenterology

24

2. Catalyze treatment: Create public-private partnershipsA first example - Cameroon

MINISTÈRE DE LA SANTÉ PUBLIQUE

Prof Roel CoutinhoProfessor of Epidemiology

Chair Medical Board PharmAccess

Local partners

Operational

partners

Implementing

organisations & funders1st 1000 treatments at a discount

Investor

Impact Bond

Patients

>500 patients ready for immediate treatment

Drugs

Harvoni , generic sofosbuvir (Mylan),

ribavirin

Doctor

6 clinics/doctors willing to join forces

Financing

PharmAccess and JLIOutcome payer (TBC)

Diagnostics

Institute Pasteur ready for all lab work

Protocol

submitted by Prof Njoyabased on PharmAccess

standard

Regulatory

Government signed MOU, committed to national approach

Quality

WHO pre-qualification generic sofosbuvir

expected by Q4

Essential elements in place to start by December 2016

3. Implement in an evidence based programExample of Cameroon

25

4. FinancingState of HCV health financing: current policy, political will to engage, what is the economic effect to cure HCV?

Characteristics of treatment cost and financing of

elimination strategies

Some financing options

• Public good financing models focus on

centralized purchasing and reducing

transaction cost

• Insurance models cater for pre-payment and

risk sharing in the population reducing risks

and enabling investments

• Performance based options can catalyze

treatment by taking out the execution risk as

payers only pay for outcome

• Impact bonds pre-fund treatment costs and

are repaid based on outcomes / cures

• Suppliers for drugs and diagnostics in future

to be reimbursed on outcomes?

Financing risk of execution and treatment cost is at the

payer / patient – benefits follow later

26

4. Kick-starting a sustainable approachExample: the HCV impact bond

Administrator

Implementing

OrganizationOutcome Payer

Service

provider

Service

provider

Service

provider

Target population

Investor

Evaluator

Funds Conditional

payment

Data Service

Attractive intervention:

• Straight forward intervention (treatment

protocol) with potential for scale

• Causal relationship between intervention

and outcome

Attractive outcome:

• Simple outcome metric: SVR sustained

virological response

• Causal relationship between outcome and

future government savings

Attractive Investment

• Short intervention cycle (12+12 weeks)

• High cure rates (>95%)

27

AdministratorAdministrator

4. Kick-starting a sustainable approachStepwise approach: test and scale in Cameroon

PAI + local

partner

IO

DEF

Outcome Payer

Service

provider

Service

provider

Service

provider

150 HCV patients

Target population

JLI

Investor

PAI

Donor

Phase 1: Test (pending final approvals) Set up operational, administrative and

contractual structure for first HCV impact bond Proof and fine-tune concept and structure Collect input/data to structure for roll out Advocate to attract players for roll out

Phase 2: roll out Government (potentially in combination with donors)

join as outcome payers Outcome investors provide short/medium term capital

for roll out International Fin. Institutions provide long term

capital to secure outcome payments

Dr. Njoya

CPC

Evaluator

Funds Conditional

payment

Data Service

IOMoH, Donors

Outcome Payer

Service

provider

Service

provider

Service

provider

[#] HCV patients

Target population

Outcome

Investors e.g.

Dr. Njoya

CPC

Evaluator

International Fin Institutions

Hep C Fund, DFIs?

4. Kick-starting a sustainable approachPhase out grants, reduce prevalence

Minus 91.4%

0,00%

0,10%

0,20%

0,30%

0,40%

0,50%

0,60%

0,70%

0,80%

0,90%

-

2.000.000

4.000.000

6.000.000

8.000.000

10.000.000

12.000.000

0 1 2 3 4 5 6 7 8 9 10

Bond model

Grants

Investment

Outcome payment

Prevalence Rate without Intervention

Prevalence Rate with Intervention

29

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