Sustainable Financing to Ensure Access for All to TB Medicines

David Collins MSH GLOBAL TB CONFERENCE 2015, BANGKOK THAILAND

Purpose of the Session

• What financing challenges exist that restrict access to TB medicines and pharmaceutical services, especially for the poor, and how can they be overcome?

• Taking into account that in some countries TB control costs are increasing and donor funding is reducing

TB Financing Tools for Advocacy and Planning

• TB Service Delivery Costing (and Financing) Tool • TB Economic Burden Analysis Tool • MDR-TB Cost-Effectiveness Analysis Tool • MDR-TB Patient Cost Analysis Tool • Treatment Interruption Impact Tool (new) All available from TB CARE I and MSH

Indonesia Data

• The Indonesia data is from before the new 2014 prevalence survey

• That survey discovered a higher prevalence rate than previously thought, which means that the case detection rate was much lower

• Mostly because case detection technology much better • Around 40% of the cases detected were asymptomatic • The implication is that the country will need much greater

numbers of diagnostic equipment, reagents, and medicines

TB Economic Burden Analysis Tool – Advocacy on the Human Burden in Indonesia

TB – Economic Burden Analysis Tool – Indonesia Advocacy on the Economic Burden

Indonesia DS-TB Caseload Targets Scenario 1 (Pre-prevalence Survey)

Missing cases are being treated in the private sector?

Indonesia MDR-TB Caseload Targets Scenario 1

Projected Cost of TB Services in Indonesia - 25 years

Indonesia TB Financing Projections

Patient Access Challenge: 3 Countries (Patient Interviews – Not Defaulter Interviews)

Financing Strategies – Steps

• Project the costs based on treatment targets • Prioritize based on likely available funding

• High-risk groups/high impact mechanisms/equity? • See what savings can be made through cost-effectiveness • Patient access and the use of enablers (e.g. for MDR-TB)

spend money to save money • See what savings can be made through efficiency • Explore financing sources • Confirm sources and align with cost elements (e.g. MDR-TB

medicines from GF)

Financing Strategies: Who Can Pay

• The importance of estimating the long-term costs of medicines, storage and transport. Government work on long terms targets (Indonesia 25 years) and successful advocacy takes time

• Financing sources • Government budgets - national, local? • National social health insurance and/or

community-based health insurance? • Special taxes (e.g. tobacco, air tickets),

corporate social responsibility

What can be done to improve cost-effectiveness? • Effective and timely detection – case

finding and diagnosis • Timely cash flows • Quantification, procurement, storage and

distribution • Prevent loss of funds due to expiry • Private sector quality control – how to

incentivize? • Prioritize the easy-to-reach symptomatic

patients?

Medicines and Diagnostics

• The planning and use of medicines is dependent on timely and accurate diagnosis

• Need to align the strategic plan elements for TB medicines and for TB diagnostics

• Delays in diagnosis due to issues of procurement, storage, and distribution result in delays in treatment and can result in more severe cases

• Incorrect diagnosis can lead to wastage of drugs • Changes in diagnosis, such as faster testing, will

change the numbers of medicines and when they are needed.

Estimating the Cost and Cost Effectiveness of Medicines Distribution • Study in Benin and Kenya

• Distribution costs are significant portion of total cost • ACTs: 18% in Benin; 24% in Kenya • RDTs: 21% in Benin; 18% in Kenya

• Major cost drivers: labor, utilities , and transport • Health facilities compose over 50% of distribution costs

• Important to make sure that resources are not wasted but also adequately budgeted. How much can distribution be integrated with other medicines?

Source: Estimating the In-Country Distribution Costs of Malaria Commodities in Benin and Kenya: Report. Brittany Johnson, Rima Shretta, Lisa Smith, Prashant Yadav, Ravi Anupindi, Seydou Doumbia. SIAPS.

The Role of the Private Sector

• Private doctors prescribe or provide and pharmacists provide TB medicines

• They generally are paid out of pocket • They need to be accredited and have quality

control • How can they be motivated to behave like public

health doctors? • Indonesia – capitation plus incentives?

Poor TB and MDR-TB Patients Cannot Fund Transport and Other Costs and Do Not Adhere to Treatment

NTP and USAID TB CARE I Project/MSH 04/06/2015

THANK YOU