Forming a medicines pricing policy for low and middle-income countries (LMICs): the case for Pakistan

Equitable access to medicines has played a vital role to improve patient health outcomes and reducing mortality globally. However, it is important to note that medicines pricing is a key determinant in promoting access to medicines. The studies and empirical data have shown that there are wide variations in prices across countries for the same brand of medicines. World Health Organisation (WHO) has provided guidelines to formulate country pharmaceutical pricing policies. However, little is known how these guidelines will be used in the country-specific setting. This commentary provides guiding principles and outlines the basis to form a medicines pricing policy in a low and middle-income country, Pakistan. It discusses the current medicines pricing policy and provides suggestions for future work. The suggested medicines pricing structure and lessons learned in this commentary can also be applied in other low-resource settings.

Ten recommendations to improve pharmacy practice in low and middle-income countries (LMICs)

Medicines are important health interventions and their appropriate use could improve health outcomes. Throughout the globe, pharmacists play a very important role to improve the use of medicines. Though high-income countries are debating on futuristic approaches, independent prescribing of pharmacists, clinical skills, and to expand pharmacy services; a large majority of low and middle-income countries still lag behind to strengthen pharmacy practice. This paper presents a key set of recommendations that can improve pharmacy practice in low and middle-income countries (LMICs). The ten recommendations include (1) Mandatory presence of graduate-level pharmacists at community pharmacies (2) Clear demarcation of the roles and responsibilities of different categories of pharmacists (3) Effective categorization and implementation of medicines into (a) prescription medicines (b) pharmacists only medicines (c) over the counter medicines (4) Enforcement of laws and regulations for the sale of medicines (5) Prohibiting doctors from dispensing medicines (the dispensing separation between pharmacists and doctors). (6) Involving pharmacies and pharmacists in Universal Health Coverage Schemes to improve the affordability of medicines (7) Strengthening national medicines regulatory authorities to improve the quality, safety, and effectiveness of medicines (8) Training of pharmacists in clinical skills, vaccination, and minor ailment schemes (9) Promoting independent medicines information for consumers and healthcare professionals by developing national medicines information strategy (10) Mandatory Continuing Professional Development (CPD) programs for the Pharmacists.

Overcoming Challenges for Successful PACS Installation in Low-Resource Regions: Our Experience in Nigeria

In this paper, we walk you through our challenges, successes, and experience while participating in a Global Health Outreach Project at the University College Hospital (UCH) Ibadan, Nigeria. The scope of the project was to install a Picture Archive and Communication System (PACS) to establish a centralized viewing network at UCH's Radiology Department, for each of their digital modalities. Installing a PACS requires robust servers, the ability to retrieve and archive studies, ensuring workstations can view studies, and the configuration of imaging modalities to send studies. We anticipated that we might experience hurdles for each of these requirements, due to limited resources and without the availability to make a site visit prior to the start of the project. While we ultimately experienced delays and troubleshooting was required at each turn of the install, with the help of dedicated volunteers both on and off-site and the UCH staff, our shared goal was accomplished.

Cultural adaptation of a peer-led lifestyle intervention program for diabetes prevention in India: the Kerala diabetes prevention program (K-DPP)

BACKGROUND

Type 2 diabetes mellitus (T2DM) is now one of the leading causes of disease-related deaths globally. India has the world's second largest number of individuals living with diabetes. Lifestyle change has been proven to be an effective means by which to reduce risk of T2DM and a number of "real world" diabetes prevention trials have been undertaken in high income countries. However, systematic efforts to adapt such interventions for T2DM prevention in low- and middle-income countries have been very limited to date. This research-to-action gap is now widely recognised as a major challenge to the prevention and control of diabetes. Reducing the gap is associated with reductions in morbidity and mortality and reduced health care costs. The aim of this article is to describe the adaptation, development and refinement of diabetes prevention programs from the USA, Finland and Australia to the State of Kerala, India.

METHODS

The Kerala Diabetes Prevention Program (K-DPP) was adapted to Kerala, India from evidence-based lifestyle interventions implemented in high income countries, namely, Finland, United States and Australia. The adaptation process was undertaken in five phases: 1) needs assessment; 2) formulation of program objectives; 3) program adaptation and development; 4) piloting of the program and its delivery; and 5) program refinement and active implementation.

RESULTS

The resulting program, K-DPP, includes four key components: 1) a group-based peer support program for participants; 2) a peer-leader training and support program for lay people to lead the groups; 3) resource materials; and 4) strategies to stimulate broader community engagement. The systematic approach to adaptation was underpinned by evidence-based behavior change techniques.

CONCLUSION

K-DPP is the first well evaluated community-based, peer-led diabetes prevention program in India. Future refinement and utilization of this approach will promote translation of K-DPP to other contexts and population groups within India as well as other low- and middle-income countries. This same approach could also be applied more broadly to enable the translation of effective non-communicable disease prevention programs developed in high-income settings to create context-specific evidence in rapidly developing low- and middle-income countries.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry: ACTRN12611000262909 . Registered 10 March 2011.

HPV prevalence in women attending cervical screening in rural Malawi using the cartridge-based Xpert® HPV assay

BACKGROUND AND OBJECTIVES

Early experience with Cepheid Xpert^® HPV assay (Xpert^® HPV) suggests that its quick turnaround time and ease of application might make it a relevant contender for routine use in low and middle income countries (LMICs). In the context of a cervical screening service in rural Malawi, we aimed to assess practicalities of local laboratory testing with Xpert^® HPV and provide preliminary high-risk HPV (HR-HPV) prevalence data.

STUDY DESIGN

Liquid-based cytology (LBC) specimens were collected from women attending cervical screening clinics in Nkhoma, Malawi. Xpert^® HPV testing was carried out according to manufacturer's instructions. Partial genotyping results were obtained immediately (HPV 16, 18/45 and HR-HPV 'other'). Review of individual channel data provided further breakdown of other HR-HPV types into HPV 31 and related; HPV 51/59 and HPV 39 and related.

RESULTS

Valid HR-HPV results were obtained from 750/763 samples. Most samples were from previously unscreened women, with 92.3% aged between 20 and 60 years. Overall HR-HPV positivity was 19.9%, with HR-HPV 'other' being more than twice as frequent as HPV 16 or HPV 18/45 and HPV 31-related (HPV 31, 33, 35, 52 or 58) most prevalent. Known HIV status was low (7.3%), but HR-HPV positivity in this group was much higher (43.4%).

CONCLUSIONS

HR-HPV testing using Xpert^® HPV was practical in a small rural laboratory. The rapid turnaround (within 2h) could facilitate a 'see and treat' programme. Partial genotyping allows assessment of risk beyond HPV 16/18. The high prevalence of HPV 31 and related types warrants further investigation.

Do minimum wages improve early life health? Evidence from developing countries

The impact of legislated minimum wages on the early-life health of children living in low and middle-income countries has not been examined. For our analyses, we used data from the Demographic and Household Surveys (DHS) from 57 countries conducted between 1999 and 2013. Our analyses focus on height-for-age z scores (HAZ) for children under 5 years of age who were surveyed as part of the DHS. To identify the causal effect of minimum wages, we utilized plausibly exogenous variation in the legislated minimum wages during each child's year of birth, the identifying assumption being that mothers do not time their births around changes in the minimum wage. As a sensitivity exercise, we also made within family comparisons (mother fixed effect models). Our final analysis on 49 countries reveal that a 1% increase in minimum wages was associated with 0.1% (95% CI = -0.2, 0) decrease in HAZ scores. Adverse effects of an increase in the minimum wage were observed among girls and for children of fathers who were less than 35 years old, mothers aged 20-29, parents who were married, parents who were less educated, and parents involved in manual work. We also explored heterogeneity by region and GDP per capita at baseline (1999). Adverse effects were concentrated in lower-income countries and were most pronounced in South Asia. By contrast, increases in the minimum wage improved children's HAZ in Latin America, and among children of parents working in a skilled sector. Our findings are inconsistent with the hypothesis that increases in the minimum wage unconditionally improve child health in lower-income countries, and highlight heterogeneity in the impact of minimum wages around the globe. Future work should involve country and occupation specific studies which can explore not only different outcomes such as infant mortality rates, but also explore the role of parental investments in shaping these effects.

Novel implementation research designs for scaling up global mental health care: overcoming translational challenges to address the world's leading cause of disability

Despite established knowledge that Low and Middle Income Countries (LMICs) bear the majority of the world's burden of mental disorders, and more than a decade of efficacy research showing that the most common disorders, such as depression and anxiety, can be treated using readily available local personnel in LMICs to apply evidence-based treatments, there remains a massive mental health treatment gap, such that 75 % of those in LMICs never receive care. Here, we discuss the use of a new type of implementation science study design, the effectiveness-implementation hybrids, to speed the translation and scale up of mental health care in LMICs. We use our current study of Interpersonal Psychotherapy (IPT) delivered by local personnel for depression and trauma-related disorders among HIV+ women in Kenya as an example of effectiveness-implementation hybrid design for mental health services research in LMICs.