Karir, Veena; Bygrave, Helen; Cepuch, Christa; Davis, Brett; Elder, Greg; Jobanputra, Kiran; Reddy, Amulya; MSF (2018)
      This is a summary of work undertaken between March 2018 and May 2018 in order to increase understanding of accessibility to medicines for major non-communicable diseases (NCDs) among Jordanians and urban Syrian refugees. It includes multiple facets of accessibility - affordability, availability, price determinants, government and out-of-pocket expenditures, the pharmaceutical and health sectors, and prescriber and consumer behaviours. Overall accessibility to medicines in Jordan for the NCDs studied here is relatively high. However, a minority of the population does not access treatment, mainly due to affordability (predominantly provider costs, but also medicines and transportation costs); these factors are most likely linked to capacity to pay given that expenditures exceed income among Jordanians and urban refugees, the majority of whom report debt. It is imperative to understand that price of medicines cannot be examined in isolation but needs to be considered in relation to capacity to pay, as even very low-priced generic medicines remain out of reach for lower-income households. All World Health Organization (WHO) essential drugs (oral plus insulin) for the NCDs studied here were registered by the Jordan Food and Drug Administration, and procured by the government for the public sector. Based on the literature, public sector availability of medicines for NCDs is generally limited among lower income countries investigated. However, only a minority of urban Syrian refugees reported unavailability of medicines in the Jordanian public sector. From the literature, private sector NCD medication availability is higher and close to 80% among higher income countries and in urban settings; it is also higher in lower income countries, for medicines to treat cardiovascular disease. These findings should hold true for Jordan. Jordan has sufficient healthcare resources. Government expenditure on health exceeds that of many Middle East North Africa (MENA) countries of the same income group, while the population has lower out-of-pocket expenditure compared to the same group of countries. Government purchases of medicines (availability) are likely sufficient for cardiovascular disease, hypertension and non-insulin-dependent diabetes if 65% or fewer of the affected population access the public sector. Most medicines used to treat major NCDs are procured at competitive prices (comparable to the international reference price) by the Jordanian government. Public tendering as well as pricing of medicines is transparent in Jordan. In the private sector, prices are essentially fixed by law, but despite this pricing is heavily influenced by the pharmaceutical sector, whose priorities lie with profitability and in general, the predominant export market. The majority of medicines for major NCDs were determined to be affordable (less than one day’s wage to purchase a 30-day supply) in the public sector, even when multiple drugs were prescribed for hypertension, cardiovascular disease and/or diabetes. Affordability in the private sector is predominantly the case for medicines for hypertension, cardiovascular disease and oral medicines for diabetes; notable exceptions include insulin, fixed-dose combination (FDC) inhalers and statins. Across both sectors, higher costs can be attributable to prescriber practices, consumer preferences and predominance of brand drugs, especially for insulin and FDC inhalers. Risk factors for NCDs among Jordanians and Syrians surpass global averages, driving disability and death. While affordability comes through as the main obstacle in accessing health care, annually Jordanians are spending more on tobacco than medical expenses. Considerations for humanitarian and other implementing organizations: - Prior to engaging in NCD interventions, evaluation of the existing health system is key to determining how to plan (if at all), where along the continuum of NCD care the focus of the response should be and whom to target. - Programming details and operational costs need to factor procurement options, as there may be governmental requirements for local and/or international sourcing. - Prevention possibilities should be reviewed in relation to NCDs given known impact on reducing death and disability.
    • Diabetes service evaluation (2014-2017) – main findings from Mweso, North Kivu, the Democratic Republic of Congo

      Jobanputra, Kiran; Ansbro, Eimhin; MSF OCA (2018-09)
      Médecins sans Frontières (MSF) has been implementing an Integrated Diabetic Clinic within the Outpatient Department of Mweso District General Hospital since 2014 in the insecure conflict-affected area of Mweso in North Kivu in the Democratic Republic of Congo (DRC). The aim of this evaluation was to examine the effectiveness of this diabetes programme, the challenges and facilitators relating to adoption and acceptance by staff and patients, and the lessons learnt from implementation that can be generalised to comparable settings. Specifically, we aimed to identify the essential elements of a simple model of care for diabetes that can be applied in humanitarian contexts.
    • Evaluation of NCD service integrated into a general OPD and HIV service in Matsapha, Eswatini, 2017

      Ansbro, Eimhin; Meyer, Inga; Okello, Velephi; Verdecchia, Maria; Keus, Kees; Piening, Turid; Sadique, Zia; Roberts, Bayard; Perel, Pablo; Jobanputra, Kiran; et al. (2018-09)
      Background: Swaziland faces a growing noncommunicable disease (NCD) burden alongside HIV and TB epidemics. MSF provided primary care services, HIV and TB programmes at Matsapha MOH comprehensive clinic from 2011 to 2018. With MOH collaboration, MSF integrated NCD care into general outpatient (OPD), HIV and TB services in April 2016. A retrospective analysis of routine clinical and programmatic data was undertaken to examine programme processes, effectiveness and costs in order to strengthen the service, facilitate handover and inform MSF and MOH policy and scale-up. The specific objectives were to: 1) describe the care model; 2) examine its effectiveness; 3) examine predictors of NCD treatment outcomes, including HIV status; and 4) determine incremental total and unit service costs. Methods: We undertook a retrospective evaluation of routine data from Matsapha Comprehensive Care Clinic, located outside Manzini, Eswatini’s largest city. This comprised: care model description; routine cohort data analysis to investigate effectiveness of care and predictors of reaching clinical targets; and incremental costing analysis. Enrolment criteria included: a diagnosis of established cardiovascular disease (CVD), hypertension, diabetes mellitus (DM) types 1 or 2, chronic respiratory disease; and committing to regular attendance. Routine clinical data of adults aged 18 or over, enrolled from July 2016 to July 2017, were analysed using descriptive statistics and logistic regression modelling. A costing analysis from the providers’ perspective utilised routine accounting, service and consumption data. Results: Model of care description: We implemented: staff training; locally adapted protocols; chronic care files; a revised appointment system and patient flow; and a new database. Doctors reviewed patients at first visit, and saw complex or unstable patients monthly, resulting in significant workload. Nurses reviewed stable patients three-monthly; patients requiring treatment initiation/adjustment, ad hoc blood testing or external referral were referred back to doctors. Thus, task sharing to nurses did not occur as intended. Specific health literacy, adherence support groups or lay counsellor involvement were lacking. Integrating NCD care resulted in longer consultation times. Repeated medication stock outs occurred despite MSF’s efforts to support the MOH supply chain. Routine cohort data analysis: Of 895 enrolled patients, mean age was 55 years (IQR 5.3 to 10.6); 66% were women, of whom 54.6% were obese. Mean follow-up was 8 months; 16.3% defaulted during the study period. The most common diagnoses at enrolment were: hypertension (85.7%) and DM type 2 (37.4%), asthma (3.8%) and DM type 1 (1.2%). 3 patients had known CVD; none had known chronic obstructive pulmonary disease. At last visit, 60.4% (n=608) of hypertensive patients and 63.3% (n=289) of diabetics were at target. Obesity and HIV positivity were weakly associated with an increased risk of uncontrolled hypertension. Descriptive costing analysis: Total 2016 incremental financial costs were: INT$437,228. The principle costs drivers were human resources (61% of total) and drugs (18%; insulin accounting for a quarter). Per patient per year (PPPY) incremental costs (INT$ 448.52) were similar to those reported for chronic HIV programmes. Conclusions and Lessons Learned: NCD care can be integrated into a HIV department and OPD setting in an MSFsupported primary care centre by utilising pre-existing structures, and can achieve acceptable intermediate clinical outcomes and retention rates at a cost that is similar to HIV programmes. The current model of NCD care is complex and time consuming, resulting in significant doctor workload. Streamlined, algorithm-driven protocols and work with the local government to extend prescribing rights for NCD medications to nurses may facilitate task sharing and decentralisation of care. Drug supply chain strengthening is required and advocacy around drug prices could reduce programme costs. Inclusion of specific treatment support and adherence counselling, learning lessons from HIV and TB care, is also essential to integrating NCD care into pre-existing services.
    • Mixed methods evaluation of MSF primary care based NCD service in Irbid, Jordon: February 2017 - February 2018

      Ansbro, Eimhin; Homan, Tobias; Jobanputra, Kiran; Rehr, Manuela; Ellithy, S; Quasim, Jamil; Tanni, Hashem; Garrett, Peter; Shoaib, Muhammad; Bil, Karla; et al. (2018-09)
      Non-communicable diseases (NCD) are the leading causes of mortality and morbidity among Syrian refugees in Jordan. Following the onset of the Syrian crisis in 2011, the Jordanian health system was overwhelmed by the chronic disease burden among this group. In response, in late 2014, Médecins sans Frontières Operational Centre Amsterdam (MSF-OCA) opened an NCD service at two primary care centres targeting non-camp based Syrian refugees and vulnerable Jordanians in Irbid, north Jordan, using a multi-disciplinary primary care model. The programme focused on the NCDs causing most deaths in pre-war Syria: cardiovascular disease (CVD), including hypertension, diabetes (DM), and chronic respiratory disease. The model evolved in response to patient needs, programmatic lessons learned and contextual changes. A programme evaluation was done, aiming to refine the model, generate evidence on its feasibility, acceptability and effectiveness and learn lessons to inform translation of a similar model of NCD care to comparable humanitarian settings.
    • Non-Communicable Diseases - programmatic and clinical guidelines

      Jobanputra, Kiran; MSF OCA (MSF OCA, 2018-03)