[Pharm-policy] Tido on Health Care Infrastructure issue

[James Love]

This was Tido's comment to Act Up Paris on the issue of health care 
infrastructure.  Jamie

Subject: Re: Message from Act Up-Paris
   Date: Sun, 19 Mar 2000 21:45:39 +0700
  From: "MSF-Drugs Bangkok" <msfdrugs@asianet.co.th>


Dear Gaelle,
barev dzez,

the question of health care infrastructure is important and needs to be
discussed more; it is a pity
that the industry, US gov and EU are using this to distract from pricing
policies and therefore make it difficult to discuss it openly. 

Proper supply and use of medicines depends on a long chain of events, from
drug development, production, bulk purchase, distribution etc to rational
prescribing and use. We will never get this chain working if everybody is
blaming another part of the chain instead of fixing their own problems.
This is exactly what the industry is doing by talking about health care
infrastructure. It is ridiculous that the industry is trying to lecture MSF
and other organizations; improving health infrastructure and access to
treatment is what MSF has been doing for 28 years. If an organization like
MSF finally comes out against drug companies than because health care
infrastructure is not the only problem. Of course, improving health care in
developing countries is an uphill struggle but it does not mean that the
industry should not clean in front of their own door. More investment into
research for simpler TB treatment, better, heat stable vaccines etc could
also make it easier to overcome problems of health care infrastructure.

Here in Thailand the problem is not that there is no water in the
hospitals or that the pharmacies are empty. Although access to ARV is
extremely limited I think that the money that is currently spent is mostly
wasted
because of very poor implementation of ART. The main problem is the
paternalistic attitude of doctors that expect patients to remain grateful
and passive without asking questions. Two weeks ago I visited a provincial
hospital that prescribes a lot of AZT+ddI (it is not clear why they have
more money than other hospitals) but let me describe you just one case: a
women comes for her first HIV related visit. No questions
asked by the doctor or the women. The doctor (head of the department!)
looks into her mouth and
diagnoses oral candida (end of examination). He then prescribes AZT, ddI
(ddI in the wrong
dose), INH + Vit B6 (TB prophylaxis), Bactrim and itraconazole (although
fluconazole would be cheaper). None of the medicines is explained to the
patient. She does not dare to ask a question but obviously can not know the
difference between the prescribed vitamin or ARV, does not know about the
side effects, length of treatment etc.
In this province, about 80% of the patients stop ddI within the first two
weeks
(why should they tolerate side effects if they don't know the benefit of
the medicine?). Many people would be able to make a long term commitment to
ART if they had more information, others might not even start if they knew
that this is a long term (hopefully life long) treatment. So the outcome is
extremely bad and money is wasted. Yes, doctors are busy and might not have
enough time to spend with the patient but at least in Thailand this is
often more a problem of bad habit than time. Also, nurses only fill in
papers instead of being part in the counseling.
There are many, many more problems but they are almost all related to
attitude of health staff towards PHA and the quality of the clinic visit
general. This is not about high tech, specialists etc but something much
more basic. 

About lab tests:
Viral load: nice to have but not necessary in order to use ARV
CD4: this is soemthing to aim for in secondary hospitals in Thailand
(provincial hospitals). On the other hand: if we could offer only one
single triple regimen it would be conceivable to only treat all symptomatic
patients even without having a CD4. If there is only one regimen there is
no rush to detect treatment failure because there is nothing to change to. 
Right now about 5% of PHA in Thailand receive ARV: the majority is on
AZT/ddI. If there is no access to CD4, AZT/ddI is started in symptomatic
PHA. Once this regimen fails there is no alternative. This strategy would
make more sense with a triple regimen because most PHA in Thailand present
to hospitals when they are already quite advanced in their HIV disease and
dual therapy is less likely to help.
There should be a possibility to check a blood count, liver functions and
amylase (pancreatitis).
Need for a specialist: not necessarily if there are only a few different
treatment options. More important is to have a physician that is
interested.

What we are working for in the health care system in Thailand:
Use the current budget in a better way:
1. get more drugs for your money by getting generics
2. No need to aim for 100% ARV coverage right away, this is not
economically or practically feasible (maybe 20-30% as a first step). Better
to start with PHA that are really motivated and in settings where the
doctors are willing to spend enough time with the patient.
3. Not advisable to start ARV when there are only 2 minutes/patient! ARV
should not be started if the PHA did not make an informed decision!
4. Only to start ARV if long term supply/funding is possible
5. Good to have CD4 but possible to use ARV even without (under certain
conditions)

My point is that you don't necessarily need a very fancy health care system
with a lot of technology and money but "only" a patient centered system
that is not too overloaded with work.

Again, there are more issues but I hope this gives you a picture.

Regards,
Tido

P.S. It would be nice to get hear more about the experience in Cote
d'Ivoire and other places that you mentioned; please send me a copy if you
write a summary.
----------
> From: gaelle krikorian <galk@compuserve.com>
> To: msfdrugs@asianet.co.th
> Subject: Message from Act Up-Paris
> Date: Thursday, March 09, 2000 12:09 AM
> 
> Hi Tido,
> Pierre Chirac has adviced me to contact you. 
> In order to counter the argument - more and more commonly use by the
> industry and people from the Trades - which say that the lack of
> infrastructures, Health falicities etc in poor countries is more a
problem
> than drug price and trade agreement, we (Act Up-Paris and others
> organizations, Helen from MSF, Jamie from CPT, people from the French
> Campaign for Treatment Access etc.) think that we should adress ourselves
> the issue of Health Care System.
> We think it's important for us to developp our argumentation on this
besides
> our demands about Compulsory licencing and trade. First because we are
> really aware of the fact that access to treatment in developping
countries
> isn't something easy to do (and more Health experts than those people).
> Second because we want to be clear on the fact that it is however
possible
> to do it.
> To build this statement we need data about treatment access field
> experience. We have already some information about ARV access initiative
in
> Ivory Coast, Ouganda, Senegal. We would like to be exhaustive about all
> aspects of access to health care for HIV patients (testing, doctors
> training, counselling, biological and clinical follow up of patients,
access
> to all needed treatments, etc.), to be clear about what is needed and
what
> has to be reinforced.
> In the next months we would like to have cost data to illustrate this so
> that we could also push government and donors to give more money (more
than
> 100 US$ is needed and this has to be clear).
> I hope you see why I mean (sorry for my bad english). Tell me if you
don't.
> Do you think you can help us with this from your experience?
> 
> Gaelle
> 
> PS: about something else : I'm wondering if you have pictures of
> demonstrations you made recently that I could use to illustrate articles
in
> our newsletter about what happen in Thailand ??
> 
> --
> Gaëlle Krikorian
> North/South Commission
> Act Up-Paris
> 
> BP 287 - 75525 Paris cedex 11
> 
> Tel: 33 1 49 29 44 75
> Fax: 33 1 48 06 16 74
> E.mail: galk@compuserve.com
>


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