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Médecins Sans Frontières (MSF) welcomes the analysis of the cost of manufacturing of human and analogue insulins by Gotham and colleagues. This work provides a realistic estimate of significantly lower market prices that would be more affordable for both governments and individuals and should open the eyes of the global health community to the shameful reality of abusive pricing as well as the gross inequity in access to treatment for people living with diabetes.
In resource-limited settings, access to insulin is centralised and rarely free of charge within the public health system. For those who can access insulin, many must travel once or often twice daily to a clinic to receive their injections, due to fears around home storage of phials and self-injecting - particularly in conflict-affected or insecure settings.
Human insulin is the only type of insulin included on the WHO Essential Medicines List (EML), and when procured in phials, costs significantly less than analogue insulin or insulin within an adapted device (cartridge or pen) which may simplify delivery. Debates continue around the impact of analogue insulins on diabetes outcomes (HbA1c), but many experts recognise that access may make regimens safer, particularly in settings where MSF works.
The market dominance of and excessive pricing by the three major human and analogue insulin producing companies - along with the lack of competition from biosimilar manufacturers to challenge this d...
Médecins Sans Frontières (MSF) welcomes the analysis of the cost of manufacturing of human and analogue insulins by Gotham and colleagues. This work provides a realistic estimate of significantly lower market prices that would be more affordable for both governments and individuals and should open the eyes of the global health community to the shameful reality of abusive pricing as well as the gross inequity in access to treatment for people living with diabetes.
In resource-limited settings, access to insulin is centralised and rarely free of charge within the public health system. For those who can access insulin, many must travel once or often twice daily to a clinic to receive their injections, due to fears around home storage of phials and self-injecting - particularly in conflict-affected or insecure settings.
Human insulin is the only type of insulin included on the WHO Essential Medicines List (EML), and when procured in phials, costs significantly less than analogue insulin or insulin within an adapted device (cartridge or pen) which may simplify delivery. Debates continue around the impact of analogue insulins on diabetes outcomes (HbA1c), but many experts recognise that access may make regimens safer, particularly in settings where MSF works.
The market dominance of and excessive pricing by the three major human and analogue insulin producing companies - along with the lack of competition from biosimilar manufacturers to challenge this dominance - has contributed to the reality that worldwide at least 50% of those in need of insulin are not able to access this life saving treatment. As Gotham and colleagues’ work clearly outlines, the cost differentials in manufacturing a phial of human insulin ($2.28 – $3.42) versus analogue insulin ($3.69 - $6.16) are not reflected in current market prices. Indeed, insulin prices around the world lie far above these ranges, with often excessively high price differentials between human and analogue. The abusive pricing strategies of pharmaceutical corporations must be challenged in light of the limited access globally, and in low income and humanitarian settings in particular.
The majority of insulin that MSF procures is human insulin in phials, from Lily and Novo Nordisk, two of the three insulin market dominators. Activism by people living with HIV, MSF and other advocates for affordable generic antiretrovirals (ARVs) and a coordinated donor response resulted in over 20 million people currently receiving treatment for HIV. The current lack of competitive biosimilar insulins – similar to the lack of generic ARVs 20 years ago – is a huge hurdle to overcome in ensuring access for people living with diabetes today. Regulatory pathways for biosimilars and lack of transparency across price negotiations are just two of the factors challenging competition in the insulin market.
People living with diabetes need insulin today, and the lack of access in 2018 is an outrage. MSF supports a coordinated global response to ensure quality, affordable human and analogue insulin formulations are available in adapted delivery devices for people in need of this life-saving treatment.
Dear Editor, We have read with interest the paper ‘Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015’ by Keats et. al (May, 2018). The authors discuss drivers of change in mortality of under five year old children in Kenya in relation to health systems, policies and financing. We believe that further discussion of conflict and governance is required in order to understand Kenya’s progress towards sustainable development. The Composite Coverage Index (CCI) calculates the coverage of preventive and curative interventions. The index looks at coverage of family planning, skilled birth attendance, skilled antenatal care, BCG-measles and DPT3 vaccinations, diarrhoea treatment and pneumonia care. We agree that increasing health workforce increases coverage of interventions and raises the CCI. In contrast, the CCI remains low in areas of conflict, displaced populations and refugee settlements despite existence of a high health workforce. For example, in the North Rift Valley and North Eastern counties (except Turkana) there is a lower CCI than in southern counties (such as Tana River, Narok, Kajiado and Kilifi) despite a larger workforce [2]. Although refugee settlement areas receive huge workforce support from humanitarian organisations and the government for coverage of interventions targeted towards health of children under five, a household and death survey carried out by Médecins Sans...
Dear Editor, We have read with interest the paper ‘Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015’ by Keats et. al (May, 2018). The authors discuss drivers of change in mortality of under five year old children in Kenya in relation to health systems, policies and financing. We believe that further discussion of conflict and governance is required in order to understand Kenya’s progress towards sustainable development. The Composite Coverage Index (CCI) calculates the coverage of preventive and curative interventions. The index looks at coverage of family planning, skilled birth attendance, skilled antenatal care, BCG-measles and DPT3 vaccinations, diarrhoea treatment and pneumonia care. We agree that increasing health workforce increases coverage of interventions and raises the CCI. In contrast, the CCI remains low in areas of conflict, displaced populations and refugee settlements despite existence of a high health workforce. For example, in the North Rift Valley and North Eastern counties (except Turkana) there is a lower CCI than in southern counties (such as Tana River, Narok, Kajiado and Kilifi) despite a larger workforce [2]. Although refugee settlement areas receive huge workforce support from humanitarian organisations and the government for coverage of interventions targeted towards health of children under five, a household and death survey carried out by Médecins Sans Frontières showed measles and diarrhea (variables of the CCI) still contributed to the major causes of under five deaths in these areas [3]. There is a gap if coverage here is low despite there being a large workforce. Under usual circumstances when there is not conflict, a large workforce is associated with an increase in CCI. However, this situation does not exist when there is conflict and political upheavals notwithstanding the larger workforce as this does not mitigate against the ravages of internal conflict. Devolution is a type of decentralisation where central government transfers authority to the local government. Devolution occurred in Kenya where political and economic powers were transferred to 47 counties. As a result of this administrative change, decisions were made at the county level by local people rather than at a national level to fulfil their needs according to local factors. However, devolution to counties did not ensure that all citizens received services as some ethnic minorities were without proper services and unable to access benefits due to lack of support at the county level [1]. Table 1 shows that advantaged and disadvantaged groups under devolution have unequal access and distribution of resources. This raises the question: how does the role of decentralised governance justify equity? We believe that human resource capacity plays an important role in the performance of a devolved government. Around 200,000 displaced Somalis seek home in refugee camps in northern Kenya. Due to the large population of Somali people in the camps, outbreaks of diseases and delays in registration affecting provision of food are common. Clearly, the humanitarian as well as governmental actions to control the under-five deaths in refugee population have failed [3]. A review of early implementation of devolution in Kilifi county of Kenya carried out by Tsofa et. al (2017), showed that insufficient human resource capacity caused confusion over management roles, and political interference with management led to job dissatisfaction which resulted in a low retention of the workforce [4]. With these effects and workforce attrition, the county capacity will be inadequate to manage large refugee populations. We agree that decentralisation of governance has shown improved healthcare impacts in developing countries such as South Africa and Rwanda. However, contextual factors like political upheavals affect the maximum benefits that can be achieved through decentralisation. When planning healthcare services, policies and financing consideration should be given to the impact of conflict, refugees, ethnic minorities and displaced populations. Discussion and research focusing on governance in disadvantaged areas will help Kenya to further reduce under-five mortality by identifying if the current governance and its capacity works best within the given circumstances. References: 1. D'Arcy, M., & Cornell, A. (2016). Devolution and corruption in Kenya: Everyone's turn to eat? African Affairs, 115(459), 246-273. 2. Keats, E. C., Macharia, W., Singh, N. S., Akseer, N., Ravishankar, N., Ngugi, A. K., Rizvi, A., Khaemba, E. N., Tole, J., & Bhutta, Z. A. (2018). Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015. BMJ global health, 3(3), e000655. 3. Polonsky, J. A., Ronsse, A., Ciglenecki, I., Rull, M., & Porten, K. (2013). High levels of mortality, malnutrition, and measles, among recently-displaced Somali refugees in Dagahaley camp, Dadaab refugee camp complex, Kenya, 2011. Conflict and health, 7(1), 1. 4. Tsofa, B., Goodman, C., Gilson, L., & Molyneux, S. (2017). Devolution and its effects on health workforce and commodities management–Early implementation experiences in Kilifi County, Kenya. International journal for equity in health, 16(1), 169.
Table 1
Winners and losers under devolution
Group members with a home county who live in their home county
Group members who live outside home county/ groups who lack a home county
Dear Editor,
We read with interest the paper: ‘Geographic coverage of demographic surveillance systems for characterising the drivers of childhood mortality in sub-Saharan Africa’ (1). This paper raises a few points that we would like to discuss (1). We focus on the authors’ extrapolation of findings from their study on children’s under five mortality [U5M] rates to the entire sub-Saharan Africa region. Other determinants we discuss include urban-rural disparities, factors that affect accessibility to health care services and the effect of political conflict in the region on under five mortality rates.
Firstly, we discuss the use of data from the east and the west regions in Africa generalised to the entire Sub Saharan Africa [SSA] region (1). The regions covered in the analysis are represented in figure 1 of the original paper by Utazi et al. (1). They point out that civil and vital registration systems are incomplete and weak in SSA (1) which makes data derived from Health and Demographic Surveillance Systems [HDSS] more important to monitor trends and causes of under-five mortality in the region (1). Although many countries in SSA region have similar features and characteristics, analysis from a limited number of countries from either the east or the west of SSA should not be used to generalise to all countries in the SSA region (2). The disadvantages of using data generalised to the broad SSA region were discussed by Cooper et al (2). We believe the resu...
Dear Editor,
We read with interest the paper: ‘Geographic coverage of demographic surveillance systems for characterising the drivers of childhood mortality in sub-Saharan Africa’ (1). This paper raises a few points that we would like to discuss (1). We focus on the authors’ extrapolation of findings from their study on children’s under five mortality [U5M] rates to the entire sub-Saharan Africa region. Other determinants we discuss include urban-rural disparities, factors that affect accessibility to health care services and the effect of political conflict in the region on under five mortality rates.
Firstly, we discuss the use of data from the east and the west regions in Africa generalised to the entire Sub Saharan Africa [SSA] region (1). The regions covered in the analysis are represented in figure 1 of the original paper by Utazi et al. (1). They point out that civil and vital registration systems are incomplete and weak in SSA (1) which makes data derived from Health and Demographic Surveillance Systems [HDSS] more important to monitor trends and causes of under-five mortality in the region (1). Although many countries in SSA region have similar features and characteristics, analysis from a limited number of countries from either the east or the west of SSA should not be used to generalise to all countries in the SSA region (2). The disadvantages of using data generalised to the broad SSA region were discussed by Cooper et al (2). We believe the results of this study may have more impact if the study had included all countries in SSA.
The paper by Utazi et al mentions risk factors that influence under five mortality, these include the prevalence of preventable diseases, maternal risk factors, sanitation practices and prevalence of stunting (1). The protective factors mentioned in the paper include education of women, vaccination coverage and access to healthcare facilities (1). These authors discuss the similarities between Health and Demographic Surveillance Systems [HDSS] sites located in urban areas compared to rural areas (1). They determined that the urban areas had higher levels of protective factors and lower levels of risk factors (1). However, the level of infrastructure, urban-rural disparities and presence of intervention strategies in urban areas could be attributed to these findings (3, 4). As Urban areas are easily accessible and tend to have basic infrastructure in place (3), intervention strategies can be implemented with relative ease in urban areas. Similarities between countries in U5M rates in urban areas could be due to urban-rural disparities, infrastructure and accessibility of intervention strategies, which are common features in many low and middle income countries (3, 4).
In our last point we consider political conflict in a region as a determinant of U5M rates (5). A study based in South Sudan discussed the effect of conflict-related health inequities and inequitable conditions of daily living on U5M (5). Healthcare service delivery becomes a challenge in regions where violence and conflict remain (5). Furthermore, in the region of South Sudan, where conflict and displacement persists, children in urban areas were at greater risk of dying before their fifth birthday, than those living in rural areas (5).
We agree with the fact that HDSS sites are an important and comprehensive tool for monitoring child mortality and influencing policies related to child mortality. However, the geographical variation in the factors associated with mortality should not be confined to only risk and protective factors as highlighted in this paper (1). We suggest that the variations should also consider factors such as political conflict, displacement and urban rural disparities.
The implications for future research point to the need for an inclusion of all countries in SSA rather than selected countries that cluster on the east and west of SSA. We have highlighted the importance of considering underlying determinants of conflict and disparities, when analysing the relationship between under five mortality rates and geospatial variables.
Reference List:
1. Utazi CE, Sahu SK, Atkinson PM, Tejedor-Garavito N, Lloyd CT, Tatem AJ. Geographic coverage of demographic surveillance systems for characterising the drivers of childhood mortality in sub-Saharan Africa. BMJ Global Health. 2018;3(2).
2. Cooper RS, Osotimehin B, Kaufman JS, Forrester T. Disease burden in sub-Saharan Africa: what should we conclude in the absence of data? The Lancet. 1998;351(9097):208-10.
3. Mulholland E, Smith L, Carneiro I, Becher H, Lehmann D. Equity and child-survival strategies. Bulletin of the World Health Organization. 2008;86:399-407.
4. Beatriz ED, Molnar BE, Griffith JL, Salhi C. Urban-rural disparity and urban population growth: A multilevel analysis of under-5 mortality in 30 sub-Saharan African countries. Health & place. 2018;52:196-204.
5. Mugo NS, Agho KE, Zwi AB, Damundu EY, Dibley MJ. Determinants of neonatal, infant and under-five mortality in a war-affected country: analysis of the 2010 Household Health Survey in South Sudan. BMJ Global Health. 2018;3(1).
This article is a valuable addition to guide researches in planning and conducting implementation research (IR). As a complement to this paper we would like to draw attention to a paper on the ethical issues relating to IR, which deserve specific consideration by researchers and must be taken into account by research ethics committees reviewing IR as outlined in https://implementationscience.biomedcentral.com/articles/10.1186/s13012-.... Specifically community engagement, sustainability, scalability, identification of all stakeholders and research participants and monitoring to anticipate/avoid harm is crucial. All ethical considerations must be taken into account from the planning stage and throughout the research activity.
Massuda and colleagues have recently published at BMJ Global Health a paper entitled “The Brazilian health system at crossroads: progress, crisis and resilience” describing the Brazilian health system and its challenges in health system financing, coverage, resource allocation and the impact over the regional disparities in access to healthcare services and health outcomes.
Brazil is a large country with an estimated population of approximately 209 million inhabitants. The Universal Health Coverage provided by Brazilian Unified Health System (SUS) is a constitutional right of every citizen. According to the National Supplementary Health Agency (ANS) in May 2018 only 22.7% of Brazilians had private insurance plans, with a 12% decrease in relative numbers during the last 30 months due to the local political and economic crisis [1].
Every two years the Brazilian National Cancer Institute generates data on cancer. According to the last publication 600,000 new cases are expected for 2018 [2]. Currently cancer is the second most common cause of death in Brazil [2].
Since the middle of the last century, the scientific understanding of cancer began to rise. This enabled the development of novel therapeutic interventions, such as new surgical techniques, modern radiotherapy, cytotoxic agents and more recently, targeted therapy and immunotherapy, giving place to a growing number of oncological interventions to combat cancer, improving quality of life, overall survi...
Massuda and colleagues have recently published at BMJ Global Health a paper entitled “The Brazilian health system at crossroads: progress, crisis and resilience” describing the Brazilian health system and its challenges in health system financing, coverage, resource allocation and the impact over the regional disparities in access to healthcare services and health outcomes.
Brazil is a large country with an estimated population of approximately 209 million inhabitants. The Universal Health Coverage provided by Brazilian Unified Health System (SUS) is a constitutional right of every citizen. According to the National Supplementary Health Agency (ANS) in May 2018 only 22.7% of Brazilians had private insurance plans, with a 12% decrease in relative numbers during the last 30 months due to the local political and economic crisis [1].
Every two years the Brazilian National Cancer Institute generates data on cancer. According to the last publication 600,000 new cases are expected for 2018 [2]. Currently cancer is the second most common cause of death in Brazil [2].
Since the middle of the last century, the scientific understanding of cancer began to rise. This enabled the development of novel therapeutic interventions, such as new surgical techniques, modern radiotherapy, cytotoxic agents and more recently, targeted therapy and immunotherapy, giving place to a growing number of oncological interventions to combat cancer, improving quality of life, overall survival or even curing patients with advanced tumors.
On the other hand, the economic burden of cancer care is a worldwide debate, as cancer cost is not only a problem for the developing world. Healthcare resource utilization and economic outcomes in this field are themes under substantial discussion.
Despite conceptually having full-coverage at public health care, Brazilians diagnosed with cancer suffer with long waiting times, delays in scheduling medical appointments, shortage of chemotherapeutic agents, backwardness in pathological reports, paucity of human resources and radiotherapy machines and lately the lack of widespread availability of newer technologies in the public health system [3]. In the prevailing Brazilian public health care environment, most of the new drugs for cancer are not affordable and minor investments in equipment and infrastructure were performed over the last years, resulting in great inequities in cancer care and outcomes comparing to the Brazilians covered by private insurance plans which provides the entire cancer treatment approved by the regulatory agency for local use [4].
In this scenario of many competing health needs, limited resources and inequalities in health access, cancer care is a real challenge if the benefits of the remarkable advancements in oncology are planned for the entire Brazilian cancer population. At this rate, resilience could be the perfect word. However, the concept described by Nassim Taleb in his book Antifragile must be put in practice [5]. Antifragility goes beyond resilience. The resilient is able to resist, but the antifragile improves with stressors. This grim scenario in the public health care system can be an opportunity to discuss its inefficiencies, health-economics driven processes to incorporate new technologies, rational precision medicine-based patient selection, and even its financing. The bottom line is to improve a public health system that is indispensable in a country so unequal as Brazil.
References:
1 - http://www.ans.gov.br/perfil-do-setor/dados-gerais - accessed on July 2018
2 - http://www.inca.gov.br/estimativa/2018 - accessed on July 2018
3 - Paulino, E; de Melo, AC; Nogueira-Rodrigues, A; Thuler, LCS . Gynecologic cancer in Brazil and the law of sixty days. Journal of Gynecologic Oncology 2018;29(3):e44.
4 - Liedke, PER; Finkelstein, DM; Szymonifka, J; Barrios, CH; Chavarri-Guerra, Y; Bines, J; Vasconcelos, C; Simon, SD; Goss, PE. Outcomes of breast cancer in Brazil related to health care coverage: a retrospective cohort study. Cancer Epidemiology, Biomarkers & Prevention 2013; 23:126-33.
5 - Antifragile: Things that gain form disorder. Nassim Nicholas Taleb, Ed Random House, 2012
To an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited...
To an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited reasons (5). Since centuries, the burden of pregnancy-related sufferings is very high in African and Asian countries. With all said above, I strongly commend the authors (1) for the challenges they have taken towards estimation of the pregnancy-related health crisis in India, Pakistan, Kenya, and Malavi. Regularization, standardization, and effectiveness are warned in pregnancy cares. In summary, India needs to act fast and effective to achieve the set sustainable developmental goals for safeguarding women's health.
Garg et al. provide a useful, but somewhat incomplete, economic perspective on Community Management of Acute Malnutrition (CMAM) in India. Potential returns, like cost per recovered child, adjusted for spontaneous improvement under the existing system, are crucial for policy makers. Sixteen weeks after completion of the treatment phase (sustenance phase), only 123/838 children (14.7%) met the definition of recovery.1 For simplicity’s sake, we ignore: (i) anticipated lower recovery rates in public programme settings; and (ii) costs for linkages with the government-run Anganwadi centres for supplementary food during the sustenance phase.1 With these assumptions, our calculation of costs per recovered child are 6.8 (100/14.7) times higher than those of Garg et al.: US$ 1575/- (Rs. 97,650/-) and US$ 381 (Rs. 23,622/-) in research and Government settings, respectively. Further, annual budgetary requirements may be considerably higher due to non-response, relapse, and fresh cases of Severe Acute Malnutrition (SAM). Data from rural Meerut, near Delhi, provides a ballpark estimate of spontaneous recovery rates (27%) within a similar follow-up period.2 Actual costs per child recovered, even unadjusted for potentially equivalent spontaneous healing, are thus much higher than those quoted by Garg et al. However, they offer no cost-effectiveness analysis reporting cost per life saved or Disability-Adjusted Life Year averted to enable robust comparisons with the existing system or oth...
Garg et al. provide a useful, but somewhat incomplete, economic perspective on Community Management of Acute Malnutrition (CMAM) in India. Potential returns, like cost per recovered child, adjusted for spontaneous improvement under the existing system, are crucial for policy makers. Sixteen weeks after completion of the treatment phase (sustenance phase), only 123/838 children (14.7%) met the definition of recovery.1 For simplicity’s sake, we ignore: (i) anticipated lower recovery rates in public programme settings; and (ii) costs for linkages with the government-run Anganwadi centres for supplementary food during the sustenance phase.1 With these assumptions, our calculation of costs per recovered child are 6.8 (100/14.7) times higher than those of Garg et al.: US$ 1575/- (Rs. 97,650/-) and US$ 381 (Rs. 23,622/-) in research and Government settings, respectively. Further, annual budgetary requirements may be considerably higher due to non-response, relapse, and fresh cases of Severe Acute Malnutrition (SAM). Data from rural Meerut, near Delhi, provides a ballpark estimate of spontaneous recovery rates (27%) within a similar follow-up period.2 Actual costs per child recovered, even unadjusted for potentially equivalent spontaneous healing, are thus much higher than those quoted by Garg et al. However, they offer no cost-effectiveness analysis reporting cost per life saved or Disability-Adjusted Life Year averted to enable robust comparisons with the existing system or other interventions.
The cost of A-HPF (Augmented, Energy-Dense, Home-Prepared Food) was overestimated: (i) food was supplied at 1.5 times assumed requirements along with fuel, which merited costing or additional benefits adjustment; (ii) in Government programme, food procurement costs will be substantially lower because of expected integration with Public Distribution System and National Food Security Act; (iii) for bulk procurement, multivitamin mineral mix costs would be lower than pharmaceutical syrup used; (iv) as with exclusion of hospitalisation expenses, iron supplementation costs for anemic children should not be included because it is part of the National Iron Plus Initiative; (v) long-term benefits for the index child and family members, of extra counselling time for preparing various recipes needed to be factored in. Similarly, in the RUTF-L (Locally produced ready-to-use food) arm, employment and local economy benefits could have been accounted for.
It is unrealistic to expect a meagrely incentivised (INR 150) ASHA with several competing responsibilities to provide the same intensity and efficiency of ‘peer support’ as in the trial (incentive INR 700). The government guidelines cited to justify the ASHA incentive actually pertain to USHAs in urban contexts, which are awaiting implementation. Considering the potential for spontaneous recovery and lack of robust cost-effectiveness data from a “real world” Indian setting, a recommendation for scaling up CMAM through ASHAs is very premature.
Finite resources for public health spending invariably compel governments in LMICs to choose among interventions labelled as “very cost-effective”. An illustrative dilemma in Government setting comprises choices between cost of recovery for one SAM child, maternity cash entitlement (INR 6000) for four women, enrolling 20-24 additional families for Ayushman Bharat (annual health insurance cover of INR 5 lakh)3, or eggs twice a week for 46-58 children. All stakeholders, particularly the intended beneficiaries, should be an integral part of such selection process.4
References
1. Bhandari N, Mohan SB, Bose A, Iyengar SD, Taneja S, Mazumder S, Pricilla RA, Iyengar K, Sachdev HS, Mohan VR, Suhalka V, Yoshida S, Martines J, Bahl R, for the Study Group. Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition: a randomised trial in India. BMJ Global Health 2016;1:e000144. doi:10.1136/bmjgh-2016-000144.
2. Sachdev HS, Sinha S, Sareen N, Pandey RM, Kapil U. Survival and recovery in severely wasted under-five children without community management of acute malnutrition programme. Indian Pediatr 2017;54:817-24.
3. FE Bureau. Modicare: Cabinet nod for Ayushman Bharat. Financial Express, New Delhi, March 22, 2018. https://www.financialexpress.com/industry/modicare-cabinet-nod-for-ayush... accessed April 18, 2018.
4. Marseille E, Larson B, Kazi DS, Kahn JG, Rosen S. Thresholds for the cost–effectiveness of interventions: alternative approaches. WHO Bulletin 2015;93:118-24.
The information conveyed by Valerie Evans, Peter Roderick, and Allyson Pollock is compelling and of serious concern. While I agree that the explosion of brand-name fixed dose combination (FDC) medications in the Indian market is not safe or rational, I worry that the presentation of the information in this analysis may create some hysteria based on some of the lay media coverage of this study. It is unfortunate that there is such little clinical evidence on the safety and efficacy of the most commonly used Metformin FDCs that are sold to treat type 2 diabetes in India, but is irresponsible to publish such an article without some discussion of the potential harms that could come from abruptly stopping the Metformin FDCs .
I agree that “the convenience of FDCs should not trump efficacy” - but there is already significant distrust in Western medicine by many patients in India without further added hysteria. The authors of this study bring to light the importance of tighter regulation and improved standards for the pharmaceutical industry in India, but the paper would have been better with a more evenhanded presentation of the information. Efficacy data on the Metformin FDCs may be limited, but there is no telling the degree of hyperglycemic crises that may emerge if many patients stop all their medications on the basis of lay media coverage of this analysis without first consulting with their prescribing physicians.
Donkin et al have highlighted the constructive steps being taken to implement policy change facilitating the Social Determinants of Health (SDH) across the globe 1. Although progress is not universal, what has been achieved deserves praise.
We write, however, to highlight one key omission from the standard SDH model: religious faith. This deserves greater recognition as a social determinant of health for two reasons. First, is scale: a recent study demonstrated that 84% of the world’s 7.4 billion people affiliated themselves to a religious group 2. Second is the impact of religious faith on health, shaping both health beliefs and use of healthcare services 3.
Theories of supernatural causation of illness are ancient and diverse. They are also universal: a 1980 study of health belief systems worldwide found evidence that supernatural causes of illness “far outweigh” natural ones 4. Of course many such models may be counter to the Western biomedical model. They should, however, still be acknowledged, not least because when believers encounter Western biomedicine the two models typically become mixed without any sense of conflict.
The close link between healthcare services and religion is evident in both the historical (for example, medieval Christian hospitals in Europe) and contemporary (e.g. faith-based non-governmental organisations worldwide) contexts. The relationship between religion and healthcare is not confined to simple delivery. Religious fait...
Donkin et al have highlighted the constructive steps being taken to implement policy change facilitating the Social Determinants of Health (SDH) across the globe 1. Although progress is not universal, what has been achieved deserves praise.
We write, however, to highlight one key omission from the standard SDH model: religious faith. This deserves greater recognition as a social determinant of health for two reasons. First, is scale: a recent study demonstrated that 84% of the world’s 7.4 billion people affiliated themselves to a religious group 2. Second is the impact of religious faith on health, shaping both health beliefs and use of healthcare services 3.
Theories of supernatural causation of illness are ancient and diverse. They are also universal: a 1980 study of health belief systems worldwide found evidence that supernatural causes of illness “far outweigh” natural ones 4. Of course many such models may be counter to the Western biomedical model. They should, however, still be acknowledged, not least because when believers encounter Western biomedicine the two models typically become mixed without any sense of conflict.
The close link between healthcare services and religion is evident in both the historical (for example, medieval Christian hospitals in Europe) and contemporary (e.g. faith-based non-governmental organisations worldwide) contexts. The relationship between religion and healthcare is not confined to simple delivery. Religious faith can influence the way individuals approach and access healthcare services available 3.
If evidence of the importance of religious faith is required, one need look no further than social and psychological resilience. Religious faith features powerfully in the stories of some of the most vulnerable populations, for example survivors of military conflict and torture. Faith is also recognised as an independent protective factor against depression and suicide 5. Increased rates of migration, conflict, and the epidemiological transition towards chronic physical and mental conditions are likely to make religious faith more relevant to health on a national and global level.
We argue that faith operates beyond social capital and may not be captured through other secular social concepts such as community, social cohesion or culture. Researchers and policymakers are unlikely to harness positive aspects of religious faith if its status as a key social determinant of health is unacknowledged. Such recognition is also important to ensure that the influence of religious faith – positive and negative – is incorporated in undergraduate and postgraduate medical curriculums.
We hope that this letter serves as a stimulus to greater recognition of religious faith within the social determinants of health.
References:
1. Donkin A, Goldblatt P, Allen J, Nathanson V, Marmot M. Global action on the social determinants of health. BMJ Glob Health. 2018;3(Suppl 1):e000603.
2. The Changing Global Religious Landscape. Pew Research Center; April 5, 2017.
3. Shenouda JEA, Cooper MJF. "One Big Family": Pastoral Care and Treatment Seeking in an Egyptian Coptic Church in England. J Relig Health. 2017;56(4):1450-9.
4. Murdock, GP. “Theories of Illness. A world survey”. University of Pitsburgh Press, 1980 page 26.
5. Norko MA, Freeman D, Phillips J, Hunter W, Lewis R, Viswanathan R. Can Religion Protect Against Suicide? J Nerv Ment Dis. 2017;205(1):9-14.
We, read with interest the article by Garg et al on costing of therapeutic feeds.
We report our results on a similar trial conducted on 1092 tribal children of SAM,randomly given 3 therapeutic feeds i.e .C-RUTF(commercially produced ready to use therapeutic food),L-RUTF (locally produced RUTF) and ARF(Amylase rich energy dense food) giving 550,513 and 420 kcals respectively.Pea nut paste,sugar ,milk powder,oil were common ingredients,in identical proportions in C-RUTF and L-RUTF while ARF contained amylase rich flour instead of peanut paste.Micro nutrients were present in all three alike.At the end of 8 weeks of treatment,52.8% recovered in C-RUTF group,43.5% in L-RUTF group and 44.8% recovered in ARF group; the difference being statistically significant.The cost of treatment was 63, 59 and 43 USD approx. in the 3 groups respectively.Thus, though cost of ARF was the least compared to C-RUTF and L-RUTF ,recovery rates in ARF group were also compromised.The logistics of preparing the feeds in tribal village Anganwadis,issues of cleanliness in food preparation,time and labour required were also matters of concern.All these factors will require consideration while scaling up of community management of SAM.
The clinical trial was registered under clinical trial registry of India,no.CTRI/2014/09/004958 and the data is the property of the Govt. of Maharashtra,India.
Médecins Sans Frontières (MSF) welcomes the analysis of the cost of manufacturing of human and analogue insulins by Gotham and colleagues. This work provides a realistic estimate of significantly lower market prices that would be more affordable for both governments and individuals and should open the eyes of the global health community to the shameful reality of abusive pricing as well as the gross inequity in access to treatment for people living with diabetes.
In resource-limited settings, access to insulin is centralised and rarely free of charge within the public health system. For those who can access insulin, many must travel once or often twice daily to a clinic to receive their injections, due to fears around home storage of phials and self-injecting - particularly in conflict-affected or insecure settings.
Human insulin is the only type of insulin included on the WHO Essential Medicines List (EML), and when procured in phials, costs significantly less than analogue insulin or insulin within an adapted device (cartridge or pen) which may simplify delivery. Debates continue around the impact of analogue insulins on diabetes outcomes (HbA1c), but many experts recognise that access may make regimens safer, particularly in settings where MSF works.
The market dominance of and excessive pricing by the three major human and analogue insulin producing companies - along with the lack of competition from biosimilar manufacturers to challenge this d...
Show MoreDear Editor, We have read with interest the paper ‘Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015’ by Keats et. al (May, 2018). The authors discuss drivers of change in mortality of under five year old children in Kenya in relation to health systems, policies and financing. We believe that further discussion of conflict and governance is required in order to understand Kenya’s progress towards sustainable development. The Composite Coverage Index (CCI) calculates the coverage of preventive and curative interventions. The index looks at coverage of family planning, skilled birth attendance, skilled antenatal care, BCG-measles and DPT3 vaccinations, diarrhoea treatment and pneumonia care. We agree that increasing health workforce increases coverage of interventions and raises the CCI. In contrast, the CCI remains low in areas of conflict, displaced populations and refugee settlements despite existence of a high health workforce. For example, in the North Rift Valley and North Eastern counties (except Turkana) there is a lower CCI than in southern counties (such as Tana River, Narok, Kajiado and Kilifi) despite a larger workforce [2]. Although refugee settlement areas receive huge workforce support from humanitarian organisations and the government for coverage of interventions targeted towards health of children under five, a household and death survey carried out by Médecins Sans...
Show MoreDear Editor,
Show MoreWe read with interest the paper: ‘Geographic coverage of demographic surveillance systems for characterising the drivers of childhood mortality in sub-Saharan Africa’ (1). This paper raises a few points that we would like to discuss (1). We focus on the authors’ extrapolation of findings from their study on children’s under five mortality [U5M] rates to the entire sub-Saharan Africa region. Other determinants we discuss include urban-rural disparities, factors that affect accessibility to health care services and the effect of political conflict in the region on under five mortality rates.
Firstly, we discuss the use of data from the east and the west regions in Africa generalised to the entire Sub Saharan Africa [SSA] region (1). The regions covered in the analysis are represented in figure 1 of the original paper by Utazi et al. (1). They point out that civil and vital registration systems are incomplete and weak in SSA (1) which makes data derived from Health and Demographic Surveillance Systems [HDSS] more important to monitor trends and causes of under-five mortality in the region (1). Although many countries in SSA region have similar features and characteristics, analysis from a limited number of countries from either the east or the west of SSA should not be used to generalise to all countries in the SSA region (2). The disadvantages of using data generalised to the broad SSA region were discussed by Cooper et al (2). We believe the resu...
This article is a valuable addition to guide researches in planning and conducting implementation research (IR). As a complement to this paper we would like to draw attention to a paper on the ethical issues relating to IR, which deserve specific consideration by researchers and must be taken into account by research ethics committees reviewing IR as outlined in https://implementationscience.biomedcentral.com/articles/10.1186/s13012-.... Specifically community engagement, sustainability, scalability, identification of all stakeholders and research participants and monitoring to anticipate/avoid harm is crucial. All ethical considerations must be taken into account from the planning stage and throughout the research activity.
Massuda and colleagues have recently published at BMJ Global Health a paper entitled “The Brazilian health system at crossroads: progress, crisis and resilience” describing the Brazilian health system and its challenges in health system financing, coverage, resource allocation and the impact over the regional disparities in access to healthcare services and health outcomes.
Show MoreBrazil is a large country with an estimated population of approximately 209 million inhabitants. The Universal Health Coverage provided by Brazilian Unified Health System (SUS) is a constitutional right of every citizen. According to the National Supplementary Health Agency (ANS) in May 2018 only 22.7% of Brazilians had private insurance plans, with a 12% decrease in relative numbers during the last 30 months due to the local political and economic crisis [1].
Every two years the Brazilian National Cancer Institute generates data on cancer. According to the last publication 600,000 new cases are expected for 2018 [2]. Currently cancer is the second most common cause of death in Brazil [2].
Since the middle of the last century, the scientific understanding of cancer began to rise. This enabled the development of novel therapeutic interventions, such as new surgical techniques, modern radiotherapy, cytotoxic agents and more recently, targeted therapy and immunotherapy, giving place to a growing number of oncological interventions to combat cancer, improving quality of life, overall survi...
To an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited...
Show MoreGarg et al. provide a useful, but somewhat incomplete, economic perspective on Community Management of Acute Malnutrition (CMAM) in India. Potential returns, like cost per recovered child, adjusted for spontaneous improvement under the existing system, are crucial for policy makers. Sixteen weeks after completion of the treatment phase (sustenance phase), only 123/838 children (14.7%) met the definition of recovery.1 For simplicity’s sake, we ignore: (i) anticipated lower recovery rates in public programme settings; and (ii) costs for linkages with the government-run Anganwadi centres for supplementary food during the sustenance phase.1 With these assumptions, our calculation of costs per recovered child are 6.8 (100/14.7) times higher than those of Garg et al.: US$ 1575/- (Rs. 97,650/-) and US$ 381 (Rs. 23,622/-) in research and Government settings, respectively. Further, annual budgetary requirements may be considerably higher due to non-response, relapse, and fresh cases of Severe Acute Malnutrition (SAM). Data from rural Meerut, near Delhi, provides a ballpark estimate of spontaneous recovery rates (27%) within a similar follow-up period.2 Actual costs per child recovered, even unadjusted for potentially equivalent spontaneous healing, are thus much higher than those quoted by Garg et al. However, they offer no cost-effectiveness analysis reporting cost per life saved or Disability-Adjusted Life Year averted to enable robust comparisons with the existing system or oth...
Show MoreThe information conveyed by Valerie Evans, Peter Roderick, and Allyson Pollock is compelling and of serious concern. While I agree that the explosion of brand-name fixed dose combination (FDC) medications in the Indian market is not safe or rational, I worry that the presentation of the information in this analysis may create some hysteria based on some of the lay media coverage of this study. It is unfortunate that there is such little clinical evidence on the safety and efficacy of the most commonly used Metformin FDCs that are sold to treat type 2 diabetes in India, but is irresponsible to publish such an article without some discussion of the potential harms that could come from abruptly stopping the Metformin FDCs .
I agree that “the convenience of FDCs should not trump efficacy” - but there is already significant distrust in Western medicine by many patients in India without further added hysteria. The authors of this study bring to light the importance of tighter regulation and improved standards for the pharmaceutical industry in India, but the paper would have been better with a more evenhanded presentation of the information. Efficacy data on the Metformin FDCs may be limited, but there is no telling the degree of hyperglycemic crises that may emerge if many patients stop all their medications on the basis of lay media coverage of this analysis without first consulting with their prescribing physicians.
Donkin et al have highlighted the constructive steps being taken to implement policy change facilitating the Social Determinants of Health (SDH) across the globe 1. Although progress is not universal, what has been achieved deserves praise.
We write, however, to highlight one key omission from the standard SDH model: religious faith. This deserves greater recognition as a social determinant of health for two reasons. First, is scale: a recent study demonstrated that 84% of the world’s 7.4 billion people affiliated themselves to a religious group 2. Second is the impact of religious faith on health, shaping both health beliefs and use of healthcare services 3.
Theories of supernatural causation of illness are ancient and diverse. They are also universal: a 1980 study of health belief systems worldwide found evidence that supernatural causes of illness “far outweigh” natural ones 4. Of course many such models may be counter to the Western biomedical model. They should, however, still be acknowledged, not least because when believers encounter Western biomedicine the two models typically become mixed without any sense of conflict.
The close link between healthcare services and religion is evident in both the historical (for example, medieval Christian hospitals in Europe) and contemporary (e.g. faith-based non-governmental organisations worldwide) contexts. The relationship between religion and healthcare is not confined to simple delivery. Religious fait...
Show MoreWe, read with interest the article by Garg et al on costing of therapeutic feeds.
We report our results on a similar trial conducted on 1092 tribal children of SAM,randomly given 3 therapeutic feeds i.e .C-RUTF(commercially produced ready to use therapeutic food),L-RUTF (locally produced RUTF) and ARF(Amylase rich energy dense food) giving 550,513 and 420 kcals respectively.Pea nut paste,sugar ,milk powder,oil were common ingredients,in identical proportions in C-RUTF and L-RUTF while ARF contained amylase rich flour instead of peanut paste.Micro nutrients were present in all three alike.At the end of 8 weeks of treatment,52.8% recovered in C-RUTF group,43.5% in L-RUTF group and 44.8% recovered in ARF group; the difference being statistically significant.The cost of treatment was 63, 59 and 43 USD approx. in the 3 groups respectively.Thus, though cost of ARF was the least compared to C-RUTF and L-RUTF ,recovery rates in ARF group were also compromised.The logistics of preparing the feeds in tribal village Anganwadis,issues of cleanliness in food preparation,time and labour required were also matters of concern.All these factors will require consideration while scaling up of community management of SAM.
The clinical trial was registered under clinical trial registry of India,no.CTRI/2014/09/004958 and the data is the property of the Govt. of Maharashtra,India.
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