WHO South-East Asia Journal of Public Health
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   Table of Contents - Current issue
Coverpage
September 2018
Volume 7 | Issue 2
Page Nos. 59-128

Online since Tuesday, August 21, 2018

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EDITORIAL  

Accelerating access to essential medicines in the WHO South-East Asia Region: opportunities for greater engagement and better evidence p. 59
Poonam Khetrapal Singh, Phyllida Travis
DOI:10.4103/2224-3151.239414  PMID:30136661
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PERSPECTIVE Top

Approaches to improving access to essential cancer medicines in the WHO South-East Asia Region p. 62
Meenakshi V Chivukula, Klara Tisocki
DOI:10.4103/2224-3151.239415  PMID:30136662
The high cancer burden in the World Health Organization (WHO) South-East Asia Region represents not only a significant cause of death, disability and suffering but also a major threat to development. In 2015, the need for equitable access to cancer treatments was underscored by the addition of 16 cancer drugs to the 19th WHO model list of essential medicines, including three high-cost medicines. This paper explores strategies to improve access, including – but not limited to – managing costs through regional cooperation; coordinated procurement mechanisms; price controls; differential pricing; and licensing agreements. The composition of the region, with small and large pharmaceutical markets with a range of manufacturing capacities and supply-chain issues, offers a unique frame of comparison and consideration for access issues. Different approaches are needed that are tailored to specific country situations. However, in the absence of global collaborative funding mechanisms, the region can advocate now, with one voice, for regional action to improve the affordability and availability of essential cancer medicines and align national cancer-control strategies to leverage regional strengths. Delays will lead to more premature cancer deaths and more households in the WHO South-East Asia Region being impoverished through out-of-pocket payments for cancer medicines.
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Access to pain relief and essential opioids in the WHO South-East Asia Region: challenges in implementing drug reforms p. 67
Nandini Vallath, MR Rajagopal, Suraj Perera, Farzana Khan, Bishnu Dutta Paudel, Klara Tisocki
DOI:10.4103/2224-3151.239416  PMID:30136663
It is a justifiable assumption that more than 15 million people in the World Health Organization South-East Asia Region are experiencing serious health-related suffering, much of it caused by persistent, severe pain. Despite this burden of suffering, overall access to pain relief and palliative care services is abysmal. The lack of access to controlled drugs for pain management is striking: the average morphine equivalence in the region in 2015 was just 1.7 mg per capita, while the global average was 61.5 mg per capita. Until recently, implementation of national legislation to facilitate medical and scientific use of opioids has proven to be very complex and difficult to achieve. The effects on the region of the exploitative British opium trade in previous centuries prompted countries to adopt draconian legislation on opioids, focused on restricting illicit use. In India, the Narcotic Drugs and Psychotropic Substances Act of 1985, for example, stipulated harsh custodial sentences for even minor clerical errors in hospitals stocking opioids. Decades of persistent efforts by civil society resulted in the landmark amendment of the Act in 2014 to improve medical access, but implementation remains highly protracted. Although some progress has been made in recent years in Bangladesh, India, Nepal, Sri Lanka and Thailand, pain is a symptom that is grossly undertreated in most parts of the region. On both human rights and public health grounds, there is an urgent need for well-formulated drug policies to increase access to opioid medications, coupled with capacity-building and comprehensive public health systems incorporating palliative care.
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Addressing the threat of antibiotic resistance in Thailand: monitoring population knowledge and awareness p. 73
Viroj Tangcharoensathien, Angkana Sommanustweechai, Sunicha Chanvatik, Hatairat Kosiyaporn, Klara Tisocki
DOI:10.4103/2224-3151.239417  PMID:30136664
The 2015 Global action plan on antimicrobial resistance (GAP-AMR) highlights the key importance of improving awareness and understanding of antimicrobial resistance among consumers. While low levels of awareness are not exclusive to consumers in low- and middle-income countries, the challenges to improving understanding are compounded in these settings, by factors such as higher rates of antibiotic self-medication and availability through informal suppliers. In 2016, Thailand set an ambitious target to increase, by 2021, public knowledge of antibiotic resistance and awareness of appropriate use of antibiotic by 20%. This involved first establishing baseline data by incorporating a module on antibiotic awareness into the 2017 national Health and Welfare Survey conducted by the National Statistical Office. The benefit of this approach is that the data from the antibiotic module are collected in parallel with data on socioeconomic, demographic and geospatial parameters that can inform targeted public communications. The module was developed by review of existing tools that have been used to measure public awareness of antibiotics, namely those of the Eurobarometer project of the European Union and a questionnaire developed by the World Health Organization. The Thai module was constructed in such a way that results could be benchmarked against those of the other survey tools, to allow international comparison. The Thai experience showed that close collaboration between the relevant national authorities allowed smooth integration of a module on antibiotic awareness into the national household survey. To date, evidence from the module has informed the content and strategy of public communications on antibiotic use and misuse. Work is under way to select the most robust indicators to use in monitoring progress. The other Member States of the World Health Organization South-East Asia Region can benefit from Thailand’s experiences in improvement of monitoring population knowledge and awareness.
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National introduction of fractional-dose inactivated polio vaccine in Sri Lanka following the global “switch” p. 79
Deepa Gamage, Samitha Ginige, Paba Palihawadana
DOI:10.4103/2224-3151.239418  PMID:30136665
As part of the Polio eradication and endgame strategic plan 2013–2018 to achieve and sustain a polio-free world, the use of oral polio vaccine (OPV) must eventually be stopped. This process started in April 2016, with the worldwide, planned synchronized “switch”, whereby use of OPV containing poliovirus type 2 ceased. Prior to the switch, in line with international guidance on risk mitigation, Sri Lanka had introduced a single full dose (0.5 mL intramuscularly) of inactivated polio vaccine (IPV) into routine immunization. However, the two global suppliers of World Health Organization (WHO)-prequalified IPV had significant challenges in scaling up production to meet the new demand, resulting in a global shortage in April 2016. The WHO Strategic Advisory Group of Experts on Immunization recommended that countries should consider a two-dose schedule of intradermal fractional IPV (fIPV). After rapid consideration of the programmatic cost and logistic implications, Sri Lanka was the first country to roll out this dose-sparing schedule nationwide. The country ensured smooth implementation of fIPV use, reaching out to all eligible infants, maintaining equity and sustaining the IPV vaccination. With expedited refresher training in intradermal vaccination, confident, well-trained and dedicated health-care staff, from the field up to provincial levels, worked together as a dedicated team. Health authorities at all levels reported that public acceptance of the additional injections of the new schedule was high. A post-introduction evaluation and an assessment of population-level immunity are under way.
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Improving access to assistive technologies: challenges and solutions in low- and middle-income countries p. 84
Viroj Tangcharoensathien, Woranan Witthayapipopsakul, Shaheda Viriyathorn, Walaiporn Patcharanarumol
DOI:10.4103/2224-3151.239419  PMID:30136666
Assistive technologies can benefit a wide range of people, including those with disabilities; those with age-related frailties; those affected by noncommunicable diseases; and those requiring rehabilitation. Access to these technologies is limited in low- and middle-income countries but the already-high need will inevitably rise further because of demographic and epidemiological transitions. Four key gaps contribute to limited access. First, although need is high, demand is low, not least because of widespread lack of awareness among potential beneficiaries, their caregivers, and their health-care providers. Second, product designs are insufficiently informed by users’ and caregivers’ preferences and environments, and transfer of technologies to low-resource settings is limited. Third, barriers to supply include low production quality, financial constraints and a scarcity of trained personnel. Fourth, there is a dearth of high-quality evidence on the effectiveness of different types of technology. Adoption of the World Health Assembly Resolution WHA71.8 in 2018 marked convergence of, commitment to and strengthening of efforts to close these gaps and improve access to assistive devices. The Global Cooperation on Assistive Technology workplan identifies four overarching, interlinked solutions for countries to improve access. First, a national policy framework for assistive technology is needed. Second, product development should be encouraged through incentive schemes that support and promote affordable assistive products. Third, capacity-building of personnel is needed, through undergraduate and in-service training. Fourth, provision needs to be enhanced, especially through integration of services with the health system. These actions need to be underpinned by government leadership, a multisectoral approach and adequate funding.
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ORIGINAL RESEARCH Top

Essential cancer medicines in the national lists of countries of the WHO South-East Asia Region: a descriptive assessment p. 90
Meenakshi V Chivukula, Klara Tisocki
DOI:10.4103/2224-3151.239420  PMID:30136667
Background In 2015, the need for equitable access to cancer treatments in low- and middle income countries was underscored by the addition of 16 essential cancer medicines to the 19th World Health Organization (WHO) model list of essential medicines (WHO EML). This study assessed the degree to which this expanded WHO EML from 2015 has influenced inclusion of cancer medicines in the most recent national essential medicines lists of the countries of the WHO South-East Asia Region. Methods The inclusion of a selected list of 38 essential cancer medicines in the 2015 WHO EML was assessed in the most recent national lists of essential medicines from the 11 countries of the WHO South-East Asia Region. Additionally, the availability of six essential cancer medicines common to the national lists of essential medicines from six countries of the WHO South-East Asia Region was explored. Results Of the 38 selected essential cancer medicines included in the 19th WHO EML, a mean of 18.0 (range 2–33) were included in the national lists of countries of the WHO South-East Asia Region. Of the 25 essential cancer medicines included in the WHO EML prior to the 19th revision, a mean of 14.6 (range 2–21) were included in national lists; notably fewer of the 13 cancer medicines added in the 2015 revision were included: mean 3.4 (range 0–12). Conclusion Compared with the WHO EML, there is a lag in the inclusion of essential cancer medicines in national lists of essential medicines in the WHO South-East Asia Region. Alignment of essential cancer medicines in national lists of essential medicines among the 11 countries in the region varies significantly. These differences may hinder regional strategies to improve access to essential cancer medicines, such as pooled procurement of selected high-cost medicines. The link between the availability and affordability of essential cancer medicines warrants further investigation, in the context of access to medicines for universal health coverage.
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Pricing policies for generic medicines in Australia, New Zealand, the Republic of Korea and Singapore: patent expiry and influence on atorvastatin price p. 99
Elizabeth E Roughead, Dong-Sook Kim, Benjamin Ong, Anna Kemp-Casey
DOI:10.4103/2224-3151.239421  PMID:30136668
Background Little is known about how the different policies available to promote use of generic medicines affect the price per unit supplied or sold. This study compares the influence of pricing policies for generic medicines on atorvastatin prices in Australia, New Zealand, the Republic of Korea and Singapore, after market entry of generic atorvastatin. Methods The annual price of atorvastatin per defined daily dose supplied (price/DDD) was examined for each country from 2006 to 2015 (≥2 years before and ≥4 years after generic market entry). Prices were converted to international dollars and cumulative percentage price reductions were calculated for the first 4 years following generic entry. Results Prior to market entry of generic atorvastatin, New Zealand had the lowest price ($0.10/DDD), and the Republic of Korea the highest ($2.89/DDD). The price/DDD fell immediately after generic entry in all countries except New Zealand, which already had low prices. The largest immediate decrease was observed in Singapore (46%, year 1). By the fourth year after generic entry, the price had fallen by 46–80% in all countries; however, large price differences between countries remained. Conclusion New Zealand’s tendering system and use of preferred medicines resulted in very low atorvastatin prices well before patent expiry. Pricing policies in the other three countries were effective in reducing atorvastatin prices, with reductions of between 46% and 80% within 4 years of generic entry. Where tendering and use of preferred medicines were the mechanisms for atorvastatin procurement (New Zealand), prices were lowest before and after generic entry. Mandatory price cuts, combined with price-disclosure policies (Australia), produced similar relative price reductions to tendering systems (New Zealand, Singapore) at 4 years. By comparison, mandatory price cuts upon generic entry as the sole measure, while initially effective, were associated with the smallest relative reduction in price after 4 years (Republic of Korea).
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Geographical disparities and determinants of anaemia among women of reproductive age in Myanmar: analysis of the 2015–2016 Myanmar Demographic and Health Survey p. 107
Hla Hla Win, Min Ko Ko
DOI:10.4103/2224-3151.239422  PMID:30136669
Background Anaemia is a significant public health challenge in Myanmar. In 2015–2016, the first demographic and health survey was done in Myanmar, and showed that almost half of all pregnant women had anaemia. To inform policy decisions, this secondary analysis of the Myanmar Demographic and Health Survey 2015–16 was done to determine the geographical disparities in prevalence of anaemia and related factors among women of reproductive age. Methods Analyses were based on weighted samples of 12 489 eligible women aged 15–49 years. Regions and states were clustered into four geographical zones: hilly, coastal, delta and central plain zones. Baseline characteristics were analysed by descriptive statistics. Odds ratios and 95% confidence intervals (CIs) were estimated using univariable and multivariate logistic regression. Results The prevalence of anaemia varied by geographical zone. Compared with women in the hilly zone, women of the coastal zone had adjusted odds of having anaemia of 1.7 (95% CI 1.43–2.05), while for those in the delta and central plain zones, the adjusted odds were 1.6 (95% CI 1.41–1.92 and 1.38–1.88, respectively). Other factors that significantly raised the adjusted odds of having anaemia were being married, pregnant, underweight/thin or aged ≥40 years, and parity of more than six children. By contrast, urban residence, educational status, employment status and wealth status were not significantly associated with anaemia. Conclusion Anaemia among women of reproductive age is a major public health problem in Myanmar, and those in the coastal region are the most vulnerable. Introducing provision of iron tablets for non-pregnant women, and improving the current low levels of provision to pregnant women, would be a simple and effective policy. As with other health outcomes, further analyses on disparities in anaemia among women of reproductive age at the state and regional level in Myanmar are warranted.
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Factors associated with stillbirths in Haryana, India: a qualitative study p. 114
Preeti H Negandhi, Sutapa B Neogi, Ankan M Das, Sapna Chopra, Amit Phogat, Rupinder Sahota, Ravi Kant Gupta, Sanjay Zodpey, Rakesh Gupta
DOI:10.4103/2224-3151.239423  PMID:30136670
Background Each year, 2.6 million babies are stillborn worldwide, almost all in low- and middle-income countries. Several global initiatives, including the Sustainable Development Goals and the Every Newborn Action Plan, have contributed to a renewed focus on prevention of stillbirths. Despite being relatively wealthy, the state of Haryana in India has a significant stillbirth rate. This qualitative study explored the factors that might contribute to these stillbirths. Methods This was a sub-study of a case–control study of factors associated with stillbirth in 15 of the 21 districts of Haryana in 2014–2015. A total of 43 in-depth interviews were conducted with mothers who had recently experienced a stillbirth, or with a family member. By use of reflexive and inductive qualitative methodology, the data set was coded to allow categories to emerge. Results Two categories and several subcategories were identified. First, factors occurring before the woman reached a health-care facility were: lack of awareness of the mothers and family members; intake of sex-selection drugs during pregnancy, in order to have a male child; non-adherence to treatment for high blood pressure; lack of prior identification of an appropriate health-care facility for delivery; and transportation to a health-care facility for delivery. Second, factors occurring once the health-care facility was reached were: lack of timely and adequate management; and use of medication during labour. Conclusion Intrapartum stillbirths are closely linked to the availability and accessibility of appropriate medical care. Timely and appropriate treatment and care, provided by a trained and skilled health worker during pregnancy and labour, as well as soon after delivery, is an absolute requirement for averting these stillbirths. This study underscores the importance of imparting and increasing awareness regarding factors that have a significant bearing on stillbirth and can be mitigated through prompt and adequate obstetric health-care services.
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POLICY AND PRACTICE Top

Successes and challenges of expansion of environmental poliovirus surveillance in the WHO South-East Asia Region p. 122
Aarti Garg, Sirima Pattamadilok, Sunil Bahl
DOI:10.4103/2224-3151.239424  PMID:30136671
The last decade has witnessed an exponential expansion of environmental surveillance (ES) of poliovirus in sewage samples in the World Health Organization (WHO) South-East Asia Region. This has grown from only three sites in Mumbai, India in 2001 to 56 sites in 2017 in Bangladesh, India, Indonesia, Myanmar, Nepal and Thailand. ES is critical to the region in providing evidence of silent transmission of vaccine-derived poliovirus and Sabin-like poliovirus type 2 – especially since the global “switch” to cease use of oral polio vaccine type 2 – and for monitoring the effectiveness of containment activities. This targeted expansion of ES to supplement surveillance for acute flaccid paralysis (AFP) required quality assurance in ES procedures, improvements in the sensitivity of the laboratory-based surveillance system, and establishment of real-time data analysis for evidence-based programmes. ES in the region has provided documentary evidence for the absence of indigenous wild poliovirus in circulation and no importations via international travellers. Post-switch, while no vaccine-derived poliovirus was detected from AFP cases, ES identified five ambiguous vaccine-derived polioviruses in 2016 and early 2017, with no evidence of circulation. Future challenges include monitoring for vaccine-derived poliovirus strains shed for a prolonged time by immunodeficient individuals, and expanding ES to areas lacking sewage networks. To maintain the polio-free status of the WHO South-East Asia Region and achieve a world free of poliomyelitis, critical evaluation of immunization coverage, continued performance of surveillance for acute flaccid paralysis, and enhanced analysis of sewage samples to detect any breach in containment are essential.
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