Medicines are at the core in treating most health conditions and good quality information on medicines use is vital. Data on uptake and prescribing, for example, informs decisions on the choice of medications to include on essential medicines lists, and helps inform their rational use. It can also offer insights into burden of disease patterns, for example the growing prevalence of non-communicable diseases (NCD) globally and especially in low- and middle-incomes countries (LMIC). The ongoing COVID-19 pandemic has disrupted essential health services—a lack of data may hamper our understanding of this disruption in specific areas. For example, a UNICEF survey from June 2020 found that up to 60 percent of countries did not know about the effects of the pandemic on treatments delivered for NCDs.
Medicines represent a substantial proportion of health care expenditure in LMIC, where they account for about 20–60 percent of health spending. While there has always been pressure to understand medicine use and the benefits (and harms) associated with certain patterns of uptake, the pandemic has created an added urgency to pursuing more rational medicine use. Improving resource allocation decisions is more vital than ever, given the adverse impacts on national economies from measures to control COVID-19 and the consequences for financing sustainable health systems for universal health coverage (UHC).
In this blog, we provide a rapid overview of the sources and wider uses of medicines data to strengthen health systems in LMIC settings, with a focus on Ghana, the first Sub-Saharan African country to establish a National Health Insurance Scheme (NHIS). Ghana has also recently launched their strategy to institutionalise Health Technology Assessment (HTA), which highlights the importance of identifying and using health data, including medicines use information.
We argue that having credible and comprehensive data on medicines use leads to better decision making (e.g., when part of an HTA process) and better medicines policy. These are necessary—although not sufficient— pre-conditions to improve health outcomes in a financially sustainable way. We recommend a greater commitment by all key stakeholders, including donors and country institutions, to ensure data systems are created to track medicines use more effectively and transparently.
Better data for the rational and safe use of medicines
Understanding of patterns of medicines use—known as pharmacoepidemiology—is important to inform the rational use of medicines and levels of adherence to HTAs and standard treatment guidelines (STGs). Medicines use studies can better reveal actual treatment pathways: we can use individual patient-level data to explore initial drug treatments and subsequent switches. We can identify potential cost savings and improve procurement decisions by knowing the actual use of medicines, especially the proportional use of originator versus generic products. Considering recent concerns about the safety profile of COVID-19 vaccines, we can also explore the safety profile of vaccines and medicines through pharmacovigilance.
Better data for exploring the burden of disease
Understanding emerging patterns in the burden of diseases is crucial to prepare for the learning health systems of the future. Demographic health surveys (DHS) are a mainstay of disease profiles but, given the growing burden of non-communicable diseases in low-and middle-income countries, we need more information about cardiovascular disease, diabetes, cancer, and mental health disorders– information not traditionally collected by DHS. This is particularly relevant to non-communicable diseases, as medicines are the cornerstone of treatments once the conditions are diagnosed. Information on patterns of medicines use can be used to elucidate both the prevalence and incidence of diseases, which might not be otherwise captured in more general disease surveys. Medicines use data—especially concomitant use—can also reveal profiles of disease co-morbidity (e.g., the use of both an antihypertensive and an antidiabetic medicine, particularly in the absence of other high-quality epidemiological data.
Better data for Health Technology Assessment
As part of its UHC goals, Ghana has committed to institutionalising health technology assessment (HTA) to inform decision making on medicines and other interventions as advocated by the World Health Organization. Ghana has established a functional HTA Steering Committee and a Secretariat. A recent study to support HTA examined the cost-effectiveness of various classes of antihypertensive medicines in Ghana. Knowing about local medicines use is a key input for cost-effectiveness and budget impact analysis of pharmaceuticals. It is critical to develop an overarching strategic and mandatory approach to the collection and use of health information to support HTA-informed resource allocation decisions, and to monitor the impact of such decisions on actual practice. Data to support HTA may not be fully formed in LMIC so a pragmatic approach—adaptive HTA—can be employed to leverage available data for decision making. However, such adaptive approaches involve trade-offs, and the lack of contextually-relevant data increases decision uncertainty.
Better data for developing health policy, monitoring and evaluation processes, and procurement
Medicine use data, especially when aligned with HTA-like processes, is essential to develop and revise essential medicines lists and standard treatment guidelines. Medicine use data can inform the national health policy and national medicines policy. Medicines, especially prescription medicines, are widely used health commodities so there is a need to understand their availability, accessibility, price, and affordability. Such surveys are regularly conducted by the WHO and Health Action International; the last published Ghanaian survey was in 2004, updated in 2018.
Medicines use data (specifically consumption data) is integral to the monitoring and evaluation activities of the health system, functions usually located in the Ministry of Health. Knowing the size and profile of health commodity markets - of which a major portion will be medicines – is vital to planning and developing sensible procurement approaches.
How to invest in building capacity for collecting and using data
There is an urgent need for locally-driven and locally-generated evidence to guide health policy and systems decision-making and implementation in West Africa and beyond. There is a need to:
Identify and describe suitable data sources of medicines use in each country. The Ghanaian National Health Insurance Scheme is potentially a rich source of data, especially with growing capacity to electronically capture claims. Other sources include private health insurance schemes, district level health information systems (DHIS2), providers of health services (such as the Ghana Health Service and Christian Health Association of Ghana), and hospital data (e.g., for tracking antibiotic use in Ghana). Such locally-sourced data can be supplemented with commercial local, regional, and global data (e.g. IQVIA and others).
Enable data custodians to appropriately curate data for secure storage, quality and completeness, and patient privacy.
Ensure timely ethical approval and governance processes, although we note this is not without difficulties, even in high income countries.
Facilitate access to de-identified and aggregated data at various levels (e.g., national and district) in the first instance; individual patient-level data will require more stringent oversight. Countries with national claims databases could aim to emulate the OpenPrescribing database in the UK.
Support ongoing political commitment and nurture partnerships among appropriate users such as policy makers, funders and institutions, and relevant academics. The first ever international conference on medicines use in Africa was held virtually in June 2021; the in-person one is planned for Accra in July 2022.
Nourish local analytical and research skills by increased access to training courses covering data storage, cleaning, coding and extraction, analysis, and interpretation. Despite published guidance, there is a need for relevant university postgraduate courses, for example the recently-created Master of Pharmacoepidemiology and Pharmacovigilance established at the Universite Nazi Boni in Burkina Faso with support from two Belgium universities.
The latest World Development Report from the World Bank highlights the benefits of harnessing the power of data for development. The data revolution has arrived in Africa. More and more countries around the world are using routinely-collected data – a component of ‘real world data’ - on medicines use to better inform health service provision and develop health policy.
Making context-relevant decisions needs context-relevant data: donors, governments and researchers should develop the necessary partnerships to build capacity around the governance and use of medicines data and other locally generated health information.
Against this background, we welcome the soon to be established continent-wide African Medicines Agency, which is hoped will bring regulatory capacity (such as pharmacovigilance) to those countries currently lacking it. Notably the AMA will be the second continent wide agency following the Africa Centers for Disease Control and Prevention (Africa CDC); this reflects the growing political commitment by African Union members for regionally led solutions to improving health and healthcare.