Do Low- and Middle-Income Countries Learn from the Experience of High-Income Countries? Lessons from the Use of Atypical Antipsychotics for Treatment of Schizophrenia

An editorial posited that low- and middle-income countries (LMICs) take longer to access schizophrenia treatment innovations, but this lag may be an advantage in that that it allows them to have better evidence to inform clinical and policy decisions. We sought to determine whether LMIC policymakers do in fact use the best available evidence to make decisions regarding access to atypical antipsychotics, the latest innovation in schizophrenia therapeutics. Since there were no relevant policy analyses, we approached the issue by assessing the quality of the scientific evidence available to policymakers and examining in detail the experience of Chile, a middle-income country. We found that there is minimal LMIC-specific scientific evidence to inform policy analyses. Moreover, the modest body of cost-effectiveness evidence is undermined by the source of its effectiveness estimates. Only two of the four cost-effectiveness studies accounted for antipsychotics' side-effects, and only one included the long-term effects of metabolically active antipsychotics. LMICs that are able to manufacture or import cheaper generic atypical drugs have readily embraced them. Chile's experience indicates that an LMIC that implemented policies when evidence from higher-income countries strongly favored atypical drugs responded to new evidence to the contrary, but not forcefully enough to counter pressure from advocates or market forces. It appears, then, that most LMIC policymakers were not aware that the modest body of LMIC-relevant cost-effectiveness evidence did not favor atypicals, or if they were aware, their decisions were not influenced by this evidence. We conclude with a discussion of the implications of this finding.