Alexandra Cameron

Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis

BACKGROUND WHO and Health Action International (HAI) have developed a standardised method for surveying medicine prices, availability, affordability, and price components in low-income and middle-income countries. Here, we present a secondary analysis of medicine availability in 45 national and subnational surveys done using the WHO/HAI methodology. METHODS Data from 45 WHO/HAI surveys in 36 countries were adjusted for inflation or deflation and purchasing power parity. International reference prices from open international procurements for generic products were used as comparators. Results are presented for 15 medicines included in at least 80% of surveys and four individual medicines. FINDINGS Average public sector availability of generic medicines ranged from 29.4% to 54.4% across WHO regions. Median government procurement prices for 15 generic medicines were 1.11 times corresponding international reference prices, although purchasing efficiency ranged from 0.09 to 5.37 times international reference prices. Low procurement prices did not always translate into low patient prices. Private sector patients paid 9-25 times international reference prices for lowest-priced generic products and over 20 times international reference prices for originator products across WHO regions. Treatments for acute and chronic illness were largely unaffordable in many countries. In the private sector, wholesale mark-ups ranged from 2% to 380%, whereas retail mark-ups ranged from 10% to 552%. In countries where value added tax was applied to medicines, the amount charged varied from 4% to 15%. INTERPRETATION Overall, public and private sector prices for originator and generic medicines were substantially higher than would be expected if purchasing and distribution were efficient and mark-ups were reasonable. Policy options such as promoting generic medicines and alternative financing mechanisms are needed to increase availability, reduce prices, and improve affordability.

The availability and affordability of selected essential medicines for chronic diseases in six low- and middle-income countries

OBJECTIVE To assess the availability and affordability of medicines used to treat cardiovascular disease, diabetes, chronic respiratory disease and glaucoma and to provide palliative cancer care in six low- and middle-income countries. METHODS A survey of the availability and price of 32 medicines was conducted in a representative sample of public and private medicine outlets in four geographically defined areas in Bangladesh, Brazil, Malawi, Nepal, Pakistan and Sri Lanka. We analysed the percentage of these medicines available, the median price versus the international reference price (expressed as the median price ratio) and affordability in terms of the number of days wages it would cost the lowest-paid government worker to purchase one month of treatment. FINDINGS In all countries<or=7.5% of these 32 medicines were available in the public sector, except in Brazil, where 30% were available, and Sri Lanka, where 28% were available. Median price ratios varied substantially, from 0.09 for losartan in Sri Lanka to 30.44 for aspirin in Brazil. In the private sector in Malawi and Sri Lanka, the cost of innovator products (the pharmaceutical product first given marketing authorization) was three times more than generic medicines. One month of combination treatment for coronary heart disease cost 18.4 days wages in Malawi, 6.1 days wages in Nepal, 5.4 in Pakistan and 5.1 in Brazil; in Bangladesh the cost was 1.6 days wages and in Sri Lanka it was 1.5. The cost of one month of combination treatment for asthma ranged from 1.3 days wages in Bangladesh to 9.2 days wages in Malawi. The cost of a one-month course of intermediate-acting insulin ranged from 2.8 days wages in Brazil to 19.6 in Malawi. CONCLUSION Context-specific policies are required to improve access to essential medicines. Generic products should be promoted by educating professionals and consumers, by implementing appropriate policies and incentives, and by introducing market competition and/or price regulation. Improving governance and management efficiency, and assessing local supply options, may improve availability. Prices could be reduced by improving purchasing efficiency, eliminating taxes and regulating mark-ups.

Differences in the availability of medicines for chronic and acute conditions in the public and private sectors of developing countries

OBJECTIVE To investigate potential differences in the availability of medicines for chronic and acute conditions in low- and middle-income countries. METHODS Data on the availability of 30 commonly-surveyed medicines - 15 for acute and 15 for chronic conditions - were obtained from facility-based surveys conducted in 40 developing countries. Results were aggregated by World Bank country income group and World Health Organization region. FINDINGS The availability of medicines for both acute and chronic conditions was suboptimal across countries, particularly in the public sector. Generic medicines for chronic conditions were significantly less available than generic medicines for acute conditions in both the public sector (36.0% availability versus 53.5%; P = 0.001) and the private sector (54.7% versus 66.2%; P = 0.007). Antiasthmatics, antiepileptics and antidepressants, followed by antihypertensives, were the drivers of the observed differences. An inverse association was found between country income level and the availability gap between groups of medicines, particularly in the public sector. In low- and lower-middle income countries, drugs for acute conditions were 33.9% and 12.9% more available, respectively, in the public sector than medicines for chronic conditions. Differences in availability were smaller in the private sector than in the public sector in all country income groups. CONCLUSION Current disease patterns do not explain the significant gaps observed in the availability of medicines for chronic and acute conditions. Measures are needed to better respond to the epidemiological transition towards chronic conditions in developing countries alongside current efforts to scale up treatment for communicable diseases.

Quantifying the impoverishing effects of purchasing medicines: A cross-country comparison of the affordability of medicines in the developing world

Laurens Niëns and colleagues estimate the impoverishing effects of four medicines in 16 low- and middle-income countries using the impoverishment method as a metric of affordability and show that medicine purchases could impoverish large numbers of people.

Availability, price and affordability of cardiovascular medicines: A comparison across 36 countries using WHO/HAI data

BackgroundThe global burden of cardiovascular disease (CVD) continues to rise. Successful treatment of CVD requires adequate pharmaceutical management. The aim was to examine the availability, pricing and affordability of cardiovascular medicines in developing countries using the standardized data collected according to the World Health Organization/Health Action International methodology.MethodsThe following medicines were included: atenolol, captopril, hydrochlorothiazide, losartan and nifedipine. Data from 36 countries were analyzed. Outcome measures were percentage availability, price ratios to international reference prices and number of days wages needed by the lowest-paid unskilled government worker to purchase one month of chronic treatment. Patient prices were adjusted for inflation and purchasing power, procurement prices only for inflation. Data were analyzed for both generic and originator brand products and the public and private sector and summarized by World Bank Income Groups.ResultsFor all measures, there was great variability across surveys. The overall availability of cardiovascular medicines was poor (mean 26.3% in public sector, 57.3% private sector). Procurement prices were very competitive in some countries, whereas others consistently paid high prices. Patient prices were generally substantially higher than international references prices; some countries, however, performed well. Chronic treatment with anti-hypertensive medication cost more than one days wages in many cases. In particular when monotherapy is insufficient, treatment became unaffordable.ConclusionsThe results of this study emphasize the need of focusing attention and financing on making chronic disease medicines accessible, in particular in the public sector. Several policy options are suggested to reach this goal.

Switching from originator brand medicines to generic equivalents in selected developing countries: how much could be saved?

OBJECTIVES In low- and middle-income countries, patients and reimbursement agencies that purchase medicines in the private sector pay more for originator brands when generic equivalents exist. We estimated the savings that could be obtained from a hypothetical switch in medicine consumption from originator brands to lowest-priced generic equivalents for a selection of medicines in 17 countries. METHODS In this cost minimization analysis, the prices of originator brands and their lowest-priced generic equivalents were obtained from facility-based surveys conducted by using a standard methodology. Fourteen medicines most commonly included in the surveys, plus three statins, were included in the analysis. For each medicine, the volume of private sector consumption of the originator brand product was obtained from IMS Health, Inc. Volumes were applied to the median unit prices for both originator brands and their lowest-priced generics to estimate cost savings. Prices were adjusted to 2008 by using consumer price index data and were adjusted for purchasing power parity. RESULTS For the medicines studied, an average of 9% to 89% could be saved by an individual country from a switch in private sector purchases from originator brands to lowest-priced generics. In public hospitals in China, US

Mapping the availability, price, and affordability of antiepileptic drugs in 46 countries.

370 million could be saved from switching only four medicines, saving an average of 65%. Across individual medicines, average potential savings ranged from 11% for beclometasone inhaler to 73% for ceftriaxone injection. CONCLUSIONS Substantial savings could be achieved by switching private sector purchases from originator brand medicines to lowest-priced generic equivalents. Strategies to promote generic uptake, such as generic substitution by pharmacists and increasing confidence in generics by professionals and the public, should be included in national medicines policies.

Practical measurement of affordability: an application to medicines

Purpose:  In low‐ and middle‐income countries (LMICs), a large proportion of people with epilepsy do not receive treatment. An analysis of the availability, price, and affordability of antiepileptic drugs (AEDs) was conducted to evaluate whether these factors contribute to the treatment gap.

Disponibilidad y asequibilidad de algunos medicamentos esenciales para las enfermedades crónicas en seis países de ingresos bajos y medios

OBJECTIVE To develop two practical methods for measuring the affordability of medicines in developing countries. METHODS The proposed methods--catastrophic and impoverishment methods--rely on easily accessible aggregated expenditure data and take into account a countrys income distribution and absolute level of income. The catastrophic method quantifies the proportion of the population whose resources would be catastrophically reduced by spending on a given medicine; the impoverishment method estimates the proportion of the population that would be pushed below the poverty line by procuring a given medicine. These methods are illustrated by calculating the affordability of glibenclamide, an antidiabetic drug, in India and Indonesia. The results were validated by comparing them with the results obtained by using household micro data for India and Indonesia. FINDINGS When accurate aggregate data are available, the proposed methods offer a practical way to obtain informative and accurate estimates of affordability. Their results are very similar to those obtained with household micro data analysis and are easily compared across countries. CONCLUSION The catastrophic and impoverishment methods, based on macro data, can provide a suitable estimate of medicine affordability when the household level micro data needed to carry out more sophisticated studies are not available. Their usefulness depends on the availability of accurate aggregated data.

Can non-physician health-care workers assess and manage cardiovascular risk in primary care?

Introduction Globally, approximately 35 million deaths (60% of all deaths) are attributable to chronic diseases each year, with more than 30 million deaths (52% of all deaths) due to cardiovascular disease (accounting for 30% of all deaths), cancer (13% of all deaths), chronic respiratory disease (7% of all deaths) and diabetes (2% of all deaths). (1) The global burden of disease resulting from all non-communicable conditions, (1) which includes premature death and disability, is 49%; 80% of these deaths occur in low- and middle-income countries. (1,2) Medicines represent a substantial proportion of the economic costs of treating chronic diseases in these countries. For example, in Latin America and the Caribbean it is estimated that medicine costs account for 44% of the direct medical costs of diabetes. (3) Further, in low- and middle-income countries 50-90% of the population have to pay for medicines themselves, (4) rendering treatment unaffordable for many. A significant proportion of chronic disease morbidity and mortality can be prevented if medications are made accessible and affordable. In patients with a high risk of cardiovascular disease, aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering medicines reduce the risk of future vascular events by about a quarter each. When used together, these medicines have the potential to reduce the relative risk by 75% and substantially reduce the recurrence of cardiovascular events. (5) Similarly, making cost-effective treatments available to patients with asthma and diabetes may lead to substantial reductions in morbidity and mortality. (6-9) Several studies have examined the availability, price and affordability of essential medicines, however none have focused specifically on medicines used to treat chronic diseases. (10-13) Little data exist on whether patients have access to affordable medicines for chronic diseases in low- and middle-income countries. A health-care facility-based study of practice patterns used for the secondary prevention of cardiovascular disease in 10 low- and middle-income countries looked at the proportion of patients with coronary heart disease and patients with cerebrovascular disease receiving medicine. (14) The proportion of coronary heart disease patients receiving aspirin was 81.2%; for beta-blockers it was 48.1%; for ACE inhibitors it was 39.8%; and for statins it was 29.8%. The proportions for patients with cerebrovascular disease were: 70.6% for aspirin; 22.8% for beta-blockers; 37.8% for ACE inhibitors; and 14.1% for statins. There are many reasons why medicines are not used more often. These include poor availability, a lack of affordability, poor prescribing practices and a lack of patient adherence. (14) Thus, despite the availability of cost-effective interventions, gaps in the treatment of chronic diseases persist. WHO is therefore initiating a global initiative to improve the care of chronic diseases in low- and middle-income countries. (15) As part of the initiatives preliminary activities, a survey of selected medicines used to treat chronic diseases was undertaken in selected countries to determine: * whether medicines were available, affordable and how much they cost; * whether there were variations in availability, price or affordability between the public and private sectors and between innovator brands (that is, the product that receives marketing authorization first, which is usually the patented version of the medicine) and generic equivalents; and * the contribution that mark-ups, taxes and other costs add to the final price of medicine. Our general hypothesis was that the essential medicines used to treat chronic diseases in low- and middle-income countries have limited availability and may not be affordable. Methods The survey was conducted in three low-middle income countries (Brazil, only in Rio Grande do Sul state; Pakistan and Sri Lanka) and three low-income countries (Bangladesh, Malawi and Nepal). …