Price, availability and affordability of medicines international comparison of 29 surveys

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Price, availability and affordability of
medicines international comparison of 29 surveys
Presented by Richard Laing World Health
Organization, Geneva Margaret Ewen, Health
Action International EuropeRichard Laing, Gilles
Forte, World Health OrganizationCo-ordinators,
WHO/HAI Project on Medicine Prices Chennai
December 2005
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Uganda pharmaceutical baseline surveySept 2002
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WHO/HAI Project on Medicine Prices

• Developed a methodology for collecting and
  analysing the prices of medicines, affordability,
  availability and component costs in various
  sectors and regions in a country
• Data freely accessible on HAIs web site so
  international price comparisons are possible
• www.haiweb.org/medicineprices
• A monthly monitoring tool, measuring prices,
  availability and affordability, is currently
  being piloted - will complement the survey tool

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Surveys underway or completed

• Middle East Lebanon, Jordan, Kuwait, Syria,
  Sudan,
• Africa Tunisia, Algeria, Morocco, Mali, Chad,
  Uganda, South Africa, Tanzania, Kenya, Ethiopia,
  Zimbabwe, Mozambique, Nigeria, Ghana, Cameroon,
  Senegal
• Asia/Pacific Pakistan, Indonesia, Philippines,
  Malaysia, Fiji, China (Shandong), Vietnam, India
  - West Bengal, Haryana, Karnataka, Maharashtra
  (2), Chennai, Rajasthan
• Central Asia Mongolia, Kazakhstan,Tajikistan,
  Kyrgyzstan, Uzbekistan
• Other Peru, Dominican Republic, Bosnia
  Herzegovina
• 43 surveys in 37 countries 9 pilot studies

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Surveys included in secondary analysis

• AFRO Cameroon, Chad, Ghana, Kenya, Mali, South
  Africa (Kwazulu Natal State), Uganda
• AM/PAHO Brazil (Rio State), Peru
• EMRO Kuwait, Lebanon, Morocco
• EURO Armenia, Kazakhstan, Tajikistan
• SEARO India - West Bengal, Haryana, Karnataka,
  Maharashtra (2), Chennai, Rajasthan, Indonesia,
  Sri Lanka
• WPRO China (Shandong), Fiji, Malaysia, Mongolia,
  Philippines

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Comparing Prices across Countries

• Only valid to compare median MPRs for price or
  availability if identical or very similar basket
  of medicines compared
• Better to compare MPRs of individual identical
  medicines (same dose and dosage form)
• For comparing affordability need to compare
  identical treatment regimens
• For price components categorize additional
  charges carefully

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Data slides..

• Glibenclamide 5mg tabs
• Government procurement prices availability
• Public sector patient prices availability
• Private retail pharmacy patient prices
  availability
• Affordability
• Combination therapy glibenclamide metformin
• Price components

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Glibenclamide 5mg tabs (generics), government
procurement prices
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Glibenclamide 5mg tabs, public sector patient
prices
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Availability Glibenclamide 5mg tabs, public
sector facilities
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Glibenclamide 5mg tabs, patient prices, private
retail pharmacies
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Affordability one months treatment,
glibenclamide 5mg twice daily, public sector,
lowest paid unskilled govt worker
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Affordability one months treatment,
glibenclamide 5mg twice daily, private retail
pharmacies
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Affordability glibenclamide 5mg x2 daily
metformin 500mg x3 daily for a month, private
pharmacies
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• Price issues
• Some huge differences within countries between
  innovator brand and generic prices brand
  premiums
• Is this a problem for patients? YES where
• the generic is not available
• the medicine is patented and faces no competition
• the brand is sold to increase profits
• medicine prescribed by brand name and
  substitution not permitted
• Some large differences within countries between
  brand generic prices, and the international
  reference price
• The wide variation in retail price for the same
  product across countries
• Public sector sometimes purchasing expensive
  innovator brands

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Affordability

• Not only is the innovator brand unaffordable in
  many countries, but sometimes also the generic
• Affordability could be improved through
• availability of generics in the public sector (in
  most but not all countries)
• therapeutic selection
• In some countries such as Tajikistan prices can
  be acceptable but wages are extremely low so
  medicines are unaffordable

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Availability issues

• Some cases, based on facilities surveyed
• - no generics found for older products
• e.g. beclometasone inhaler in Philippines (2002
  2005)
• valproic acid in Malaysia
• - some important medicines not found at all
• e.g. phenytoin in Tajikistan
• In many countries where medicines are free in the
  public sector, availability is extremely low
• In private sector high priced innovator may be
  only product available

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Manufacturers selling price vs Add-on costs
(cumulative) private sector
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Malaysia 2003
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Add-on component costsshown as actual costs,
private sector
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Add-ons do they matter?

• add-ons vary tremendously both in type and
  quantity
• e.g. in some states in India lt40, in Peru gt
  100
• pharmacy profits largely based on mark-ups
• variable range 15 to 55, Malaysia and
  Uganda gt 100
• governments in some countries are taxing the sick
  by applying high import taxes and adding VAT/GST
• Peru - 12 import tax and 18 VAT are added
• Tajikistan - removing taxes duties would reduce
  total additional costs from 82 to 32
• a small component cost applied early in the
  distribution chain can contribute significantly
  to the final price
• as most add-ons are applied as percentages, the
  higher the manufacturers price, the higher the
  price to the patient
• Both manufacturers prices and add-on costs
• need to be lower to improve access to essential
  medcines

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Possible options to lower prices

• EDLs purchase low priced quality generics for
  off-patent meds
• Regional pooled procurement with open tenders
• Patented meds equitable prices, use the
  flexibilities of trade agreements to introduce
  generics while patent is in force
• Aid generic competition eg fast-tracking, waive
  registration fees
• Stop taxing essential medicines
• Where there is little competition, goverments
  should consider regulating prices - from
  manufacturers selling price to margins in
  wholesale and retail.
• Pharmacists remuneration linked to service not
  value of medicine
• If mark-ups needed, stimulate dispensing of
  cheaper generics
• Standard treatment guidelines
• Educate doctors and consumers on availability and
  acceptability of generics
• Prescribe by INN and have a generic substitution
  policy
• Separate prescribing and dispensing

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• Medicine Prices web-site
• www.haiweb.org/medicineprices