Improving Access to Medicines in Developing Countries

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Improving Access to Medicines in Developing
Countries

• Richard Laing
• Dept. of International Health
• Boston University School of Public Health

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Introduction

• Access depends on
• Price
• Ability to pay
• Delivery system
• In developing countries, pharmaceuticals as a
  percentage are a major portion of health
  expenditure, BUT in absolute terms the amounts
  spent are still very low

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Demographic Effect of HIV /AIDS

• Leading to negative population growth in some
  countries
• Women affected at younger age causing a missing
  care generation
• More adults in their 60s and 70s in Botswana in
  20 years time than there will be adults in their
  40s and 50s

http//www.unaids.org/epidemic_update/report/Epi_r
eport_chap_devastation.htm
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Impact on Children
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Impact of HIV/AIDS on countries

• Orphans 11 million in Africa and counting
• Mortality rates rocketing (In Zimbabwe 14-45 CDR
  increased from 7 to 30/1000
• Social Impacts on all members of society
• Economic Impacts on disposable income,
  productivity, training costs etc
• Health system Impacts on demand, supply of
  services and staff morale and numbers

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HIV/AIDS and TB in context

• The present HIV/AIDS and TB epidemic in Africa is
  the worst public health disaster since the Great
  Plague of 1347-1351

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Where are we going? - Diseases in Developing
countries

• Continued development of Antimicrobial resistance
  to common agents for malaria, TB, HIV/AIDS
  bacteria e.g. gonorrhea typhoid
• Neglect of diseases such as leishmaniasis,
  trypanosomiasis etc
• Infrastructural obstacles to delivering existing
  products effectively

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Antimicrobial resistance AMR

• TB resistance to one drug from 2.9 in New
  Caledonia to 41 in Estonia Median 11
• MDR 0 in Finland to 18 in Estonia Median 1.8
• Malaria now resistant to chloroquin in most
  countries

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Malaria Drug resistance
Source http//www.cdc.gov/ncidod/emergplan/box23.
htm
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Multiplicity of Health and Pharmacy systems in
developing countries

• Public sector - Preventive and a leaking safety
  net Oftenlt2 per head for pharmaceuticals
• Private sector often the major provider
• High end and low end may coexist
• Not for profit sector (NGOs) may be major
  provider in rural areas

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How will African countries cope?

• Poor countries getting poorer!
• Efforts at development which focused on
  Structural Adjustment Programs have adversely
  affected public sector service delivery and
  reduced investment in basic educational health
  infrastructure
• Wars, corruption and genocide have compounded
  problems
• Even without AIDS TB Africa would be in trouble!

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GDP of African Countries and US States
Population

• Louisiana 129.3 Bn 4.4 million
• South Africa 119Bn 41 million
• Hawaii 39.7Bn 1.2 million
• Nigeria 36.4Bn 121 million
• Vermont 16.3Bn 0.6 million
• Ivory Coast 10.1Bn 14 million
• Zimbabwe 7.1 Bn 12 million

Source FORTUNE Nov 13 2000
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Global Pharmaceutical Market 2002 406 billion
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US, Europe Japan 78
1.3
Market projected to grow 7.8 annually
Source www.ims-global.com/insight/report/global/re
port.htm
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1999 Pharmaceutical Company Reports except for
Pharmacia 2001
Data from SEC 10K filings and 1999 2001 Company
Annual reports
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1999 2000 CEO Income Note in millions of US
dollars
Melvin R. Goodes CEO, Warner-Lambert Unexercised
stock options 250,680,776
Fred Hassan CEO, Pharmacia 2000 Total
Salary 50.56 million
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Where are we going? - Pharmaceutical Industry

• The pharmaceutical industry will continue growing
  and consolidating
• Will emphasize profitable life style and chronic
  medications
• Interested in rapid return on Blockbusters
• Stockholders expect high rate of returns
• Hosbjor Doha meetings in 2001 resolved many
  issues around IP

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Strategies for Lowering Drug Prices

• Differential/tiered pricing (market segmentation)
  by big pharma
• Local production under voluntary licensing
  agreements
• Global procurement and distribution system
• Increased competitiveness in the pharmaceutical
  market

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Where are we going? - Global Funds

• STOP TB Global Drug Facility 2001
• 10 million 17 countries drugs only, some
  difficulties in procuring, and selecting
  recipients
• Global Fund for AIDS, TB Malaria
• 1.9Bn pledged 7-900 million to be expended 2002
  proposals solicited but TAC and Director not yet
  appointed Unclear how the fund will be
  operationalized

http//www.stoptb.org/GDF/default.asphttp//www.g
lobalfundatm.org/
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What should be done? - Access

• Segment markets - OECD and everybody else
  (Follows 80-20 rule)
• Voluntary license products to multiple regional
  suppliers with dosage form and registration
  restrictions to prevent back flow
• Skeptical of Merck approach to undercut regional
  generic producers by radical differential pricing
• Promote use of Fixed Dose Combination products
  for all anti microbial drugs. This may require
  patent pooling

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What should be done? - Neglected Diseases

• Use voluntary license fees for regional research
• Offer molecule library for high throughput
  screening for neglected diseases
• Provide Human resource support for regional
  research including Managment of clinical trials

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What should be done? - Antimicrobial resistance

• Research to attack AMR e.g. Clavulenic acid and
  amoxycillin
• Combine new antimicrobials to prevent resistance
  to new drugs e.g. Co-Artem
• Promote the use of Fixed Dose Combinations eg
  4FDCs for TB
• Encourage global funds to only supply FDCs
• Lobby to change regulatory obstacles to FDCs

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What should be done? -Infrastructure

• Limited opportunities for pharmaceutical
  companies - not their area of expertise BUT
• Could assist Drug Regulatory Authorities to
  improve regulation, QA GMP
• May wish to offer opportunities for QA staff to
  spend time in developing countries (WB example)

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What should be done? - Support NGOs employers

• NGOs cover 20-30 of health expenditures in
  low-income Asian countries and in Sub-Saharan
  Africa
• NGOs provide up to 50 of curative services in
  some countries esp in rural areas
• Employer-provided health services can provide
  services which improve access to drugs

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What should be done? - Funding Sources

• Revenue from voluntary licenses
• Shareholder tick-offs
• Pharmaceutical Foundations
• Do not forget the contributions that can be made
  by staff from within the companies. They do not
  like being the villains of John le Carres
  novels!

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Conclusion

• In the face of the worst public health emergency
  since 1347, extraordinary measures are needed!
• Divisions in the world are widening between the
  wealthy-well and the poor-sick
• Pharmaceutical companies need to move beyond knee
  jerk defense of IP rights to a coherent effort to
  retain profitable markets in OECD countries while
  finding ways to make their products and expertise
  available to those who most need help