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2d. Chronic Care: Prices, Affordability and Financing of Medicines for Chronic Diseases in LMIC
Availability, Price, and Affordability of Cardiovascular Medicines: A Comparison across 36 Countries Using WHO/HAI Data
1Essential Medicines and Pharmaceutical Policies, World Health Organization, Geneva, Switzerland; 2University Medical Center Utrecht, The Netherlands.; 3Health Action International - Global, Amsterdam, the Netherlands
Problem statement: In developing countries, the burden of cardiovascular diseases (CVDs) is growing rapidly, and many countries are already in, or will soon enter, the stage of the epidemiological transition in which cardiovascular diseases are the most important cause of death. Successful treatment of CVD requires adequate pharmaceutical management; however, research has shown that the accessibility of medicines for CVD may be limited in developing countries.
Objective: To examine the availability, pricing, and affordability of cardiovascular medicines in developing countries
Design: Data on medicine prices, availability, and affordability were obtained through facility-based surveys conducted using a standard methodology developed by the World Health Organization and Health Action International (WHO/HAI). A total of 45 surveys conducted in 36 countries between 2001 and 2006 were included. Five medicines were investigated: atenolol, captopril, hydrochlorothiazide, losartan, and nifedipine. Outcome measures were percentage availability, price ratios to international reference prices, and number of day’s wages needed by the lowest paid government worker to purchase one month of treatment. Patient prices were adjusted for inflation and purchasing power, procurement prices for inflation only.
Results: For all measures, there was great variability across surveys. Average availability of cardiovascular medicines was poor (26.3% and 57.3% in public and private sectors, respectively). Procurement prices were competitive in some countries (i.e., comparable to international reference prices), whereas others consistently paid high prices. In general, patient prices were substantially higher than international references prices, but some countries performed well. Generic products were usually sold at lower prices than originator brands. The private sector consistently had higher prices than the public sector. Chronic treatment with anti-hypertensive medication cost more than one day’s wages in many cases. When monotherapy was not sufficient to achieve treatment goals, treatment costs became even less affordable.
Conclusion: The results of this study emphasize the need of focusing attention and financing on making chronic disease medicines accessible, in particular in the public sector. Policy options include improving availability in the public sector by focusing resources on generic essential medicines, and exempting medicines from taxes and duties, which could make medicines less expensive. Regulating mark-ups in a way that does not encourage dispensing more expensive products can help promote the use of generic formulations. Other options for promoting generic uptake include preferential registration procedures; ensuring product quality; and increasing the confidence of physicians, pharmacists, and patients in generic products.
Funding Source(s): None
Prices of Antihypertensive Medicines in Sub-Saharan Africa and Alignment to World Health Organization’s Model List Of Essential Medicines
1Heymans Institute of Pharmacology and Department of Family Medicine and Primary Health Care, Ghent University, Belgium; 2Center for Health Economics, Department of Public Health, Ghent University, Belgium; 3Heymans Institute of Pharmacology, Ghent University, Belgium; 4Department of Pharmacy, Faculty of Medicine, National University of Rwanda and PhD Fellow - Department of Pharmacology Sahlgrenska Academy at the University of Gothenburg; 5Heymans Institute of Pharmacology, Ghent University, Belgium
Problem Statement: Based on the World Health Organization (WHO) Model List of Essential Medicines (EML), most sub-Saharan Africa (SSA) countries have nowadays elaborated a National List of Essential Medicines. Those national lists standardizes hypertension management and aims to increase accessibility of care in most of sub-Saharan African countries, where drugs are not subsidized through social insurance.
Objective: To investigate compliance of existing (15th edition, March 2007) National EML with the WHO/EML and to compare prices of antihypertensive drugs in and between 13 SSA countries.
Methodology: All hypertension medicines advocated by the WHO/EML 15th edition 26 were surveyed: amlodipine, atenolol, enalapril, hydralazine, hydrochlorothiazide, and methyldopa. In addition, this survey included also advocated use of captopril and nifedipine—drugs from previous editions (12th-14th WHO/EML) which were still used in more than half of the sampled countries. Data on NEMLs and drug prices were collected from the Ministry of Health or National Pharmaceutical Office of 13 SSAs: Rwanda, Burundi, Tanzania, Uganda, DRC, Kenya, Cameroon, Congo, Gabon, Ivory Coast, Senegal, Niger, and Mozambique. Prices were compared with the International Drug Price Indicator Guide (IDPIG, 2007). The cost of drug treatment within a country was calculated using defined daily doses (DDD) and between countries using DDD prices adjusted for purchasing power parity-based gross domestic product per capita.
Results: The WHO/EML advises four antihypertensive drugs from a different class: hydrochlorothiazide, atenolol, enalapril, and amlodipine. However, no one has the 4 advocated drugs, but 11/13 have a drug in all 4 drug classes. All surveyed countries had a national EML. However, none of these lists was in complete alignment with the 2007 WHO/EML, and 38% had not been updated in the last 5 years. Surveyed medicines were cheaper when on the national EMLs; they were also cheaper in public than in private pharmacies. Prices varied greatly per medicine. A large majority of the public prices were higher than those indicated by the IDPIG. Overall, hydrochlorothiazide is the cheapest drug.
Conclusion: There are substantial differences in national EML composition between the 13 SSA countries. The proportion of national EMLs not regularly updated was double the global UN estimates. Prices of WHO/EML advised drugs differ largely between drugs and for each drug within and between countries. In general, the use of drugs on the national EML improves financial accessibility and these drugs should be prescribed preferentially. Since hydrochlorothiazide is the cheapest drug, it should be the first drug to be considered.
Funding Source: This study was sponsored by (1) the Flemish Interuniversity Council (VLIR-Vlaamse Interuniversitaire Raad) through Own Initiative Project; (2) Laboratory of Pharmaceutical Technology (of the faculty of pharmaceutical sciences at Ghent University; and (3) the Heymans institute of pharmacology, Ghent University.
Irrational Use of Diabetes Medicines in Resource-Poor Settings
International Insulin Foundation, United Kingdom
Problem statement: Access to diabetes care is problematic in many resource-poor settings
Objectives: To clearly identify the barriers to access to diabetes care in resource-poor settings
Design: The Rapid Assessment Protocol for Insulin Access (RAPIA) is a practical field guide composed of a series of data collection tools and structured as a multilevel assessment of the different elements that influence the access to diabetes care. Its aim is to get a picture of the health system and to provide different stakeholders involved in diabetes with recommendations for action. RAPIA provides information about (1) health service structure and functioning; (2) diabetes policies written and enacted; (3) reported and observed practice for diabetes management; (4) availability of insulin, syringes, medicines, and monitoring equipment; (5) other problems hampering access to diabetes care.
Setting: At least 3 different areas of the following countries: Kyrgyzstan, Mali, Mozambique, Nicaragua, Vietnam, and Zambia
Study population: Convenience sample of the following stakeholders in each country: ministerial levels, private sector, National Diabetes Association, Central Medical Store, educators, provincial health officers, health care settings (e.g., hospitals, clinics, health centres), pharmacies and dispensaries, caregivers (i.e., health care workers and traditional healers), and people with diabetes
Outcome measures: Barriers to diabetes care at different levels of the health system in these countries were identified.
Results: RAPIA has identified a variety of issues that are responsible for poor access to diabetes care. One major contributor to the difficulties is a failure to use the least costly but effective treatments. The purchase of insulin can consume as much as 10% of government expenditure on drugs. Selection of the type of insulin and oral medicines can have a huge impact on cost, with the newer analogue insulin formulations costing between 3 and 13 times more than biosynthetic human insulin. Similar considerations apply to most of the newer treatments for people with Type 2 diabetes, which may cost up to 40 times more than metformin and sulphonylureas. Availability in the public sector and generic substitution also have a large impact on cost to the individual.
Conclusions: A variety of barriers to diabetes care exist in the countries studied. One of these is the irrational purchase and use of insulin and medicines not adapted to the health and economic situation of the given country. What is clear from this research is that multiple health system, economic, and social factors affect diabetes care, and these cannot be considered in isolation from each other.
World Diabetes Foundation, Diabetes Foundation (UK based Charity), Diabetes UK, the World Health Organisation, the Barnett & Sylvia Shine No 2 Charitable Trust, other donations from organisations and individuals and administrative support from University College London.
Variation in Service-Providers’ Prescribing Behaviour and Policy Implications for Women with Genitourinary Tract Infections in Ramallah, Occupied Palestinian Territory (oPt)
Institute of Community and Public Health-Birzeit University, Palestine
Problem statement: Worldwide, infections of the reproductive and urinary tracts are reasons women most often seek health care. These infections are associated with adverse pregnancy outcomes and negatively affect the quality of life. Resistance to antibiotics that are active against uropathogens has been noted worldwide, but few data for microbial resistance patterns in Ramallah, West Bank, oPt, are available. Although some treatment guidelines for infections of the reproductive and urinary tracts might have been available in clinics in 2010 when the study was undertaken, practitioners were generally not aware of the existence of such guidelines. The aim in this study was to assess variations in service-providers’ prescribing behaviours for infections of the genitourinary tract in selected women’s health clinics in Ramallah and to provide evidence needed to inform improvements in policy and practice.
Methods: Women and service providers in 11 clinics that provide women’s health services in Ramallah were interviewed in a survey. Ministry of Health, UN Relief and Works Agency, and nongovernmental clinics in urban, rural, and refugee camps also took part in the survey. Data for 100–120 cases per clinic were gathered during 4 months. Women were interviewed by use of a pretested structured questionnaire, and physicians completed a pretested form. Appropriateness of treatment was determined by the drugs selected, dose regimens, and duration of treatment,
assuming that the diagnosis was correct.
Findings: 162 (15%) of 1052 women were diagnosed with any urinary or reproductive tract infection; their mean age was 31 years (SD 9); 156 (96%) women were married and in the low and middle socioeconomic groups (67 [43%] and 75 [48%], respectively). The drugs prescribed to 132 (81%) of 162 women at the time of diagnosis were not in accord with treatment guidelines. Inappropriate drugs were prescribed to 62 (70%) of 89 women with reproductive tract infections, 56 (95%) of 59 with urinary tract infections, and all 14 with both infections (women with both infections were not included in the other two categories); 65 (40%) of 162 women were prescribed drugs that were inappropriate for their indications, 22 (14%) for dose regimen, and 81 (50%) for duration of treatment.
Interpretation: Written treatment protocols informed by results of studies of local microbial resistance patterns, with mechanisms to ensure implementation, are needed to guide practitioners in providing the correct treatment and avoiding the emergence of resistant bacterial strains. Provision of continued education for physicians, with feedback and supervision, especially about rational antibiotic use, is essential.
Addendum: Published in The Lancet Online, July 2011; available from:
Funding source: Ford Foundation, as part of a larger study of women’s health services in Ramallah