Access to Essential Medicines selection, affordability, financing, supply systems Marthe M Everard Policy, Access, and Rational Use (PAR) Essential Drugs and Medicines Policy (EDM) World Health.
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Access to Essential Medicines selection, affordability, financing, supply systems Marthe M Everard Policy, Access, and Rational Use (PAR) Essential Drugs and Medicines Policy (EDM) World Health Organization Access to essential medicines: staggering inequities - unparalleled opportunities Inequities Opportunities 2 WHO Access.ppt (7-Nov-15) Inequities Economic inequity - percent of population below the poverty line has changed little in 2 decades Percent of population below poverty line (US $1 per day) E. Europe & Central Asia 1993 1977 Middle East & North Africa Latin America East Asia Sub-Saharan Africa South Asia 0 3 WHO Access.ppt (7-Nov-15) 10 Source: WHO/HFA (1997) 20 30 40 50 Inequities Health status inequity - infant mortality still varies 10-fold among regions of the world High Income Countries E. Europe & Central Asia Latin America East Asia Arab States South Asia Sub-Saharan Africa 0 20 40 60 80 Deaths per 1000 live births 4 WHO Access.ppt (7-Nov-15) Source: WHO/HFA (1997) 100 Inequities Affordability inequity - number of working hours to pay full treatment course 600 Hours 500 500 460 400 Tuberculosis 300 200 Shigellosis Gonorrhoea 120 100 20 0 Tanzania 20 6 Thailand Based on average worldwide price and national per capita income. Source: WHO/EDM 5 WHO Access.ppt (7-Nov-15) 1.4 1.4 0.4 Switzerland Inequities Financing inequity - the burden falls heaviest on those least able to pay Medicines are the largest health expenditure for poor households Azerbaijan Drugs 61% Bangladesh Drugs 73% Mali Drugs 80% Inequity in health and pharmaceutical financing: High income countries: 50-90 % publicly funded Low/middle income countries: 50-90 % out-of-pocket Fees, Other 39% Fees, Other 27% Source: Azerbaijan - UNICEF-Bamako Technical Report No. 35 ; Bangladesh 1995 - National Accounts 1996/97 Mali (1986) - Diarra K and Coulibaly S. Financing of recurrent health costs in Mali. Health Policy and planning; 1990, 5(2);126-138 6 WHO Access.ppt (7-Nov-15) Fees, Other 20% Inequities R&D inequity - expenditures grow, new medicines are launched, few specific for tropical diseases New chemical entities launched (number) 65 Between 1975 and 1997 1,223 new compounds launched only 11 for tropical diseases R&D expenditure (US$ billions top companies) 40 35 60 30 55 25 50 20 45 15 40 10 35 30 1985 7 WHO Access.ppt (7-Nov-15) 5 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Sources: D. Gannaway and PriceWaterhouseCoopers (1999) R&D, NCE data; P. Trouiller et al (1999) tropical research data 1996 0 1997 Inequities Pharmaceutical care inequity - a 100-fold variation in pharmacists per million population Italy Canada United Kingdom Denmark Thailand Europe, N. America Asia Sri Lanka (150 to 940 per million) (10 to 70 per million) Philippines Myanmar Bhutan Pharmacists per one million population Swaziland Benin Africa Malawi (1 to 30 per million) Ethiopia Central African Republic 0 8 WHO Access.ppt (7-Nov-15) 200 400 Source: WHO/HST/GSP/94.1 (1994) 600 800 1000 Inequities Access inequity - financing, delivery, and other constraints still limit access to essential medicines Percentage of population with regular access to essential medicines (1997) 1/3 of world’s population lacks regular access 320 million in Africa have <50% Problem worsens with economic pressures 1 = <50% 2 = 50-80% 3 = 80-95% 4 = >95% 5 = No data available 9 WHO Access.ppt (7-Nov-15) Source: WHO/DAP (1998) (36) (68) (33) (41) (1) Access to essential medicines: staggering inequities - unparalleled opportunities Inequities Opportunities 10 WHO Access.ppt (7-Nov-15) Ensuring access to essential medicines - framework for collective action 2. Affordable prices 2. Affordable prices 11 WHO Access.ppt (7-Nov-15) financing 3. Sustainable financing ACCESS 4. Reliable health and supply systems selection 1. Rational selection and use ACCESS 1. Rational 3. Sustainable 4. Reliable health and supply systems Rational selection - define what is most needed The essential medicines concept is nearly universal: 146 countries have national list of essential medicines Key actions: 12 develop evidence-based treatment guidelines define essential medicines list based on treatment guidelines regularly update guidelines based on best evidence use list for supply, reimbursement, training, etc. WHO Access.ppt (7-Nov-15) The WHO Model List of Essential Medicines is a model process, model product and public health tool The WHO Essential Medicines Library WHO clusters Clinical guidelines WHO/PAR Summary of clinical guidelines WHO Model Formulary WHO/EC, Cochrane Reasons for inclusion Systematic reviews Key references BNF WHO Model List WHO/QSM MSH UNICEF MSF 13 Cost: - per unit - per treatment - per month - per case prevented WHO Access.ppt (7-Nov-15) Statistics: - ATC - DDD WCCs Oslo/Uppsala Quality information: - Basic quality tests - Intern. Pharmacopoeia - Reference standards Affordable prices - competition lowers prices Key actions: 14 price information generics policies reduce duties, taxes, mark-ups differential pricing of newer essential medicines apply WTO/TRIPS safeguards as appropriate WHO Access.ppt (7-Nov-15) Selection Affordability Financing Health systems Advocacy, corporate responsiveness, & competition have reduced prices 95% in 3 years Indicative annual cost per person for triple therapy in Africa (US $) $10,000 $8,000 UN Drug Access Initiative $6,000 $4,000 Domestic production $2,000 Accelerated access initiative ?? Generic offers $0 1996 15 WHO Access.ppt (7-Nov-15) 1997 1998 1999 2000 2001 2002 Sustainable financing - contain financial costs of ill-health & increase sustainable funding In over 38 countries public drug expenditures are < US$2 per capita - inadequate by most estimates Key actions: increase public funding for cost-effective medicines expand drug benefits in health insurance 16 better use of out-of-pocket spending seek external funding for the poorest populations WHO Access.ppt (7-Nov-15) Selection Affordability Financing Health systems Drug benefits in public health insurance access and risk-sharing Medicines covered by public health insurance 17 WHO Access.ppt (7-Nov-15) Reliable health and supply systems - ensure quality and availability Key actions: 18 integrate supply management into health system development develop efficient mix of public - private - NGO systems assure drug quality throughout distribution channels promote rational use of medicines WHO Access.ppt (7-Nov-15) Selection Affordability Financing Health systems Reliable health and supply systems - successful examples exist in all regions Direct delivery system - privatized, decentralized Primary distributor system - privatized, centralized Autonomous medical stores - partly private, centralized 19 WHO Access.ppt (7-Nov-15) Conclusion Staggering inequities exist - in income, health status, R&D, pharmaceutical care, and access Unparalleled opportunities exist - to build on local successes to expand access for those in need 1. Rational selection & use 3. Sustainable financing ACCESS 2. Affordable prices 20 WHO Access.ppt (7-Nov-15) 4. Reliable health systems Department of Essential Drugs and Medicines Policy Http://www.who.int/medicines Thank you