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 Economic inequity - percent of population below the poverty line has changed little in 2 decades Source: WHO/HFA (1997)

Inequities Health status inequity - infant mortality still varies 10-fold among regions of the world Source: WHO/HFA (1997)

Inequities Affordability inequity - number of working hours to pay full treatment course This examples should illustrate what it would mean for a Tanzanian or Swiss to work for identical treatment, if world average prices were applied. Fortunately prices in Tanzania are different from Switzerland, but not 500 times lower! Maybe 20 times. This graphic illustrates where the problem lies: In most low income countries pharmaceuticals are often the largest household health expenditure. Equity in purchasing essential drugs can only be achieved if drug prices are more closely related to real economical power. A lot has already been achieved in the last years -- but more needs to be done in using creative mechanism in financing to increase the number of people having access to essential drugs. Based on average worldwide price and national per capita income. Source: WHO/EDM

Inequities Financing inequity - the burden falls heaviest on those least able to pay Medicines are the largest health expenditure for poor households Inequity in health and pharmaceutical financing: High income countries: 50-90 % publicly funded Low/middle income countries: 50-90 % out-of-pocket 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

Inequities R&D inequity - expenditures grow, new medicines are launched, few specific for tropical diseases Between 1975 and 1997 - 1,223 new compounds launched only 11 for tropical diseases R&D expenditure (US$ billions - top companies) New chemical entities launched (number) Sources: D. Gannaway and PriceWaterhouseCoopers (1999) R&D, NCE data; P. Trouiller et al (1999) tropical research data

Inequities Pharmaceutical care inequity - a 100-fold variation in pharmacists per million population Pharmacists per one million population Europe, N. America (150 to 940 per million) Asia (10 to 70 per million) Africa (1 to 30 per million) This examples should illustrate what it would mean for a Tanzanian or Swiss to work for identical treatment, if world average prices were applied. Fortunately prices in Tanzania are different from Switzerland, but not 500 times lower! Maybe 20 times. This graphic illustrates where the problem lies: In most low income countries pharmaceuticals are often the largest household health expenditure. Equity in purchasing essential drugs can only be achieved if drug prices are more closely related to real economical power. A lot has already been achieved in the last years -- but more needs to be done in using creative mechanism in financing to increase the number of people having access to essential drugs. Source: WHO/HST/GSP/94.1 (1994)

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 = <50% (36) 2 = 50-80% (68) 3 = 80-95% (33) 4 = >95% (41) 5 = No data available (1) 1/3 of world’s population lacks regular access 320 million in Africa have <50% Problem worsens with economic pressures Source: WHO/DAP (1998) 10 12

Access to essential medicines: staggering inequities - unparalleled opportunities

Ensuring access to essential medicines - framework for collective action 1. Rational selection 4. Reliable health and supply systems 2. Affordable prices 3. Sustainable financing ACCESS 1. Rational selection and use 4. Reliable health and supply systems 2. Affordable prices 3. Sustainable financing ACCESS

Rational selection - define what is most needed The essential medicines concept is nearly universal: 146 countries have national list of essential medicines Key actions: 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.

Summary of clinical guidelines The WHO Model List of Essential Medicines is a model process, model product and public health tool The WHO Essential Medicines Library WHO clusters WHO/PAR Clinical guidelines Summary of clinical guidelines BNF WHO Model Formulary WHO/EC, Cochrane Reasons for inclusion Systematic reviews Key references WHO Model List WHO/QSM Cost: - per unit - per treatment - per month - per case prevented Statistics: - ATC - DDD Quality information: - Basic quality tests - Intern. Pharmacopoeia - Reference standards MSH UNICEF MSF WCCs Oslo/Uppsala

Affordable prices - competition lowers prices Key actions: price information generics policies reduce duties, taxes, mark-ups differential pricing of newer essential medicines apply WTO/TRIPS safeguards as appropriate

 Selection  Affordability  Financing  Health systems Advocacy, corporate responsiveness, & competition have reduced prices 95% in 3 years UN Drug Access Initiative Domestic production Accelerated access initiative ?? Generic offers

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 better use of out-of-pocket spending seek external funding for the poorest populations

Drug benefits in public health insurance - access and risk-sharing  Selection  Affordability  Financing  Health systems Drug benefits in public health insurance - access and risk-sharing Medicines covered by public health insurance

Reliable health and supply systems - ensure quality and availability Key actions: 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

 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

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 4. Reliable health systems

Department of Essential Drugs and Medicines Policy Http://www.who.int/medicines Thank you