1. 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

2. Access to essential medicines: staggering inequities - unparalleled opportunities

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

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

5. 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

6. 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: % publicly funded
Low/middle income countries: % out-of-pocket
Source: Azerbaijan - UNICEF-Bamako Technical Report No. 35 ; Bangladesh 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);

7. Inequities
R&D inequity - expenditures grow, new medicines are launched, few specific for tropical diseases
Between 1975 and
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

8. 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)

9. 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

10. Access to essential medicines: staggering inequities - unparalleled opportunities

11. 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

12. 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.

13. 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

14. 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

15.  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

16. 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

17. 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

18. 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

19.  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

20. 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

21. Department of Essential Drugs and Medicines Policy
Thank you