1. Lebanon, 2004 Medicine price survey in Lebanon, 2004 undertaken by Dr Rita Karam, Ministry of Health Marg Ewen (on behalf of Dr Karam) WHO/HAI post-medicine price survey regional workshop, Cairo 7-9 January 2007

2. Lebanon, 2004 Country background Population in millions: 4 (excluding foreign residents & refugees) Population in millions: 4 (excluding foreign residents & refugees) % of rural population: 85 % % of rural population: 85 % Total adult literacy rate: 88 % Total adult literacy rate: 88 % GDP per capita: 5611 US $ GDP per capita: 5611 US $ Total health expenditure: 10.4 % of GDP Total health expenditure: 10.4 % of GDP Government health expenditure 29.3% of total health expenditure Government health expenditure 29.3% of total health expenditure Public sector – medicines supplied by MoH (free) and NSSF (75-80% of patient price reimbursed) Public sector – medicines supplied by MoH (free) and NSSF (75-80% of patient price reimbursed)

3. Lebanon, 2004 Methodology Number of medicines surveyed: 32 Core 26 Supplementary 6 Year of MSH reference price used: 2002 Number of regions surveyed: 4 Total number of facilities sampled: Sector (patient prices) Number Public20 Private retail pharmacies 40 OtherNS

4. Lebanon, 2004 Availability PublicPrivate IBLPGIBLPG Median availability 0%0%95%84%

5. Lebanon, 2004 Prices: summary MPRs and examples ProcurementPublicPrivate IBLPGIBLPGIBLPG Median MPR 5.91.2free12.96.1 ciprofloxacin10429.3 metronidazole4.74231.7 beclometasone0.63.31.4 IB = innovator brand LPG = lowest priced generic

6. Lebanon, 2004 Affordability (No. of days wages) Daily wage (US$) PublicPrivate = $6.60 IB LPG LPG IBIBIBIB IB LPG Amoxicillin 500mg tabs, 21 free free 1.4 0.5 Captopril 25mg tab, 90 3 1.2 Ranitidine 150mg tabs, 60 8.2 1.2

7. Lebanon, 2004 Price components Official figures: imported medicine Type of charge Charge basis Amount of charge Price of dispensed quantity Cumulative % mark-up FOB20000% Shipping/insurancepercent7.5%21507.5% Customs/clearancepercent11.5%239719.86% Importers mark-up percent10%263731.85% Pharmacy mark-up percent30%342871.4% Official figures: locally manufactured medicine Manufacturers selling price 10000% Distributors mark-up percent10%110010% Pharmacy mark-up percent30%143043%

8. Lebanon, 2004 Main Findings Public sector procurement prices vary from acceptable to high Public sector procurement prices vary from acceptable to high Availability of medicines in the public sector is extremely poor Availability of medicines in the public sector is extremely poor Availability of medicines in private retail pharmacies is good Availability of medicines in private retail pharmacies is good Prices are very high for both generics and innovator brands in the private sector Prices are very high for both generics and innovator brands in the private sector

9. Lebanon, 2004 Recommendations Develop a National Drug Policy Develop a National Drug Policy Annual budget allocation for essential medicines in the public sector Annual budget allocation for essential medicines in the public sector Unify public sector procurement, use tenders Unify public sector procurement, use tenders Streamline the public sector supply system Streamline the public sector supply system Review the pricing scheme in order to lower prices Review the pricing scheme in order to lower prices Permit and encourage generic substitution Permit and encourage generic substitution

10. Lebanon, 2004 Follow-up activities 2004: Committee of 4 pharmacists compared FOB prices of about 2200 imported medicines with prices paid by Saudi Arabia & Jordan. Outcome: 1100 meds (25% of all registered medicines) had FOB price reduced by 20-30% Committee of 4 pharmacists compared FOB prices of about 2200 imported medicines with prices paid by Saudi Arabia & Jordan. Outcome: 1100 meds (25% of all registered medicines) had FOB price reduced by 20-30% Budget increased for cancer, HIV & other specialised medicines from $14M per annum to $40M Budget increased for cancer, HIV & other specialised medicines from $14M per annum to $40M

11. Lebanon, 2004 2005: Implemented a new pricing structure for all imported medicines, estimated to reduce patient prices by 3-15% FOB $ ShippingInsuranceCustomsClearanceImporterMarkupPharmacyMarkupCumulat.Markup 0- $10 0- $106%10%10%30%66% $10 - $50 4.5%8.5%10%30%62% $50 - $100 3.5%7.5%9%27%54% > $100 2.5%6.5%8%24%46%

12. Lebanon, 2004 2006: Information on patient prices & pharmacy margin included on MoH website. Updated every 2 weeks. 2007: First Lebanese National Formulary to be distributed in April to all doctors & pharmacists. Comparative information on brand/generic products registered in Lebanon, strength/dosage form, country of origin, price and coverage by NSSF. To be updated annually. First Lebanese National Formulary to be distributed in April to all doctors & pharmacists. Comparative information on brand/generic products registered in Lebanon, strength/dosage form, country of origin, price and coverage by NSSF. To be updated annually. Project to review price structure of locally manufactured medicines (700, generics, prices quite low) Project to review price structure of locally manufactured medicines (700, generics, prices quite low)2008/2009: Implementing a re-pricing scheme for all medicines – reducing the FOB price