1. Price, availability and affordability of medicines international comparison of 29 surveys Presented by: Richard Laing World Health Organization, Geneva Margaret Ewen, Health Action International Europe Richard Laing, Gilles Forte, World Health Organization Co-ordinators, WHO/HAI Project on Medicine Prices Chennai December 2005

2. Uganda pharmaceutical baseline survey Sept 2002

3. WHO/HAI Project on Medicine Prices Developed a methodology for collecting and analysing the prices of medicines, affordability, availability and component costs in various sectors and regions in a country Data freely accessible on HAIs web site so international price comparisons are possible www.haiweb.org/medicineprices A monthly monitoring tool, measuring prices, availability and affordability, is currently being piloted - will complement the survey tool

4. Surveys: underway or completed Middle East: Lebanon, Jordan, Kuwait, Syria, Sudan, Africa: Tunisia, Algeria, Morocco, Mali, Chad, Uganda, South Africa, Tanzania, Kenya, Ethiopia, Zimbabwe, Mozambique, Nigeria, Ghana, Cameroon, Senegal Asia/Pacific: Pakistan, Indonesia, Philippines, Malaysia, Fiji, China (Shandong), Vietnam, India - West Bengal, Haryana, Karnataka, Maharashtra (2), Chennai, Rajasthan Central Asia: Mongolia, Kazakhstan,Tajikistan, Kyrgyzstan, Uzbekistan Other: Peru, Dominican Republic, Bosnia Herzegovina 43 surveys in 37 countries + 9 pilot studies

5. Surveys included in secondary analysis AFRO: Cameroon, Chad, Ghana, Kenya, Mali, South Africa (Kwazulu Natal State), Uganda AM/PAHO: Brazil (Rio State), Peru EMRO: Kuwait, Lebanon, Morocco EURO: Armenia, Kazakhstan, Tajikistan SEARO: India - West Bengal, Haryana, Karnataka, Maharashtra (2), Chennai, Rajasthan, Indonesia, Sri Lanka WPRO: China (Shandong), Fiji, Malaysia, Mongolia, Philippines

6. Comparing Prices across Countries Only valid to compare median MPRs for price or availability if identical or very similar basket of medicines compared Better to compare MPRs of individual identical medicines (same dose and dosage form) For comparing affordability need to compare identical treatment regimens For price components categorize additional charges carefully

7. Data slides….. Glibenclamide 5mg tabs Government procurement: prices & availability Public sector: patient prices & availability Private retail pharmacy: patient prices & availability Affordability Combination therapy: glibenclamide + metformin Price components

8. Glibenclamide 5mg tabs (generics), government procurement prices

9. Glibenclamide 5mg tabs, public sector patient prices

10. Availability: Glibenclamide 5mg tabs, public sector facilities

11. Glibenclamide 5mg tabs, patient prices, private retail pharmacies

12. Affordability: one months treatment, glibenclamide 5mg twice daily, public sector, lowest paid unskilled govt worker

13. Affordability: one months treatment, glibenclamide 5mg twice daily, private retail pharmacies

14. Affordability: glibenclamide 5mg x2 daily + metformin 500mg x3 daily for a month, private pharmacies

15. Price issues Some huge differences within countries between innovator brand and generic prices: brand premiums –Is this a problem for patients? YES where: –the generic is not available –the medicine is patented and faces no competition –the brand is sold to increase profits –medicine prescribed by brand name and substitution not permitted Some large differences within countries between brand & generic prices, and the international reference price The wide variation in retail price for the same product across countries Public sector sometimes purchasing expensive innovator brands

16. Affordability Not only is the innovator brand unaffordable in many countries, but sometimes also the generic Affordability could be improved through: –availability of generics in the public sector (in most but not all countries) –therapeutic selection In some countries such as Tajikistan prices can be acceptable but wages are extremely low so medicines are unaffordable

17. Availability issues Some cases, based on facilities surveyed: - no generics found for older products e.g. beclometasone inhaler in Philippines (2002 & 2005) valproic acid in Malaysia - some important medicines not found at all e.g. phenytoin in Tajikistan In many countries where medicines are free in the public sector, availability is extremely low In private sector high priced innovator may be only product available

18. Manufacturers selling price vs Add-on costs (cumulative) private sector

19. Malaysia 2003

20. Add-on component costs shown as actual costs, private sector

21. Add-ons – do they matter? add-ons vary tremendously both in type and quantity e.g. in some states in India 100 % pharmacy profits largely based on mark-ups variable range – 15% to 55%, Malaysia and Uganda > 100% governments in some countries are taxing the sick by applying high import taxes and adding VAT/GST Peru - 12% import tax and 18% VAT are added Tajikistan - removing taxes & duties would reduce total additional costs from 82% to 32% a small component cost applied early in the distribution chain can contribute significantly to the final price as most add-ons are applied as percentages, the higher the manufacturers price, the higher the price to the patient Both manufacturers prices and add-on costs need to be lower to improve access to essential medcines

22. Possible options to lower prices EDLs – purchase low priced quality generics for off-patent meds Regional pooled procurement with open tenders Patented meds – equitable prices, use the flexibilities of trade agreements to introduce generics while patent is in force Aid generic competition eg fast-tracking, waive registration fees Stop taxing essential medicines Where there is little competition, goverments should consider regulating prices - from manufacturers selling price to margins in wholesale and retail. Pharmacists remuneration – linked to service not value of medicine If mark-ups needed, stimulate dispensing of cheaper generics Standard treatment guidelines Educate doctors and consumers on availability and acceptability of generics Prescribe by INN and have a generic substitution policy Separate prescribing and dispensing

23. Medicine Prices web-site: www.haiweb.org/medicineprices