1. 1 Availability, price and affordability of cardiovascular medicines 2001-2006 Richard Laing for Alexandra Cameron & Maaike van Mourik International Conference on Improving the Use of Medicines (ICIUM) November 2011

2. 2 Presentation outline Introduction & Background Methodology Results –Availability –Pricing –Affordability Conclusions & policy options Future research agenda

3. 3 Introduction & Bac k ground Cardiovascular diseases: 30% of deaths worldwide, 80% of which in developing countries WHO-PREMISE study –Many patients did not get medicines needed for adequate management. Non-WHO studies –Problems with availability, pricing and affordability WHO report on chronic disease medicines (30 surveys) –Poor availability and affordability Aim: Secondary analysis of price, availability and affordability of CVD medicines in 36 developing countries that have undertaken WHO/HAI surveys

4. 4 Methodology WHO/HAI data –Standardized data collection –Prices as Median Price Ratios (MPRs) –Medicines: Atenolol 50mg, Captopril 25mg, Hydrochlorothiazide (HCT) 25mg, Losartan 50mg and Nifedipine retard 20mg. Secondary analysis –Adjustments for inflation and purchasing power –Analysis by World Bank Income Groups and WHO regions.

5. 5 Country list Low income Chad Ethiopia (2004) Ghana (2004) India-Chennai (2004) India-Haryana (2004) India-Karnataka (2004) India-Maharashtra 12 districts (2004) India-Maharashtra 4 regions (2005) India-Rajasthan (2003) India-West Bengal Kenya (2004) Kyrgyzstan (2005) Mali (2004) Mongolia (2004) Nigeria (2004) Pakistan (2004) Sudan-Gadarif (2006) Sudan-Khartoum (2005) Sudan-Kordofan (2006) Tajikistan (2005) Tanzania (2004) Uganda (2004) Uzbekistan (2004) Yemen (2006) Lower-middle income Armenia (2001) Cameroon (2002) China-Shandong Province (2004) China-Shanghai (2006) El-Salvador (2006) Fiji (2004) Indonesia (2004) Jordan (2004) Morocco (2004) Peru (2005) Philippines (2005) Sri Lanka (2001) Syria (2003) Tunisia (2004) Upper-middle income Brazil-Rio de Janeiro (2001) Kazakhstan (2004) Lebanon (2004) Malaysia (2004) South Africa - Kwazulu Natal (2001) High Income Kuwait (2004) United Arab Emirates (2006) p.21 of the report

6. 6 Results: Availability (%)

7. 7 Results: Availability by WBIG

8. 8 Results: Procurement pricing Public sector procurement Procurement vs. public sector patient pricing –Mark-up –Taxes –Procurement at a different price –Cross-subsidizing MPR = 1

9. 9 Results: Patient pricing Price ratio's in the public & private sector

10. 10 Results: Patient pricing by WBIG

11. 11 Results: Private sector brand premiums

12. 12 Results: Affordability Number of day's wages the lowest-paid government worker needed to purchase one month of chronic treatment –Large variations, on average 1.8 day's wages for single medicine –Most affordable: atenolol 50mg (1.1 day's wages) –High income areas more affordable than low income Note: –Average income often below lowest government wage –Need for multiple medicines

13. 13 Conclusions & policy options Availability –Focus on small group of medicines from national STG –Increase public sector funding for NCD medicines –Private sector distribution of publicly subsidized medicines Procurement –Some countries: can improve on procurement prices Patient prices –Lower taxes & tariffs –Promote the use of generics –Reduce mark-ups