1. Medicines Transparency Alliance18/10/2015 1 Towards Improving Availability of Essential Medicines in Jordan’s Public Health Sector Presenter Name Job Title

2. Medicines Transparency Alliance Overview of Public Health Sector 18/10/2015MeTA2 Jordan is characterized by a diverse and fragmented public health sector. It consists of: MoH, RMS, two University Hospitals, King Hussein Cancer Center and Prince Hamzeh Hospital The public health sector covers about 72% of the population Pharmaceutical expenditure as % of total health expenditure is 34.0% Public pharmaceutical expenditure as % of total pharmaceutical expenditure accounts for 33.3%. Pharmaceutical expenditure is growing at 17% annually compared to GDP growth of 3.3% The public sector is represented at the Jordan MeTA Council by 9 members out of 18 Source: Jordan National Health Accounts (NHA) 2007

3. Medicines Transparency Alliance Problem Definition The biggest challenge in our public sector is poor availability and certain essential drugs are consistently out- of-stock. In 2004, the WHO/HAI study of prices, availability and affordability of essential showed that availability in the public sector is extremely low, with a median of 28% availability of essential medicine ( this results in patients having to buy their medicine in the private sector at higher prices). Generics were found to be as much as 10x more expensive in private sector than in public Originator brands cost 2x as much as generics in private sector 18/10/20153

4. Medicines Transparency Alliance Problem Definition cont. Lack of national STGs and Rational Drug Use (RDU): we cannot ensure that healthcare treatment options provided to populations are the best and most appropriate that the country can afford without having providers adhere to national STGs Unethical promotion of medicines by pharmaceutical companies to prescribers increases cost of individual treatment courses, not allowing public sector to purchase appropriate cost- effective medicines Need to consider pharmaco-economic evidence-based medicine (EBM) in decisions of selection of medications in the RDL The budget that the Government is willing to allocate for medicines should be evaluated considering RDU, since RDU might be one of the main reasons for high expenditure in medicines 18/10/20154

5. Medicines Transparency Alliance Problem Definition cont. Public Sector Supply Chain: logistics inefficiency in the MOH/ public sector is due to: 1.Insufficient space in main warehouse. The (JPD) orders are not spaced in time - twice a year quantity of goods received often exceeds capacity of main warehouse. This forces Supply Department to organize ad hoc shipments to secondary warehouses in North & South of our country 2.Warehouse equipment is not adequate in terms of racks design, labor security, tooling, IT system… etc. 3.Poor visibility (ability to track and trace shipments) in the Supply Chain after product is delivered to districts, interfering with ability to create optimal stock positioning All these issues affect medicines availability ! 18/10/20155

6. Medicines Transparency Alliance How MeTA has addressed Availability The MeTA Council identified medicines availability as a key issue to address in the MeTA country workplan by: Recommending that selection of medicines on RDL should be implemented using evidence based & pharmaco-economic concepts Improving rational use of medicine and developing national STGs. Poor adherence to STGs and irrational drug use makes supply planning very difficult, leading to demand for particular drugs, in turn leading to stock-outs, supply imbalances, and to lower availability Commissioning a study to analyze the supply chain to come up with recommendations to improve efficiency 18/10/20156

7. Medicines Transparency Alliance Milestones The following activities have been accomplished under the MeTA initiative in Jordan: 1.UNDER Baseline pharmaceutical assessments on Price, Availability and Use Collaborating with WHO, the MeTA Council is overseeing the Baseline Level-II Assessment and Household Survey, which also includes the WHO/HAI Pricing Component. This enables MeTA Jordan to have strong updated primary data & evidence to advocate for necessary policy changes to improve availability of medicines. In addition, the surveys provide a baseline against which to measure impact of MeTA interventions in the future. 2.UNDER introducing Pharmaco-economic, evidence-based medicine (EBM) in the RDL: Organized a national workshop to raise awareness of the concepts of evidence-based medicine (EBM), pharmaco-economics to PTCs & RDL committees 18/10/20157

8. Medicines Transparency Alliance Milestones cont. Reviewed classification of drugs (restricted, unrestricted, authorized) in RDL and suggested detailed evidence based regulations for implementation of classification of drugs Reviewed TORs and SOPs of various disease-related committees involved in selection of drugs (COI declaration, and development of COI guidelines) Reviewed criteria for adding and deleting drugs to and from RDL A workshop was conducted on use of cost effectiveness tools to pharmacists from Local Industry and Generic Importers and to MoH/ PTC NEXT STEPS: a workshop will be held to promote adherence to RDL by prescribers in the public health institutions 18/10/20158

9. Medicines Transparency Alliance Milestones cont. 3. UNDER Rational Drug Use: Conducted a gap and situation analysis for availability and use of STGs Developed an Essential Hypertension STG, based on best available evidence adapted for the Jordanian setting, with technical help from UK NICE Organized a workshop to promote rational use of medicines to prescribers, dispensers and consumers NEXT STEPS: – will develop and implement a strategy to stimulate the acceptance and use of the STG by health providers in the public sector – will organize a workshop to promote ethical promotion of medicines guidelines to healthcare providers in the public sector 18/10/20159

10. Medicines Transparency Alliance Milestones cont. 4. UNDER Procurement Worked with JPD and its stakeholders/ public health institutions to review procurement guidelines and to promote adherence to good procurement guidelines and procedures 5. UNDER Supply Chain Commissioned the analysis of the Medicines Supply Chain in Jordan 18/10/201510

11. Medicines Transparency Alliance Successes and Impact The MeTA Council decided to update the 2004 WHO/HAI pricing & availability survey by working with WHO to conduct a WHO level 2 household, health facility and pricing surveys. Preliminary results of the 2009 WHO/HAI Pricing Component show a median availability of 58.8% for lowest-priced generic essential medicines in the public sector. The process is underway for getting official approval for the newly developed Essential Hypertension STG from the RDU Steering Committee, headed by the Minister of Health and the implementation plan is being developed Transparent Good Procurement practices have been approved by JPD stakeholders and are being implemented 18/10/201511

12. Medicines Transparency Alliance Successes and Impact NEXT STEPS: Results from WHO/HAI pricing survey and WHO level 2 household and health facility surveys, will be presented to the Minister of Health and will provide updated evidence for discussion with the MeTA Council on potential policy interventions that could help solving the problem of low availability A national workshop to build consensus with all governorate partners, prescribers and dispensers will soon be held on the model Essential Hypertension STG and the very first steps of the implementation plan. In addition, measurable indicators will be set prior to and after the use of the STG to assess impact on availability of medicines for essential hypertension. 18/10/201512

13. Medicines Transparency Alliance Challenges The two year period for the MeTA pilot is too short to measure outcomes and impact on availability of medicines in the public sector and on Rational Drug Use High prices in the private sector affect the public sector, since lack of availability of medicines in the public sector will lead to patients buying their medicines from the private sector High Physician autonomy and resistance to adherence to STGs and challenge is to obtain all health stakeholders 'buy in' to following national STGs Changing patient behaviour in terms of medicine consumption to improve Rational Use Powerful pharmaceutical company promotion of medicines 18/10/201513

14. Medicines Transparency Alliance Lessons learned UPDATED country baseline pharmaceutical data should have been collected and available prior to deciding on interventions to solve the main problem of lack of availability of medicines in the public sector It was important to involve primary care & specialist physicians in developing the model STG for Essential Hypertension, in order to ensure their ‘buy in’/leadership in helping convince their peers of benefits of implementing STGs to improve rational use of medicines and ultimately access to essential medicines More time is needed in order to measure impact of interventions for improving availability A multi-stakeholder approach, with all sectors working together, is needed to improve availability and Rational Use of Medicines 18/10/201514

15. Medicines Transparency Alliance References 2004 HAI/WHO Medicine prices, availability, affordability & price components in Jordan- Rania Bader (2007) http://www.haiweb.org/medicineprices/surveys/200405JO/survey_report.pdf Analysis of the Pharmaceutical Supply Chain in Jordan- Prashant Yadav, Simon Conesa, Rania Bader (2009) WHO (2008) Jordan Country profile: World Health Report National Health Accounts of 2007 (published July 2009) http://www.who.int/nha/country/jor/jordan_nha_2007.pdf Medicines Transparency Alliance: Scoping Report for Hashemite Kingdom of Jordan - Samia Saad(2007) Jordan National MeTA Workplan (February 2009) http://www.medicinestransparency.org/fileadmin/uploads/Documents/MeTA- Jordan-workplan.pdf World Bank Health Sector Reform Project Final Report- Jordan http://www- wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2005/06/01/000090341 _20050601121727/Rendered/PDF/31986.pdf 18/10/201515

16. Medicines Transparency Alliance18/10/201516 Thank you Name of presenter: Job Title: Email: Mobile number: +962 Website: www.meta.jowww.meta.jo