1. Medicine Prices, Availability, Affordability and Price Components in Kazakhstan, Kyrgystan, Tajikistan & Uzbekistan Margaret Ewen Health Action International

2. WHO/HAI Project on Medicine Prices & Availability improve the availability and affordability of essential medicines Develop a reliable methodology for collecting and analysing price and availability data across healthcare sectors in a country Price transparency; survey data on a freely accessible website allowing international comparisons Advocate for appropriate pricing policies and monitor their impact

3. Launched WHA 2003 Measures medicine  prices  availability  affordability  component costs 55+ surveys to date in all regions of the world Medicine Prices a new approach to measurement www.haiweb.org/medicineprices

4. Methodology - Data collection Systematic sampling: now at least 6 regions, minimum of 5 pharmacies/facilities per sector per region Public sector facilities, private retail pharmacies and ‘other’ sectors (e.g. dispensing doctors or NGO sector) Prices of 30 pre-selected commonly used medicines – now14 global + 16 regional Predetermined dose form & strength, & recommended pack size Supplementary medicines highly encouraged, adapted to local needs Prices of originator brand and lowest price generic All components of price from manufacturer to retailer identified

5. Data analysis Price calculated as Median Price Ratio (MPR) local price compared to MSH International Drug Price Indicator Guide (procurement prices offered to developing countries) Availability calculated as number of facilities having that product on the day of data collection (%) Affordability assessed for ten pre-selected courses of treatment compared to daily wage of lowest paid unskilled government worker

6. Public sector Procurement price Public sector Patient price Originator brand Lowest priced generic Originator brand Lowest priced generic Kazakhstan Nov043.854.84 Kyrgyzstan Feb05No data collected Tajikistan Feb05No data collected2.38 Uzbekistan Dec042.41No data collected Median price ratio, public sector, glibenclamide 5mg tabs

7. Public sector Procurement price Public sector Patient price Originator brand Lowest priced generic Originator brand Lowest priced generic Kazakhstan60.79 Kyrgystan1.03 Tajikistan1.84 Uzbekistan2.8 Median price ratio, public sector, ciprofloxacin 500mg

8. Patient prices, private retail pharmacies fluconazole 150mg tabs

9. Patient prices, private retail pharmacies co-trimoxazole paed susp. 8+40mg/ml

10. Public sectorPrivate sector OriginatorGenericOriginatorGeneric Kazakhstan 0% 40% Kyrgyzstan 0%53% Tajikistan 0%5%0%5% Uzbekistan 0%73% Availability: amitriptyline 25mg tabs

11. Affordability: captopril 25mg x 2 tab/day 30 days treatment, private retail pharmacies

12. Taxes & duties on medicines KazakhstanKyrgyzstanTajikistanUzbekistan Value Added Tax (VAT)20% Import tax0.15% Customs Duty5%0-10% a Customs Procedure0.15% Central Government Tax5% City Tax1% b Retail Tax4.08% c Cumulative Taxes and Duties0.15%4.24%27%26-39% Net Income Tax d 30%20% 12% Other Taxes1.5% e a. Preferential rates for certain countries (e.g., Ukraine, Russia) b. The 1% Dushanbe city tax is applied at the retail point. c. Includes 4% retail sales tax, 0.08% road tax, d. Taxes paid on net profits only e. Emergency tax from gross revenues

13. Policy options include… Off-patent medicines - purchase low priced quality generics, public and private sector Patented medicines – equitable prices, use the flexibilities of trade agreements to introduce generics while a patent is in force, internal reference pricing Where there is little competition, consider regulating prices - from manufacturers’ selling price to margins in wholesale and retail.

14. Aid generic competition eg fast-tracking, waive registration fees Permit generic substitution and provide incentives for the dispensing of generics Educate doctors and consumers on availability and acceptability of generics, and publicise the price of generics Stop taxing essential medicines Separate prescribing and dispensing Multiple policy options