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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

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Presentation outline

• Introduction & Background• Methodology• Results

– Availability– Pricing– Affordability

• Conclusions & policy options• Future research agenda

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Introduction & Background• 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

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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.

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Country listLow incomeChadEthiopia (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 BengalKenya (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 incomeArmenia (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 incomeBrazil-Rio de Janeiro (2001)Kazakhstan (2004)Lebanon (2004)Malaysia (2004)South Africa - Kwazulu Natal (2001)

High IncomeKuwait (2004)United Arab Emirates (2006)

p.21 of the report

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Results: Availability (%)

0

10

20

30

40

50

60

70

80

Atenolol Captopril Hydrochloro-thiazide

Losartan Nifedipine All

Pe

rce

nta

ge

av

ail

ab

ilit

y

Public sector LPG Public sector OB Private sector LPG Private sector OB

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Results: Availability by WBIG

Public sector percentage availability (weighted)

Atenolol Captopril Hydrochloro-

thiazide Losartan Nifedipine All

LPG OB LPG OB LPG OB LPG OB LPG OB LPG OB

LI 40.7 0.8 18.6 1.4 15.0 0.4 2.2 0.0 24.5 0.2 20.8 0.6

LMI 17.8 3.8 59.4 8.7 51.3 0.0 8.6 12.1 20.4 21.5 32.6 9.0 UMI 5.0 3.3 5.0 66.7 33.3 0.0 0.0 30.0 35.0 0.0 14.4 21.4

HI 93.0 10.5 81.3 5.6 46.9 0.0 0.0 72.2 50.0 100.0 60.3 38.1

All 38.9 2.3 31.5 9.1 27.7 0.5 3.7 10.4 26.0 11.7 26.3 6.8

Private sector percentage availability (weighted)

Atenolol Captopril Hydrochloro-

thiazide Losartan Nifedipine All

LPG OB LPG OB LPG OB LPG OB LPG OB LPG OB

LI 79.7 32.5 25.9 24.0 35.5 1.7 46.0 5.7 74.8 13.0 52.3 17.0

LMI 59.1 38.9 83.5 39.4 64.3 8.9 37.8 42.9 45.6 38.6 58.8 33.9 UMI 72.3 66.8 68.5 84.4 55.5 21.7 15.0 66.7 82.1 36.9 60.1 57.7

HI 76 98.0 16.7 94.0 50.0 0.0 0.0 100.0 34.8 98.0 39.4 85.0

All 73.3 42.8 59.4 36.5 45.9 6.7 38.6 29.8 65.6 26.5 57.3 29.2

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Results: Procurement pricing

• Public sector procurement

• Procurement vs. public sector patient pricing– Mark-up – Taxes– Procurement at a different price– Cross-subsidizing

0

2

4

6

8

10

12

14

16

Atenolol Captopril HCT Nifedipine All

CP

I ad

just

ed M

PR

Generic Brand

MPR = 1

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Results: Patient pricing

0

20

40

60

80

100

120

140

160

Atenolol Captopril Hydrochloro-thiazide

Nifedipine All

CP

I an

d P

PP

ad

just

ed M

PR

Public sector LPG Public sector OB Private sector LPG Private sector OB

Price ratio's in the public & private sector

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Results: Patient pricing by WBIG

Patient MPRs (MSH2003, CPI and PPP adjusted) for the LPG (weighted averages) in the public and private sector. Atenolol Captopril Hydrochloro-

thiazide Nifedipine All

Public Private Public Private Public Private Public Private Public Private

LI 15.7 21.0 7.2 12.4 40.5 85.2 9.8 11.8 15.9 35.6

LMI 40.2 41.5 6.9 14.7 12.0 66.6 9.5 27.8 15.3 45.7 UMI 13.2 8.9 15.2 36.0 9.5 11.1 12.4 22.4

HI 26.8 10.7 55.2 13.9 38.5

All 23.0 25.8 7.0 12.7 25.0 73.0 9.7 15.0 15.5 30.2

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Results: Private sector brand premiums

0.0

1.0

2.0

3.0

4.0

5.0

6.0

Atenolol Captopril Nifedipine All

Rel

ativ

e b

ran

d p

rem

ium

LI LMI UMI HI All

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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

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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