Access to Essential MedicinesAccess to Essential Medicinesselection, affordability, financing, supply selection, affordability, financing, supply

systemssystems

Marthe M EverardPolicy, Access, and Rational Use (PAR)

Essential Drugs and Medicines Policy (EDM)World Health Organization

2 WHO Access.ppt (Apr 11, 2023)

Opportunities

InequitiesInequitiesInequitiesInequities

Access to essential medicines: staggering inequities - unparalleled opportunities

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Economic inequityEconomic inequity - percent of population below the poverty line has changed little in 2 decades

Inequities

Percent of population below poverty line (US $1 per day)

0 10 20 30 40 50

South Asia

Sub-Saharan Africa

East Asia

Latin America

Middle East & North Africa

E. Europe & Central Asia1993

1977

Source: WHO/HFA (1997)

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Health status inequityHealth status inequity - infant mortality still varies 10-fold among regions of the world

0 20 40 60 80 100

Sub-Saharan Africa

South Asia

Arab States

East Asia

Latin America

E. Europe & Central Asia

High Income Countries

Deaths per 1000 live births

Source: WHO/HFA (1997)

Inequities

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Based on average worldwide price and nationalper capita income. Source: WHO/EDM

Affordability inequityAffordability inequity - number of working hours to pay full treatment course

Hours

500

20 1.4

460

20 1.4

120

6 0.40

100

200

300

400

500

600

Tanzania Thailand Switzerland

Tuberculosis

Shigellosis

Gonorrhoea

Inequities

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AzerbaijanDrugs61%

Fees, Other39%

Bangladesh

Drugs73%

Fees, Other27%

Mali

Fees, Other20%

Drugs80%

Source: Azerbaijan - UNICEF-Bamako Technical Report No. 35 ; Bangladesh 1995 - National Accounts 1996/97Mali (1986) - Diarra K and Coulibaly S. Financing of recurrent health costs in Mali. Health Policy and planning; 1990, 5(2);126-138

Medicines are the largest health expenditure for poor households

Financing inequityFinancing inequity - the burden falls heaviest on those least able to pay

Inequity in health and pharmaceutical financing:High income countries: 50-90 % publicly fundedLow/middle income countries: 50-90 % out-of-pocket

Inequities

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R&D inequityR&D inequity - expenditures grow, new medicines are launched, few specific for tropical diseases

30

35

40

45

50

55

60

65

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

0

5

10

15

20

25

30

35

40

New chemical entitieslaunched (number)

R&D expenditure(US$ billions - top companies)

Between 1975 and 1997 - 1,223 new compounds launched only 11 for tropical diseases

Sources: D. Gannaway and PriceWaterhouseCoopers (1999) R&D, NCE data; P. Trouiller et al (1999) tropical research data

Inequities

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Inequities

0 200 400 600 800 1000

Central African Republic

Ethiopia

Malawi

Benin

Swaziland

Bhutan

Myanmar

Philippines

Sri Lanka

Thailand

Denmark

United Kingdom

Canada

Italy

Pharmacists per one million population

Europe, N. America (150 to 940 per million)Asia

(10 to 70 per million)

Africa(1 to 30 per million)

Pharmaceutical care inequityPharmaceutical care inequity - a 100-fold variation in pharmacists per million population

Source: WHO/HST/GSP/94.1 (1994)

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Access inequityAccess inequity - financing, delivery, and other constraints still limit access to essential medicines

1/3 of world’s population lacks regular access

320 million in Africa have <50%

Problem worsens with economic pressures

Source: WHO/DAP (1998)

Percentage of population with regular access to essential medicines (1997)

1 = <50% (36)2 = 50-80% (68)3 = 80-95% (33)4 = >95% (41)5 = No data available (1)

Inequities

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OpportunitiesOpportunitiesOpportunitiesOpportunities

Inequities

Access to essential medicines: staggering inequities - unparalleled opportunities

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Ensuring access to essential medicines - framework for collective action

1. R

atio

nal

sele

ctio

n

4. R

elia

ble

hea

lth

an

dsu

pp

lysy

stem

s

2. Affordable

prices

3. Sustainable

financing

ACCESS

1. Rationalselection and use

4. Reliablehealth and

supply systems

2. Affordableprices

3. Sustainablefinancing

ACCESS

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Rational selection - define what is most needed

The essential medicines concept is nearly universal:

146 countries have national list of essential medicines

Key actions:

develop evidence-based treatment guidelines

define essential medicines list based on treatment

guidelines

regularly update guidelines based on best evidence

use list for supply, reimbursement, training, etc.

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The WHO Model List of Essential Medicines is amodel process, model product and public health tool

The WHO Essential Medicines Library

WHOModel List

Summary of clinical guidelines

Reasons for inclusionSystematic reviewsKey references

WHO Model Formulary

Cost:- per unit- per treatment- per month- per case prevented

Quality information:- Basic quality tests- Intern. Pharmacopoeia- Reference standards

Clinical guidelines BNF

WHO clusters

MSHUNICEF

MSF

WHO/QSM

WHO/PAR

WHO/EC, Cochrane

Statistics:- ATC- DDD

WCCs Oslo/Uppsala

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Affordable prices - competition lowers prices

Key actions:

price information

generics policies

reduce duties, taxes, mark-ups

differential pricing of newer essential medicines

apply WTO/TRIPS safeguards as appropriate

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Indicative annual cost per person for triple therapy in Africa (US $)

$0

$2,000

$4,000

$6,000

$8,000

$10,000

1996 1997 1998 1999 2000 2001 2002

UN Drug Access Initiative

Domestic production

Accelerated access initiative

Generic offers

Advocacy, corporate responsiveness, & competition have reduced prices 95% in 3 years

????

Selection Affordability Financing Health systems

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Sustainable financing - contain financial costs of ill-health & increase sustainable funding

In over 38 countries public drug expenditures are< US$2 per capita - inadequate by most estimates

Key actions:

increase public funding for cost-effective medicines

expand drug benefits in health insurance

better use of out-of-pocket spending

seek external funding for the poorest populations

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Drug benefits in public health insurance - access and risk-sharing

Medicines covered by public health insurance

Selection Affordability Financing Health systems

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Reliable health and supply systems - ensure quality and availability

Key actions:

integrate supply management into health system

development

develop efficient mix of public - private - NGO

systems

assure drug quality throughout distribution channels

promote rational use of medicines

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Reliable health and supply systems - successful examples exist in all regions

Direct delivery system - privatized, decentralized

Primary distributor system - privatized, centralized

Autonomous medical stores - partly private, centralized

Selection Affordability Financing Health systems

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Unparalleled opportunities exist - to buildon local successes to expand access for those in need

Unparalleled opportunities exist - to buildon local successes to expand access for those in need

Staggering inequities exist - in income, health status, R&D, pharmaceutical care, and access

Staggering inequities exist - in income, health status, R&D, pharmaceutical care, and access

Conclusion

1. Rationalselection & use

4. Reliablehealth

systems

2. Affordableprices

3. Sustainablefinancing

ACCESS

Department of Essential Drugs and Medicines Policy

Thank you

Http://www.who.int/medicines