Access to essential drugs:
staggering inequities - unparalleled opportunities
Jonathan D. Quick, MD, MPH
Director, Essential Drugs and Medicines Policy
Health Technology and Pharmaceuticals Cluster
World Health Organization
Presented at SEAM Conference, Washington, DC
27-29 November 2001
Access to essential drugs:
staggering inequities - unparalleled opportunities
Inequities
Opportunities
2 WHO SEAM Access.ppt (20-Dec-11)
Inequities
Economic inequity - percent of population below
the poverty line has changed little in 2 decades
Percent of population below poverty line (US $1 per day)
E. Europe & Central Asia
1993
Middle East & North Africa
1977
Latin America
East Asia
Sub-Saharan Africa
South Asia
0 10 20 30 40 50
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Source: WHO/HFA (1997)
Inequities
Health status inequity - infant mortality still
varies 10-fold among regions of the world
High Income Countries
E. Europe & Central Asia
Latin America
East Asia
Arab States
South Asia
Sub-Saharan Africa
0 20 40 60 80 100
Deaths per 1000 live births
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Source: WHO/HFA (1997)
Inequities
R&D inequity - expenditures grow, new drugs
are launched, few specific for tropical diseases
Between 1975 and 1997 -
R&D expenditure
New chemical entities 1,223 new compounds launched (US$ billions -
launched (number) only 11 for tropical diseases top companies)
65 40
60 35
30
55
25
50
20
45
15
40
10
35 5
30 0
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
Sources: D. Gannaway and PriceWaterhouseCoopers (1999)
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R&D, NCE data; P. Trouiller et al (1999) tropical research data
Therapeutic inequity - growing resistance is
affecting prevalent infectious diseases
Malaria
chloroquine resistance in 81/92 countries
Tuberculosis
2 - 40 % primary multi-drug resistance
Gonorrhoea
5 - 98 % penicillin resistance in N. gonorrhoeae
Pneumonia and bacterial meningitis
12 - 55 % penicillin resistance in S. pneumoniae
Diarrhoea: shigellosis
10-90+ % amp, 5-95% TMP/SMZ resistance
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Source: DAP, EMC, GTB, CHD (1997)
Inequities
Health literacy inequity - information explosion
for some people, information poverty for others
Among high income countries -
300+ million world-wide internet users by 2000
2/3 of users search for health information
43% of 700,000 US doctors or their staff browse the Web
67% of doctor’s patients have Internet information
Among low and middle income countries -
available information often under-utilized
1/2 of drugs with sufficient information for safe, effective use
only 1/4 of drug packets in Asia contain inserts
25-45% of adult women illiterate - over 90% in some countries
Source: D. Gannaway (1999), World Development
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Report (1997), WHO/DAP (1998), WHO/EDM (1999)
Inequities
Pharmaceutical care inequity - a 100-fold
variation in pharmacists per million population
Italy
Canada
United Kingdom
Denmark
Thailand Europe, N. America
Sri Lanka Asia (150 to 940 per million)
Philippines (10 to 70 per million)
Myanmar
Bhutan
Swaziland Pharmacists per one million population
Benin
Malawi
Africa
Ethiopia (1 to 30 per million)
Central African Republic
0 200 400 600 800 1000
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Source: WHO/HST/GSP/94.1 (1994)
Inequities
Affordability inequity - number of working
hours to pay full treatment course
Hours
600
500
500 460
400
Tuberculosis
300
Shigellosis
200 120 Gonorrhoea
100 20 20 6 1.4 1.4 0.4
0
Tanzania Thailand Switzerland
Based on average worldwide price and national
per capita income. Source: WHO/EDM
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Inequities
Financing inequity - the burden falls heaviest on
those least able to pay
Drugs are the largest health expenditure for poor households
Azerbaijan Bangladesh Mali
Drugs
61% Drugs Drugs
73% 80%
Inequity in health and pharmaceutical financing:
High income countries: 50-90 % publicly funded
Low/middle income countries: 50-90 % out-of-pocket
Fees,
Fees, Other
Other 20%
Fees,
Other 27%
39%
Source: Azerbaijan - UNICEF-Bamako Technical Report No. 35 ; Bangladesh 1995 - National Accounts 1996/97
Mali (1986) - Diarra K and Coulibaly S. Financing of recurrent health costs in Mali. Health Policy and planning; 1990, 5(2);126-138
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Inequities
Access inequity - financing, delivery, and other
constraints still limit access to essential drugs
Percentage of population with regular access to essential drugs
(1997)
1/3 of world’s population
lacks regular access
320 million in Africa
have 95% (41)
5 = No data available (1)
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Source: WHO/DAP (1998)
Inequities
People are needlessly suffering and dying - drugs
unavailable, unaffordable, unsafe, or wrongly used
AIDS
14%
Acute In Africa and S.E.Asia:
Other causes respiratory
35%
1/2 of deaths among children,
infections young adults due to 6 diseases
11%
prompt diagnosis and
treatment could save over
Diarrhoeal 3 million lives per year
diseases
11%
Malaria
Maternal & 8%
perinatal TB
2% Measles
conditions
6%
13%
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Access to essential drugs:
staggering inequities - unparalleled opportunities
Inequities
Opportunities
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Ensuring access to essential drugs
- framework for collective action
3. Sustainable
1. Rational financing
3. Sustainable
selection and use financing
1. Rational
selection
ACCESS
ACCESS
health and
4. Reliable
systems
supply
4. Reliable
2. Affordable
health and
prices
2. Affordable supply systems
prices
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Selection Affordability Financing Health systems
Essential drugs concept nearly universal - lists
and guidelines put the concept into practice
158 countries with
essential drugs lists
90 countries with
treatment guidelines
83 countries with both Essential drugs lists (only) (75)
Treatment guidelines (only) (7)
Essential drug list & guidelines (83)
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Selection Affordability Financing Health systems
Standard treatment guidelines (STGs) -
save lives when effectively implemented
STG, training, mass education
STG & training
STG, training, mass education
STG, supervision, training
STG, mass education, print materials
Supervision, training
Supervision, training
Supervision, training
0% 10% 20% 30% 40% 50% 60%
% reduction in acute respiratory infection (ARI) mortality
among children age 5 and under
Source: WHO/CDS/CSR/DRS/2001.9
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Selection Affordability Financing Health systems
Getting mothers and clinicians to talk
- reducing injection use in Indonesia
100% Interactive group discussion
Proportion of visits
Seminar (both groups)
with injection
80%
60% District-wide monitoring
(both groups)
40%
20%
0%
1 3 5 7 9 11 13 15 17 19 21 23 25
Months
Comparison group Interactive group discussion
Source: Long-term impact of small group interventions, Santoso et al.,
1996
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Selection Affordability Financing Health systems
Advocacy, corporate responsiveness, &
competition have reduced prices 95% in 3 years
Indicative annual cost per person for triple therapy in
Africa (US $)
$10,000
$8,000
UN Drug Access Initiative
$6,000
$4,000 Domestic production
$2,000 Accelerated access initiative
??
Generic offers
$0
1996 1997 1998 1999 2000 2001 2002
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Selection Affordability Financing Health systems
Competition is highly effective in reducing
prices - the example of antiretrovirals
Cost per capsule or tablet (US $)
No competition Competition (2 to 6 producers per product)
5
4
2.90
3
2.00 1.85
2 1.72 1.55
1.31
1.04
1 0.83
0.51
0.08
0
Product A Product B Product C Product D Product E
1996 1997 1998 1999 2000
Source = UNAIDS, B. Samb, 2000
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Selection Affordability Financing Health systems
Drug benefits in public health insurance -
access and risk-sharing
Drugs covered by public health insurance (71)
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Selection Affordability Financing Health systems
Global Fund to fight AIDS, Tuberculosis and
Malaria - pledges from May to August 2001
?
1,600 $ 1.5 billion
1,400
1,200
US $ millions
1,000
800
600
400
200
0
3- 10- 17- 24- 31- 7- 14- 21- 28- 5- 12- 19- 26- 2-
May May May May May Jun Jun Jun Jun Jul Jul Jul Jul Aug
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Selection Affordability Financing Health systems
Shopkeeper training - helping households get
the best value for their health spending
% of surrogate shoppers
70%
60%
Training Training
50%
40%
30%
20%
10%
0%
1998 1999 2000 1998 1999 2000
Southern zone Northern zone
Fevers treated with antimalarials Antimalarials given appropriately
Source: Marsh et al, 2001
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Selection Affordability Financing Health systems
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
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Selection Affordability Financing Health systems
India - state essential drugs programmes
developed through an NGO
Himachal Pradesh
Punjab
Components
Haryana
State drug policy Delhi State
Essential drugs lists by level of care Rajasthan
Pooled procurement Bihar
Efficient distribution Madhya Pradesh
Gujarat
Quality assurance West Bengal
Information--patients & prescribers Maharashtra
Training in rational prescribing
Studies on drug use, pharmacoeconomics Andhra Pradesh
Goa
13 states - total population
580 million Tamil Nadu
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Conclusion
Staggering inequities exist - in income,
health status, R&D, pharmaceutical care, and access
Unparalleled opportunities exist - to build
on local successes to expand access for those in need
1. Rational 3. Sustainable
selection & use financing
ACCESS
4. Reliable
2. Affordable
health
prices
systems
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