August 27th 2008 1
Availability, Pricing and Affordability of Cardiovascular Medicines 2001-2006
Draft report for comments
Maaike S.M. van MourikUniversity Medical Center UtrechtIntern with Department of Medicine Access and Rational Use (MAR)
Supervisors:Alexandra CameronRichard Laing
August 27th 2008 2
Outline
Introduction & Background Methodology Results
Availability Pricing Affordability
Discussion & Policy options
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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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Surveys included
Low incomeChad (2004)Ethiopia (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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Discussion & Policy options
Availability Focus on small group of medicines from national STG Increase public sector funding for NCD medicines
Procurement Some countries: can improve on procurement prices Differential pricing for public & private sector
Patient prices Lower taxes & tariffs Promote the use of generics Reduce mark-ups