Download - Medicine Prices Matter to People and Insurance Companies Margaret Ewen Health Action International
Medicine Prices MatterMedicine Prices Matterto
People and Insurance CompaniesPeople and Insurance Companies
Margaret EwenHealth Action International
Medicines coverage in Medicines coverage in health insurance systemshealth insurance systems
Equitable Access
available to the poor
Quality Use
necessary, safe, effective, properly taken
Affordable cost
to patient & system
Source: MedIC
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
• Launched WHA 2003
• Measures medicine prices availability affordability component costs
• 55+ surveys to date in all regions of the world
Medicine PricesMedicine Pricesa new approach to measurementa new approach to measurement
www.haiweb.org/medicinepriceswww.haiweb.org/medicineprices
Methodology - Data collection
• Systematic sampling: 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)
• Prices of 30 pre-selected commonly used medicines (core medicines)
• 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
Data analysis
• Price calculated as Median Price Ratio (MPR) local price compared to Management Sciences for Health’s International Drug Price Indicator Guide (procurement prices offered to developing countries for multi-source medicines)
• 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
Selected surveys in WHO Eastern Mediterranean Region
Country No. of Meds
Conducted by
Jordan, 2004 29 JFDA
Kuwait, 2004 29 University of Kuwait
Lebanon, 2004 32 Ministry of Health
Sudan (Khartoum) 2005 41 Ministry of Health
Syria, 2003 27 Ministry of Health
Tunisia, 2004 27 Ministry of Health &National Union of Mutual Insurance Companies
Yemen, 2006 35 Ministry of Health
Median % availability - public sector
0102030405060708090
100
Jordan Kuwait Lebanon Sudan Tunisia Yemen
med
ian
% a
vaila
bilit
y
Originator brand Lowest priced generic
Median % availability - private sector
0
20
40
60
80
100
Jordan Kuwait Lebanon Sudan Syria Tunisia Yemen
med
ian %
avail
abilit
y
Originator brand Lowest priced generic
Public sector Procurement price
Public sectorPatient price
Originator brand
Lowest priced
generic
Originator brand
Lowest priced
generic
Jordan 0.69 0.84
Kuwait 4.96 free
Lebanon 1.45 free
Sudan 6.13
Syria 1.56 not surveyed
Tunisia 0.96 free
Yemen 0.41
Public sector prices: Public sector prices: glibenclamide 5mg tabs
Adjusted to same reference price (MSH 2003) & inflation/deflation
Public sector Procurement price
Public sectorPatient price
Originator brand
Lowest priced
generic
Originator brand
Lowest priced
generic
Jordan 2.46 2.41
Kuwait 18.43 free
Lebanon free
Sudan 1.32 5.67
Syria 11.39 3.42 not surveyed
Tunisia 7.99 3.58 free
Yemen
Public sector prices: Public sector prices: diazepam 5mg tabs
Adjusted to same reference price (MSH 2003) & inflation/deflation
Lowest Price Generic and “Brand Premium” in Private Retail Outlets by Country Income
0
5
10
15
20
25
30
India(n=7)
Low (n=7) Lower Mid(n=10)
UpperMid-High
(n=3)
World Bank Income Group
Med
ian M
PR
for
Core
M
edic
ines
Found
MinMaxAverage
Low Price Generic
10%
300%
218% 126%
Brand
* MPR = Median price of core medicines found in 4+ outlets as ratio of MSH generic procurement priceNote: Surveys with 8+ medicines on WHO/HAI core list found in both OB and LPG
Patient prices: Patient prices: private retail pharmaciesdiclofenac 25 mg tabs
Adjusted to same reference price (MSH 2003) & inflation/deflation
0
10
20
30
40
50
60
70
80
90
Jordan Kuwait Lebanon Sudan Syria Tunisia Yemen
MPR
Originator brand
Lowest priced generic
Patient prices: Patient prices: private retail pharmaciesatenolol 50 mg tabs
0
10
20
30
40
50
60
Jordan Kuwait Lebanon Sudan Syria Tunisia Yemen
MPR
Originator brand
Lowest priced generic
AffordabilityAffordability: glibenclamide 5mg 3xday 30 days treatment, purchased by lowest paid unskilled govt
worker from private sector – by country income group
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
India(n=7)
Low(n=15)
Lower Mid(n=11)
Upper Mid-High
(n=3)
World Bank Income Group
Ave
rage
Day
s' W
ages
N
eeded
to P
ay for
Tre
atm
ent
LPGBrand
AffordabilityAffordability: atenolol 50mg daily 30 days treatment, purchased by lowest paid unskilled
govt worker from private sector
0 1 2 3 4 5 6
Jordan
Kuwait
Lebanon
Sudan
Syria
Yemen
days' wages
Lowest priced generic
Originator brand
Price components
Wholesale mark-up
Retail mark-up
Cumulative mark-up
Jordan 19% 26% 62%
Kuwait 35% 25% 70%
Lebanon 10%* 30%* 60%*
Sudan 15% 20% 67%
Syria 8% regressive: 8-30% variable
Tunisia 8.7% regressive: 31.6-42.9% variable
Yemen 10% 20% 57%
TaxesJordan: import fee up to 5%, sales tax 4%Sudan: customs duty 10%, MoD duty 1%Yemen: import tax 5%, tax 5%Tunisia: VAT 6%
* After the survey Lebanon implemented regressive mark-ups for importers, wholesalers & pharmacies
Key issues from survey results
Govt. procurement – over-reliance on originator brands for old, off-patent medicines when cheaper generics exist
Public sector – availability poor and prices not always low
Private sector - prices generally high for both originator brands and lowest priced generics
Affordability – standard treatments generally affordable for low wage earners in the public sector when generic medicines available, but not in private sector especially for originator brands
Price components – largest component in final patient price is the manufacturer’s selling price, taxes applied to essential medicines, fixed % mark-ups provide incentives to wholesalers and retailers to sell more expensive medicines
Workshop: Towards equitable and affordable medicine prices policies in Jordan
4-5 Dec 2007, Dead Sea90+ policy-makers, civil society groups, industry, health professional
orgs, health insurance industry & othersHosted by JFDA and HAI, under the patronage of his Excellency,
Minister of Health Dr. Salah Mawajdeh
Key recommendations:- Improve public sector procurement and supply chain management- Implement pro-generics policies & programmes- Abolish taxes and duties on medicines- Review price setting in the private sector (not supported by all eg.
pharmaceutical industry)- Establish monitoring system: prices, availability & affordability
Pricing in the private sector
Pricing controls in Jordan:Method includes external reference pricing & generics up to 80% of originator
price- choice of comparator countries is crucial- which price are you benchmarking against & why?
eg. procurement, manufacturers selling price, reimbursement price, retail price
Outcome: - high priced generics (shown in survey)- favouring export market not local people - review requested at workshop by many
Alternatives include- stimulate competition amongst generics- modify formula & reduce the manufacturers selling price- subsidise local price for key essential medicines especially for the poor
(SMART card)
Evaluation of all options is needed
Role of insurance systems in educating consumers
Educate people about prevention, health problems and treatment options, medicines, acceptability of generics, support adherence
Governments to publish results of quality testing (and insurance companies use information in purchasing decisions)
Publish prices - newspapers, health facility notice boards etc.
Control drug promotion
Prescribing at major medical institutions
I DON’T TAKE CHANCES, I ONLY USE ORIGINALS Guatemala 2006
Source: WHO/ HAI Drug Promotion Database 2004
Evidence about effects of promotion on physician behaviour
• Evidence about the problem– Promotion and samples impact prescribing– Sponsorship influences practice and research– Doctors do not realise or acknowledge influence
• Evidence about solutions– Voluntary regulation and guidelines are ineffective– Some strategies show promise
• Government regulation• Unbiased information to professionals & consumers• Training medical students about promotion• Media exposure of abusive promotion
Consumer perspective on Jordan National Health Insurance Scheme
Equitable coverage and transparent system
Basic package:- meet people’s needs- affordable charges (especially for the poor)
Everyone knows their entitlements including knowing the prices of medicines
Civil society organisations should be actively involved in the design, implementation and monitoring of the scheme