public arv procurement data: using information to obtain lower prices brenda waning march 6, 2008...
TRANSCRIPT
Public ARV Procurement Data:Using Information to Obtain Lower
Prices
Brenda WaningMarch 6, 2008
Open Society Institute SeminarKiev, Ukraine
Funded by United Kingdom Department of International Development,Medicine Transparency Alliance (MeTA) Project
Background to Procurement Practices
Countries typically struggle with medicine
procurement– Unreliable suppliers, unknown medicine quality– Insufficient funds and financial systems– Unsure of fair, market price(information asymmetry)– Result is enormous variation in price and across countries
Global Fund (GF) Offers Level Playing Field– “Sufficient” financing– Public posting of prices paid by all recipients– Limited # pre-qualified ARVs and suppliers– Expect little price variation in this environment
Reality and Remedy Extreme price variation exists for
identical ARV products across countries
2 Publicly available databases can provide price information historically impossible to obtain– Global Fund Purchase Price Report– WHO Global Price Reporting Mechanism
Public ARV Procurement Databases
Global Fund Purchase Price Report– ARV procurement transactions reported by
GF principle recipients
WHO Global Price Reporting Mechanism– Includes GF data PLUS ARV procurements
reported by international procurement agencies (IDA, UNICEF), WHO country offices, John Snow, MSH, etc.
Both available on the web in Excel format
Using Existing Data to Assess ARV Prices
Merged GF & Global Price Reporting Mechanism (GPRM) Data Sets– Country– Date of order– Generic name– Strength– Dosage form– Total # units– Price per unit– Type of package– Manufacturer– Country of manufacturer– INCO term
Expanded data set created at Boston University– Price per unit calculated– Year of procurement– WHO Region of country – World Bank Income of
country– ARV drug class– Fixed-Dose Combination– Generic/Brand– PEPFAR country– Clinton Foundation eligible– Differential Price eligible– WHO 1st/2nd line regimens
2003 & 2006 guidelines– Daily doseFinal Data Set: 9,731 procurements
July 02 – Oct 07 103 countries $636 million
ExtensiveData Cleaning
nevirapine 200mg
0
10
20
30
40
50
60
70
80
90
100
0,00
0,07
0,14
0,21
0,28
0,35
0,42
0,49
0,56
0,63
0,70
0,77
0,85
0,92
0,99
1,06
1,13
1,20
1,28
1,35
1,42
1,63
1,78
1,87
2,05
2,20
2,43
2,70
2,91
3,30
3,61
4,32
4,99
6,84
11,2
524
,03
stavudine 15mg
0
2
4
6
8
10
12
14
16
18
20
stavudine 15mgGuyana high outlierprices verified
High price outliers: screens to assess efficiency, policy, governance
nevirapine 200mgRussia 20x times more expensive than median price
lamivudine 150mg
0
20
40
60
80
100
120
140
160
lamivudine 150mg76 similar highprice outliersremoved
price per tablet
volu
me
price per tablet price per tablet
volu
me
volu
me
Extreme Price VariabilityHighest Price/Lowest Price
0
10
20
30
40
50
60
70
EF
V 5
0mg
EF
V 2
00m
g
EF
V 6
00m
g
NV
P 2
00m
g
d4T
+3T
C+N
VP
30+1
50+2
00m
g
d4T
+3T
C+N
VP
40+1
50+2
00m
g
IDV
400
mg
NF
V 2
50m
g
LP
V/r
133.
3/33
.3m
g
RT
V 1
00m
g
NNRTI & FDC PI
Hig
hes
t p
rice
pai
d/L
ow
est
pri
ce p
aid
Generic Version
Brand Version
Percentile Definition & Comparisons
25th percentile– 25% of prices paid for that particular ARV were
equal to or less than the price you paid
75th percentile– 75% of prices paid for that particular ARV were
equal to or less than the price you paid
If we compare each procurement made by a country with the global price distribution for that exact same product, the desire is to be in the <25th percentile (few countries paid less than you)
Country Benchmarking% of Country Procurements Across
Quartiles of Global Price Distribution*
Country (#) <25th
percentile
25th-50th
percentile
51st -75th
percentile
>75th
percentile
Armenia (19) 5.3% 10.5% 15.8% 68.4%
Belarus (14) 7.1% 42.9% 14.3% 35.7%
Estonia (11) 0% 0% 0% 100%
Georgia (15) 20% 20% 20% 40%
Kazakhstan (7) 28.6% 28.6% 0% 42.9%
Russian Fed. (32)
0% 6.3% 0% 93.8%
Tajikistan (9) 22.2% 22.2% 22.2% 33.3%
Ukraine (47) 17% 19.1% 34% 29.8%
Uzbekistan (8) 0% 0% 50% 50%Prices for July 2006-June 2007
Amount of Money Spent in Excess of Global Median Price (7/06-
6/07)*Country (# procurements)
Amount Spent Above Median
Armenia (19) $18,252 Belarus (14) $148,216 Estonia (11) $1,075,273 Georgia (15) $33,483 Kazakhstan (7) $74,208 Russian Federation (32) $12,399,841 Tajikistan (9) $3,773 Ukraine (47) $3,615,215
Uzbekistan $79,804
% Generic ProcurementsCountry Total #
Procurements
# Generic (%)
Armenia 19 4 (21%) Belarus 14 7 (50%) Estonia 11 0 (0%) Georgia 15 9 (60%) Kazakhstan 7 5 (71%) Russian Federation
32 0 (0%)
Tajikistan 9 9 (100%) Ukraine 47 22 (47%)
Uzbekistan 8 7 (88%)
stavudine 40mgGlobal Median Price =
$0.05/tabletEstonia Russian
Federation
Ukraine Uzbekistan
3.03*3.17*
0.69* 0.040.05
2.89*
July 2006 - June 2007
*Brand Name ARV
efavirenz 600mgGlobal Median Price =
$0.65/tabletEstoni
aKazakhsta
nRussia
n Feder-ation
Tajikistan
Uzbekistan
$2.07* $0.21 $0.65*$0.98*
$0.67 $0.92
July 2006 - June 2007
*Brand Name ARV
zidovudine 300mg/lamivudine 150mg
Global Median Price = $0.19/tablet
Estonia
Kazakh-stan
Russia
Ukraine
Tajiki-stan
Uzbeki-stan
$4.32* $0.38 $1.33*$1.71*
$0.16$0.18$0.21
$0.21 $0.23
July 2006 - June 2007
*Brand Name ARV
TJ: $151 pp/yearKZ: $274 pp/yrRussia: $958 pp/yr
lopinavir 133mg/ritonavir 33mg
Global Median Price = $0.33/tabletKazakhstan Russian
FederationUkraine
$1.95* 1.87*$1.44*
$0.52*$1.12*
July 2006 - June 2007
*Brand Name ARV
Comparison of WHO 2003, 2006, and 2008 ART Guidelines
WHO 2003 ART Guidelines– 12 ARVs– 10 regimens: 4 first line, 6 second line
WHO 2006 Revised ART Guidelines– 23 ARVs – 108 regimens: 24 first line, 84 second line
WHO 2008 2nd Line Prioritization– 20 ARVs (1st and 2nd line)– 42 2nd line regimens (10 Urgent, 22 High,
10 Important)
0
100
200
300
400
500
600
700
1 2 3 4
Regimens
Ann
ual C
ost
($U
S)
GenericBranded
0
200
400
600
800
1000
1200
1400
1600
1 2 3 4 5 6 7
Regimens
An
nu
al
Cos
($U
S)
GenericBranded
2003 WHO regimensGeneric: $170-$431Brand: $500-$619
WHO First line regimens: generic price < brand(Median Prices July 2005-June 2006)
2006 WHO regimens Generic: $170-$1,234Brand: $431-$1,393
Low range of cost of brand regimens is higher than upper end ofcost generic regimens
Upper end of cost of generic regimens is 3 times higher than 2003
2006 STG big potential $ impact, even for 1st line
WHO 2nd line regimens: generic price > brand (Median Prices July 2005-June 2006)
0500
10001500200025003000350040004500
1 2 3
Regimens
Ann
ual C
ost
($U
S)
GenericBranded
0500
10001500200025003000350040004500
1 2 3 4 5 6
Regimens
Ann
ual C
ost
($U
S) GenericBranded
2003 WHO regimensGeneric: $2,913 - $4,117Brand: $1,714 - $2,351
2006 WHO regimensGeneric: $948 - $4,245Brand: $865 - $2,577
Mostly due to price of protease inhibitors
WHO 1st and 2nd line RegimensMedian Prices Paid July 2006-June
2007 Prices changing dramatically Decisions about country adoption MUST
involve price, among other things– Median 1st line prices
Generics range $102-$730 pp/year Brand range $595-$1,015 pp/year
– Median 2nd line prices range Generics range $540-$6231 pp/year Brands range $880-$2,044 pp/year
Generic PIs more competitive with brands, except Lop/r
Multiple Regression to Examine Predictors of Price
Regression model included 7 variables: – volume (divided in tertiles)– year of procurement– INCO terms – generic/brand – CHAI-eligible – Differential price-eligible – Country World Bank income stage
Higher Volume does NOT mean Lower Price
High Volum
e
Middle Volume
Low Volume
Efavirenz 600mg
Ref 3.75% 6.85%
Lop+rit 133.3+33.3mg
Ref 12.18% 23.87%
Sta+lam+nvp 40+150+200mg
Ref 12.87% 19.03%
Zidovudine 300mg
Ref 4.57% 2.00%Only 4 of 24 dosage forms showed volume-price association
Remaining 20 Dosage FormsNo Price-Volume Association
Abacavir 300mgDidanosine 100mgDidanosine 200mgDidanosine 400mgEfavirenz 50mgEfavirenz 200mgIndinavir 400mgLamivudine 150mgNelfinavir 250mgNevirapine 200mg
Ritonavir 100mgStavudine 20mgStavudine 30mgStavudine 40mgSta+lam 30+150mgSta+lam 40+150mgSta+lam+nvp
30+150+200mgTenofovir 300mg
Zidovudine 100mg
Zid+lam 300+150mg
CHAI Generic Prices Compared to Non-CHAI Generic Prices
11 comparisons– 1 (EFV 600mg) CHAI 22% less expensive Non-
CHAI– 4 ARVs CHAI 8-13% less expensive Non-CHAI– 6 ARVs CHAI price was <5% less than non-
CHAI
CHAI Inferences: CHAI Setting Market Prices for All?
0
5
10
15
20
25
Date ARV was added to CHAI list
% p
rice
dif
fere
nce
, C
HA
I an
d
no
n-C
HA
I g
ener
ic
Oct 2003 Jan 2006
Differential Prices (DP)
19 ARVs available under DP scheme– Most less expensive than brand prices
when DP not available 7 of the 19 DP-ARVs compared to
generic prices– 5 of these 7 DP ARVs more expensive
than generics
DP Offers little savings over generics for most ARVs
Summary & Conclusions Transparency of medicine prices using
electronic databases can potentially lead to increased access to medicines
Knowledge can be power– BUT only if information is accurate,
comprehensive (this data represents ~40-50% of all GF procurements),
High level political commitment needed from donors to mandate data be reported – No Policy from World Bank or PEPFAR to
report (although SCMS is voluntarily reporting)
Summary & Conclusions (2) Databases have potential to inform and
create accountability – donors, countries, and programs– Rapidly changing market place; requires
constant monitoring Need to understand how data can be most
useful to implementers– User-friendly interfaces– Accessible in low resource settings– Incorporate into procurement system
Acknowledgements:– Funding: United Kingdom Department for
International Development– Michael Borowitz (DFID)– Research team: Warren Kaplan, Matthew Fox,
Alexis King, Danielle Lawrence, Richard Laing, Bert Leufkens, Rose Radin, Sapna Mahajan
Thank you!
Brenda Waning: [email protected]