Summary of key conference findings and recommendations

1. Summary of key conference findings and recommendations Hans V. Hogerzeil, MD, PhD, FRCP Edin

2. Recurrent themes in the conference We know so much more! The place of RUM in the value chain Prices, generics, NCDs Adherence, soft values The future of RUM The Jewish Rabbi

3. “We have so much more data now!” • RUM indicator studies as baseline for advocacy, comparisons and progress (Kathy Holloway, Dennis Ross-Degnan) • Very detailed quantitative country reports, routine data • Oman: AB from 60% (1995) to 15% (2010) (Batool Jaffar Suleiman) • Kenya: comprehensive report (Regina Mbindyo) • WHO/HAI price and availability surveys (Marg Ewen) • Introduction of ACTs as part of the AMfM (e.g. Tanzania) • IMS data(Peter Stevens) • Market entry of generic medicines (USA, South Africa) • Allows for truly evidence-based policy advice to MICs • ATM Index to measure commitment, transparency, business model and behaviour of large R&D companies

4. Funding for essential medicines over time: Ghana 100% Colonial times % public expenditure on medicines Pooled funding, health insurance Public funding "NHS" model Early independence Donors time

5. Funding for essential medicines over time 100% Colonial times % public expenditure on medicines Pooled funding, health insurance Public funding "NHS" model Early independence Essential Medicines policies through reimbursement Essential Medicines policies in public sector Essential Medicines policies impossible time

6. The next generation of essential medicines:What do countries need in the next decade? Most of the New Middle East is poor (no oil in Tunisia, Egypt, Yemen, Syria) New Middle East: New medicine policies, good governance, human human rights, universal access, careful public expenditure India: Advocacy, medicine policy, democracy, human rights, care for the poor, universal access, public funding Africa: Democracy, transparency, carefully increasing public/pooled expenditure, quality assurance, social marketing in middle-income group China: Quality assurance, cost-containment (rational use) MICs: Expand health insurance, pricing policies, cost containment, generic policies, regulatory collaboration and harmonization Latin America: Cost containment, generic policies, rational use, unethical promotion, selection of expensive EMs OECD: WHO standards/review of new EMs for NTDs, regulatory collaboration

7. The future of essential medicines as a function of % public/pooled expenditure on medicines over time 100%- % public/pooled expenditure on medicines Colonial times USA/EC/Australia Rational use Thailand Generic policies Early independence L.America Cost containment MICs Pricing policies Public / pooled funding China Social health insurance Poor Asia Poor M.East Social marketing Africa Regulation, quality India Selection Advocacy Policy time

8. RUM in the value chain:Medicine prices • Royalties are the LIC/MIC contribution to research costs (Suerie Moon) • Taxes can be OK, depending who pays, and for which medicines (David Henry) • The level of scheduling (OTC, Pharmacy only, Prescription only) has a large effect on price (4x) (Travor Mabugu) • Tiered prices are still higher than competitive generics (MSF) • There is no global standard for allowing differential prices to countries/patients (GDP, LICs, HDI, high-burden, poor patients)

9. “The real enemy of the generics are the doctors, not the patients” Dr Ahmed Al Saidi, Minister of Health, Oman RUM in the value chain: generic policies • Switching to generics saves 65% of the medicine budget of Chinese hospitals (Sun Jing) • 52% of GPs in Malaysia think that generics are less regulated than branded products; 62% think that generic medicines have less efficacy (Mohamed Assali) with similar results from South Africa (Aarti Patel) • NCDs are the political argument for generic policies

10. “I wish I had AIDS”Cambodian diabetes patient, quoted by Chean Men The lack of treatment of NCDs / chronic conditions • Most treatments are cheap: <$1 per month, $12 per year • Same for depression/chronic psychosis: $4-6 per year (Robert Sebbag) • Difference in availability of 54% for acute medication vs 36% for chronic medication means: the system can do it (Richard Laing)

11. “Let’s not only look at technical solutions, but also improve the soft values” Birna Trap, Uganda Adherence • Current drop-out rates are not to be trusted, as there is no standard! (John Chalker) • The new INRUD-IAA standard methodology to measure adherence per facility is an excellent tool for intervention. This is INRUD at its best! (all INRUD teams) • Cell-phone methodology is very promising • There have been many experiences and studies on adherence since last ICIUM– do we now know what to do for scaling up? • “Promoting RUM is support, not policing”(Batool Jaffar Suleiman)

12. “The right to health costs money” Access to essential medicines as part of the right to health • In Thailand access to essential medicines is not a charity, but a right (SuwitWibulpolprasert) • In Pakistan women have less access to depression treatment (Anita Wagner). But what about women and girls in Yemen, Somalia, India and Afghanistan? • Arab Spring: Examples of good constitutional text are available. But be modest in your constitution (Vera Pepe, Jono Quick) and plan for an implementation programme and the necessary finances • Recommendation: Make a briefing paper for Arab spring countries, do advocacy NOW

13. “Many of today’s problems are based on yesterday’s solutions”Irene Akua Agyepong, Minister of Health, Ghana Evidence-based interventions: • How to involve patients/community in developing clinical guidelines in MICs? • How to manage medicine reimbursement in MICs? • How to use reimbursement data to promote RUM? • How to achieve cost-efficiency and sustainability of cell phone programmes for adherence? Descriptive studies for advocacy: • Disaggregated access statistics in selected countries • The economic cost and health impact of RUM inefficiency

14. “The future of RUM lies with the health insurance companies” • RUM is part of the value chain: you have to wait for the right moment and for the right incentives If you want to fast-forward RUM: ▼ ▼

15. “The future of RUM lies with the health insurance companies” • RUM is part of the value chain: you have to wait for the right moment and for the right incentives If you want to fast-forward RUM • Promote RUM as part of procurement costs; start with the GFATM, PEPFAR, PMI and UNITAID • Make a convincing case, based on economic benefits (for funders) and better health outcomes (for prescribers) ▼ ▼

16. “Public good or private gain”?Minister Bengzon, Philippines • Fight against the “normalization of corruption”(Richard Laing) • Advocate for the poor, against exploitation

17. Maimonides Jewish scholar (1135-1204) Rabbi, physician and philosopher in Morocco and Egypt

18. “Everyone must always regard himself as half innocent and half guilty. And he should regard the whole of mankind in the same way. If he then commits one more sin, he weighs down the scale of guilt against himself and against the whole world. And he himself causes the destruction of all. But if he fulfills one commandment, he turns the scale of merit in his favor and perhaps he saves the whole world. He by himself has the power to bring salvation to all men of the world. Everyone has this divine opportunity. The charity you do tomorrow may save the world.” Maimonides Jewish scholar (1135-1204) Rabbi, physician and philosopher in Morocco and Egypt

19. Saving lives with the right (to) medicines www.who.int / medicines