Financing Essential Medicines in Low- and Middle-income Countries: Cameroon Case Study

1. Financing Essential Medicines in Low- and Middle-income Countries: Cameroon Case Study Dr Dele Abegunde (MAR) & Mrs Helen Tata (MCP/MAR)

2. Inequalities (or inequities) access to medicines: growing with needs • Access to pharmaceuticals essential to healthcare • 25 -70% of health spending in the developing countries, • 10-18% in OECD countries • Marginal cost of consumption at point of need: • for most consumers in the developing countries is way greater than zero. • Less that 3% of population in low-income countries have some forms of insurance cover • Total pharmaceutical expenditure: • 0.2 – 3.8% of GDP • TPE / Total Health expenditure: • 25 – 36% OECD countries. Likely higher in LIMC countries? • Share of TPE from external sources • increased from 12% in 2000 to 17% in 2006 in LMIC, 22% in the 49 least developed countries.

3. Inequality in access = poor access to medicines • 80% global TPE spent on 18% of population: May suggest regressive global financing scenario • Medicines financing remain regressive in LMIC: Medicines are largely financed through OOP – only about 3% have access to some forms of insurance mechanism • Market failures justify public intervention: global economic recession threatening to dry up traditional funding sources

4. Dimensions to medicines financing • Providers (Supply of medicines) • National governments • Collaborating & Development partners (NGOs) • Health care systems and direct provides • Consumers (Demand for medicines) • General needs consumers • Special needs consumers Nearly all the global financing efforts to increase access to medicines is actively focused on Supply of medicines

5. Government health expenditure (as source) is Increasing

6. Official Development Assistance (ODA) and Health ODA Official Development Assistance (ODA) for Health, Bilateral and Multilateral flows [in constant 2006 US$ billions] 10 100 9 90 8 80 7 70 6 60 "Health" ODA US$ billions Total ODA US$ billions 5 50 4 40 3 30 2 20 1 10 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 ODA for Health Total ODA Source: OECD

7. Tanzania: Funding by Supply Type(2006-2007 Data) ESSENTIAL MEDICINES ARVs MALARIA TB OI ARVs Ped REAGENT Blood safety (+ HIV test) VACCINES CONDOMS CONTRACEPTIVES MEDICAL SUPPLIES GOVERNMENT BILATERAL DONOR MULTILATERAL DONOR NGO/PRIVATE C S S C O M S S I D A N O R A D C I D A UN I TA I D H A V A R D P E P F A R GLOBAL FUND CL I NTON A X I O S P F I Z E R J ICA C D C C O L U M B I A G A V I C U A M M U N I C E F U S A I D W B GOVERNMENT A B B O T T Source Of Funds Source: Supply management, WHO/EMP/MAR

8. Source: Helen Tata, WHO

9. Zambia: Funding by Supply type ESSENTIAL MEDICINES ARVs MALARIA TB OI ARVs Ped REAGENT Blood safety (+ test HIV) VACCINES CONDOMS Contraceptives MEDICAL Supplies ITN Category of Products Color GOVERNMENT BILATERAL DONOR MULTILATERAL DONOR NGO/PRIVATE UN I TA I D GLOBAL FUND C H A I WORLD B A N K P E P F A R U S A I D C D C D F I D W H O WORLD VISION Z A B A R T C H A Z B G A T E S U N I C E F U N F P A A XIOS M O H J ICA G L A S E R Source Of Funds Source: Supply management, WHO/EMP/MAR

10. Players and Partners?

11. What is happening in countries? Increased funding, more investment to improve access to medicines Access to medicines improving in some disease areas? Impact on health systems and unfavoured diseases areas Pharmaceutical work force challenges Uneven development of the procurement, supply and systems Demand for medicines is increasing in scale and scope Hardly any active planning budgeting for medicines in countries Is optimal and equitable access to medicines being achieved?

12. Challenges • Distorted view of total medicines financing with inputs to specific disease programs by donors • Reduced government contributions to health and medicines • Constrained technical capacity in countries • Political will • Global economic (financial) crisis • Human resources • Healthcare systems. • Weak tax systems – large informal sector

13. Innovative financing mechanism galore • hypotheticated taxes, e.g. 'sin taxes' for tobacco and alcohol • national and state lotteries dedicated to health • public-private partnerships between governments and the private sector to co-fund health care. • Other mechanisms are internationally focused, such as: • the (recently proposed) International Finance Facility (IFF). This would front-load development assistance by selling government bonds secured by future aids flows • debt for health swaps, in which external government debt is converted into domestic debt, thereby resulting in less pressure to generate foreign exchange for debt service. A debt-for-health swap also represents an opportunity for a foreign donor to increase the local currency equivalent of a donation. • the use of public-private partnerships to develop new products using capital markets.

14. Financing demand for medicines • Mechanisms to empower consumers such that economic considerations diminishes in making the decision to use medicines rationally to restore or improve health. • Insurance & reimbursement systems • Prepayment mechanisms • Market system manipulation and affordability

15. Global Picture: Medicines reimbursement Health insurance coverage and medicines reimbursement coverage by countries’ 2011 World Bank income classification

16. Global Picture: Medicines reimbursement Health Insurance coverage Reimbursement for medicines

17. Global Picture: Medicines reimbursement Health Insurance coverage Reimbursement for medicines

18. Persisting Situation • Medicines reimbursement reflects comparable coverage with health insurance coverage in countries with universal, or tax financed insurance systems. • Drug Revolving Funds are often precursors of community health insurance schemes in the developing countries and may explain the slightly higher medicines cover in low-income countries. • Community health insurance is growing in low- and middle-income countries, • but majority of countries and populations have no access to health insurance compared to high-income countries.

19. CHI Community finance schemes • This market is evolving in the contest of: • Government failure to organize taxes, public finance, provision of social protection to vulnerable populations and to exercise oversight over the health sector. • Market failure to offer effective exchange between demand and supply • Strength • Social capital • Pre existing community institutions • Interconnectivity between local communities • Limitations to overcome to serve the community well • Lack of insurance and reinsurance mechanisms to spread risk over larger population • Isolation from formal financing and provider networks • Have difficulties in mobilizing enough resources to cover costs of priority health services for the poor • Limited ability to encourage prevention or use of therapies effectively • Rely on management staff with limited professional training.

20. Community Health Insurance and Access to Medicines: Evidence from Cameroon

21. Essential Medicines Program • Supported by GTZ and Cameroon government in 3 regions • North West • South West • Littoral • An effective medicines supply system on cost-recovery basis • Hosted by Provincial Special Funds for Health (the FUNDs) • Strong community participation

22. Public Medicines Supply System in Cameroon

23. Community Mutual Health Organisation (Mutuelle) • A subsidiary of the Fund. • Built on well mobilized community platform of the EMP • Not-for-Profit community-based health financing schemes • Provides a viable alternative health financing mechanism • Pulls resources together from households • Risk sharing • Affordable health care to the rural poor

24. AIM of study Evaluate the impact of the community health insurance schemes on supply and distribution of essential medicines to public health care facilities in 3 regions in Cameroon.

25. Methodology (1) • Medicines selection • Antimalarial • Antibiotic • Maternal health • Chronic ailments (diabetes and hypertension) • Detailed supply records kept at regional medical stores (RMS) • Supply details to Health Facilities of 8 essential medicines (aminophyline, amoxicillin, co-trimoxazole, folic acid in combination with ferrous sulphate, metformin, nifedipine paracetamol and quinine)

26. Analysis • Two-by-two Analysis • mean monthly quantity of orders per facility • (Ho): zero mean difference between the comparative groups (across the two partitions), rejected at 95% degree of confidence • student t test used to evaluate the significance of the mean difference after and before CMHO.

27. Results: Mean Differences (Total Supply)

28. Results: North West Mean Monthly Facility Ordering Trends from 2005 to 2010 in the North West Region Provider Facilities Non-provider Facilities (a) Hospital 250000 250000 200000 200000 150000 150000 100000 100000 50000 50000 0 0 2005m1 2006m1 2007m1 2008m1 2009m1 2010m1 2005m1 2006m1 2007m1 2008m1 2009m1 2010m1 Datemonthvalue Datemonthvalue (b) Health Centre level 150000 150000 100000 100000 50000 50000 0 0 -50000 -50000 2005m1 2006m1 2007m1 2008m1 2009m1 2010m1 2005m1 2006m1 2007m1 2008m1 2009m1 2010m1 Datemonthvalue Datemonthvalue

29. Results: South West Mean Monthly Facility Ordering Trends from 2005 to 2010 in the South West Region Provider Facilities Non-provider Facilities (a) Hospital 60000 60000 40000 40000 20000 20000 0 0 2008m1 2008m7 2009m1 2009m7 2010m1 2010m7 2008m1 2008m7 2009m1 2009m7 2010m1 2010m7 Datemonthvalue Datemonthvalue (b) Health Centre level 30000 30000 20000 20000 10000 10000 0 0 2008m1 2008m7 2009m1 2009m7 2010m1 2010m7 2008m1 2008m7 2009m1 2009m7 2010m1 2010m7 Datemonthvalue Datemonthvalue

30. Results: Littoral Region Mean Monthly Facility Ordering Trends from 2005 to 2010 in the Littoral Region Provider Facilities Non-provider Facilities (a) Hospital 150000 150000 100000 100000 50000 50000 0 0 2005m1 2006m1 2007m1 2008m1 2009m1 2010m1 2005m1 2006m1 2007m1 2008m1 2009m1 2010m1 Datemonthvalue Datemonthvalue (a) Health Centre level 200000 200000 0 0 -200000 -200000 -400000 -400000 2005m1 2006m1 2007m1 2008m1 2009m1 2010m1 2005m1 2006m1 2007m1 2008m1 2009m1 2010m1 Datemonthvalue Datemonthvalue

31. Summary of Results • Regularly supply sustained in all centres - including non provider centres • Increased consumption of medicines and utilization of associated services • Evidently sustainable financing of medicines • Indications or demand for quality of medicines and care

32. Conclusion • A well designed and positioned mutual health insurance systems can have a positive impact on access to medicines and associated health services. • A well designed and functioning medicines supply system is essential for community health insurance to function.