Access to Essential Medicines selection, affordability, financing, supply systems

1. Access to Essential Medicines selection, affordability, financing, supply systems Marthe M Everard Policy, Access, and Rational Use (PAR) Essential Drugs and Medicines Policy (EDM) World Health Organization

2. Opportunities Access to essential medicines: staggering inequities - unparalleled opportunities Inequities

3. Inequities Economic inequity - percent of population below the poverty line has changed little in 2 decades Source: WHO/HFA (1997)

4. Inequities Health status inequity - infant mortality still varies 10-fold among regions of the world Source: WHO/HFA (1997)

5. Inequities Affordability inequity - number of working hours to pay full treatment course Based on average worldwide price and national per capita income. Source: WHO/EDM

6. Inequities Financing inequity - the burden falls heaviest on those least able to pay Medicines are the largest health expenditure for poor households • Inequity in health and pharmaceutical financing: • High income countries: 50-90 % publicly funded • Low/middle income countries: 50-90 % out-of-pocket Source: Azerbaijan - UNICEF-Bamako Technical Report No. 35 ; Bangladesh 1995 - National Accounts 1996/97 Mali (1986) - Diarra K and Coulibaly S. Financing of recurrent health costs in Mali. Health Policy and planning; 1990, 5(2);126-138

7. Inequities R&D inequity - expenditures grow, new medicines are launched, few specific for tropical diseases • Between 1975 and 1997 - • 1,223 new compounds launched • only 11 for tropical diseases R&D expenditure (US$ billions - top companies) New chemical entities launched (number) Sources: D. Gannaway and PriceWaterhouseCoopers (1999) R&D, NCE data; P. Trouiller et al (1999) tropical research data

8. Inequities Europe, N. America (150 to 940 per million) Asia (10 to 70 per million) Pharmacists per one million population Africa (1 to 30 per million) Pharmaceutical care inequity - a 100-fold variation in pharmacists per million population Source: WHO/HST/GSP/94.1 (1994)

9. Inequities Percentage of population with regular access to essential medicines (1997) (36) 1 = <50% (68) 2 = 50-80% 3 = 80-95% (33) (41) 4 = >95% (1) 5 = No data available Access inequity - financing, delivery, and other constraints still limit access to essential medicines 1/3 of world’s population lacks regular access 320 million in Africa have <50% Problem worsens with economic pressures Source: WHO/DAP (1998)

10. Opportunities Access to essential medicines: staggering inequities - unparalleled opportunities Inequities

11. 1. Rational selection 3. Sustainable financing 1. Rationalselection and use 3. Sustainablefinancing ACCESS ACCESS 4. Reliable health and supply systems 4. Reliable health and supply systems 2. Affordableprices 2. Affordable prices Ensuring access to essential medicines- framework for collective action

12. Rational selection - define what is most needed The essential medicines concept is nearly universal: 146 countries have national list of essential medicines Key actions: • develop evidence-based treatment guidelines • define essential medicines list based on treatmentguidelines • regularly update guidelines based on best evidence • use list for supply, reimbursement, training, etc.

13. The WHO Model List of Essential Medicines is amodel process, model product and public health toolThe WHO Essential Medicines Library WHO clusters WHO/PAR Clinical guidelines Summary of clinical guidelines BNF WHO Model Formulary WHO/EC, Cochrane Reasons for inclusion Systematic reviews Key references WHO Model List WHO/QSM Statistics: - ATC - DDD Cost: - per unit - per treatment - per month - per case prevented Quality information: - Basic quality tests - Intern. Pharmacopoeia - Reference standards MSH UNICEF MSF WCCs Oslo/Uppsala

14. Affordable prices - competition lowers prices Key actions: • price information • generics policies • reduce duties, taxes, mark-ups • differential pricing of newer essential medicines • apply WTO/TRIPS safeguards as appropriate

15. SelectionAffordabilityFinancingHealth systems UN Drug Access Initiative Domestic production Accelerated access initiative Generic offers Advocacy, corporate responsiveness, & competition have reduced prices 95% in 3 years ??

16. Sustainable financing - contain financial costs of ill-health & increase sustainable funding In over 38 countries public drug expenditures are < US$2 per capita - inadequate by most estimates Key actions: • increase public funding for cost-effective medicines • expand drug benefits in health insurance • better use of out-of-pocket spending • seek external funding for the poorest populations

17. SelectionAffordabilityFinancingHealth systems Medicines covered by public health insurance Drug benefits in public health insurance - access and risk-sharing

18. Reliable health and supply systems - ensure quality and availability Key actions: • integrate supply management into health system development • develop efficient mix of public - private - NGO systems • assure drug quality throughout distribution channels • promote rational use of medicines

19. SelectionAffordabilityFinancing Health systems Reliable health and supply systems - successful examples exist in all regions Direct delivery system - privatized, decentralized Primary distributor system - privatized, centralized Autonomous medical stores - partly private, centralized

20. 1. Rationalselection & use 3. Sustainablefinancing ACCESS 4. Reliable health systems 2. Affordableprices Conclusion Staggering inequities exist - in income, health status, R&D, pharmaceutical care, and access Unparalleled opportunities exist - to build on local successes to expand access for those in need

21. Department of Essential Drugs and Medicines Policy Http://www.who.int/medicines Thank you