Access to essential drugs: staggering inequities - unparalleled opportunities

1. Access to essential drugs: staggering inequities - unparalleled opportunities Jonathan D. Quick, MD, MPH Director, Essential Drugs and Medicines Policy Health Technology and Pharmaceuticals Cluster World Health Organization Presented at SEAM Conference, Washington, DC 27-29 November 2001

2. Opportunities Access to essential drugs: 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 R&D inequity - expenditures grow, new drugs 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

6. Therapeutic inequity - growing resistance is affecting prevalent infectious diseases • Malaria • chloroquine resistance in 81/92 countries • Tuberculosis • 2 - 40 % primary multi-drug resistance • Gonorrhoea • 5 - 98 % penicillin resistance in N. gonorrhoeae • Pneumonia and bacterial meningitis • 12 - 55 % penicillin resistance in S. pneumoniae • Diarrhoea: shigellosis • 10-90+ % amp, 5-95% TMP/SMZ resistance Source: DAP, EMC, GTB, CHD (1997)

7. Inequities Health literacy inequity - information explosion for some people, information poverty for others • Among high income countries - • 300+ million world-wide internet users by 2000 • 2/3 of users search for health information • 43% of 700,000 US doctors or their staff browse the Web • 67% of doctor’s patients have Internet information • Among low and middle income countries - • available information often under-utilized • 1/2 of drugs with sufficient information for safe, effective use • only 1/4 of drug packets in Asia contain inserts • 25-45% of adult women illiterate - over 90% in some countries Source: D. Gannaway (1999), World Development Report (1997), WHO/DAP (1998), WHO/EDM (1999)

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

10. Inequities Financing inequity - the burden falls heaviest on those least able to pay Drugs 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

11. Inequities Percentage of population with regular access to essential drugs (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 drugs 1/3 of world’s population lacks regular access 320 million in Africa have <50% Problem worsens with economic pressures Source: WHO/DAP (1998)

12. Inequities People are needlessly suffering and dying - drugs unavailable, unaffordable, unsafe, or wrongly used • In Africa and S.E.Asia: • 1/2 of deaths among children, young adults due to 6 diseases • prompt diagnosis and treatment could save over3 million lives per year

13. Opportunities Access to essential drugs: staggering inequities - unparalleled opportunities Inequities

14. 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 drugs- framework for collective action

15. SelectionAffordabilityFinancingHealth systems Essential drugs lists (only) (75) Treatment guidelines (only) (7) Essential drug list & guidelines (83) Essential drugs concept nearly universal - lists and guidelines put the concept into practice 158 countries with essential drugs lists 90 countries with treatment guidelines 83 countries with both

16. SelectionAffordabilityFinancingHealth systems Standard treatment guidelines (STGs) - save lives when effectively implemented Source: WHO/CDS/CSR/DRS/2001.9

17. SelectionAffordabilityFinancingHealth systems Interactive group discussion Seminar (both groups) District-wide monitoring (both groups) Getting mothers and clinicians to talk- reducing injection use in Indonesia Source: Long-term impact of small group interventions, Santoso et al., 1996

18. 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 ??

19. SelectionAffordabilityFinancingHealth systems No competition Competition (2 to 6 producers per product) Competition is highly effective in reducing prices - the example of antiretrovirals Source = UNAIDS, B. Samb, 2000

20. SelectionAffordabilityFinancingHealth systems Drugs covered by public health insurance (71) Drug benefits in public health insurance - access and risk-sharing

21. SelectionAffordabilityFinancingHealth systems ? Global Fund to fight AIDS, Tuberculosis and Malaria - pledges from May to August 2001 $ 1.5 billion US $ millions

22. SelectionAffordabilityFinancingHealth systems Training Training Southern zone Northern zone Shopkeeper training - helping households get the best value for their health spending Source: Marsh et al, 2001

23. 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

24. SelectionAffordabilityFinancing Health systems India - state essential drugs programmes developed through an NGO Himachal Pradesh Punjab Components • State drug policy • Essential drugs lists by level of care • Pooled procurement • Efficient distribution • Quality assurance • Information--patients & prescribers • Training in rational prescribing • Studies on drug use, pharmacoeconomics Haryana Delhi State Rajasthan Bihar Madhya Pradesh Gujarat West Bengal Maharashtra Andhra Pradesh Goa 13 states - total population 580 million Tamil Nadu

25. 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