Dele Abegunde & Kathleen Holloway

1. Inefficiencies Due to Poor Access to and Irrational Use of Medicines to Treat Acute Respiratory Tract Infections in Children Dele Abegunde & Kathleen Holloway Medicines Access and Rational Use

2. Background Inefficiencies exist generally in all aspects of the health systems. The extent of its attribution to poor access to appropriate treatment and irrational use of medicines is not well known. Exploration of the level of inefficiencies will provide strong basis for evaluating the impact of interventions to improve access and rational use of medicines.

3. Objectives To estimate and compare the cost of medicines for treating acute respiratory infections (ARI) in the under five year population accessing care under two comparator scenarios: 1. business-as-usual; and 2. treatment according to recommended guidelines.

4. Methods Incidence based estimation of new cases in year 2010 (incremental cost) Scenarios: business-as-usual compared with the counterfactual scenarios. Bayesian algebra on data obtained from a number of sources including WHO, UNICEF, Probability tree is constructed to estimate cost of medicines to treat ARIs in the under 5-year olds. The counterfactual scenario assumes that new cases were provided with the appropriate medicines according to UNICEF/WHO recommended guidelines. Cost per branch = (branch probability) X ((under5 population X incidence of ARI) X (Treatment coverage)) X (episode/annum) year 2010 Comparing these costs provides a rough indication of waste from inappropriate (ineffective) access to the appropriate medicines for treating ARI.

5. Methods • Setting A cross section of the under-5 population in 134: low-, lower middle-, upper middle - and high-income countries spanning 9 WHO sub regions, at risk of acute respiratory tract infection in year 2010. • Outcome Measure (s): Acquisition cost of medicines consumed in international procurement prices and dollars (source MSH) Excluding the freight-on-board (f.o.b), shipping, mark-ups, taxes and other additional (in-border) charges which are specific to countries.

6. Treatment outcome possibility frontier Treatment outcome possibility frontier: Implicit in the guidelines for treating ARI Overkill: More cost combination to achieve unattainable treatment optimum given available inputs F X A X Treatment output Y B X C X Under treatment: Sub-optimal out put with associated input costing E X D X Treatment output X

7. Methods Very sever Moderately sever Business as Usual Scenario Treatment to Guidelines Pneumonia URTI Treatment coverage Very sever Acute Respiratory Tract Infection (ARI) Moderately sever Treatment non Guidelines Pneumonia URTI Very sever Treatment coverage Moderately sever Treatment to Guidelines Pneumonia Counterfactual: everyone gets right treatment. URTI Figure 1: ARI treatment tree: Partitioned to business as usual and counterfactual scenarios

8. Results Figure 2: Comparing costs of medicines for treating ARIs for the business-as-usual and counterfactual scenarios

9. Results Figure 3. Pattern of medicines use for the treatment of common cold in under-5 year olds.

10. Results Figure 4: Pattern of treating ARIs across regions

11. Estimates of cost of medicines in the under 5s Cost of medicines to treat ARI in the under fives: • business-as-usual scenario is aggregated to $21million $4million is due to cost for the proportion of patients who could access appropriate and effective care while $17million(81%) represents cost of medicines for those who had no access to proper care. Over 80% of the cost of treating ARI in those who accessed care is spent on suboptimal and inefficient care. • The estimated cost of the counterfactual (assuming full coverage to appropriate care): $16million. When compared to the business as usual scenario, about $6million could be wasted on inappropriate care.

12. Cost inefficiencies Only 17.6% of the estimated cost of medicines for those who had access to care is due to appropriate and effective treatment. This implies that over 80% of the cost of treatment is inefficiently applied to suboptimal treatments. Total cost of medications giving current treatment (business-as-usual) scenario is 36% in excess of total cost of medicines that would be incurred if there was full access to appropriate treatment for those who accessed care. Cost estimates for proportion of new cases which had access to effective and appropriate treatment in the current treatment (business-as-usual) scenario represent 24% of the total cost of medicines giving full access to appropriate medicines.

13. Summary Pattern of treatment and inefficiencies are similar for all WHO regions but magnitude is highest in the SEARO followed by WprB and the Afro Regions (figure 4) Majority of the inappropriate treatment occur with the treatment of common cold. Antibiotics cost 53% of the total cost of medicines used (figure 3). Antibiotics are not routinely recommended common cold in the standard WHO/UNICEF guidelines for treatment of ARIs in under-fives.

14. Conclusion • The implication of these results is that inappropriate treatment of under-5 ARI results in excess cost of treatment ranging from 24% - 36% of the cost needed for appropriate treatment of ARI. • Efforts to motivate rational use and prescription of medicines in developing countries can potentially results into cost efficiencies and cost savings. http:www.who.int/healthsystems/topics/financing/healthreport/BP52ARIFINAL.pdf

16. Many thanks for listening