Elsevier

The Lancet

Volume 373, Issue 9659, 17–23 January 2009, Pages 240-249
The Lancet

Articles
Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis

https://doi.org/10.1016/S0140-6736(08)61762-6Get rights and content

Summary

Background

WHO and Health Action International (HAI) have developed a standardised method for surveying medicine prices, availability, affordability, and price components in low-income and middle-income countries. Here, we present a secondary analysis of medicine availability in 45 national and subnational surveys done using the WHO/HAI methodology.

Methods

Data from 45 WHO/HAI surveys in 36 countries were adjusted for inflation or deflation and purchasing power parity. International reference prices from open international procurements for generic products were used as comparators. Results are presented for 15 medicines included in at least 80% of surveys and four individual medicines.

Findings

Average public sector availability of generic medicines ranged from 29·4% to 54·4% across WHO regions. Median government procurement prices for 15 generic medicines were 1·11 times corresponding international reference prices, although purchasing efficiency ranged from 0·09 to 5·37 times international reference prices. Low procurement prices did not always translate into low patient prices. Private sector patients paid 9–25 times international reference prices for lowest-priced generic products and over 20 times international reference prices for originator products across WHO regions. Treatments for acute and chronic illness were largely unaffordable in many countries. In the private sector, wholesale mark-ups ranged from 2% to 380%, whereas retail mark-ups ranged from 10% to 552%. In countries where value added tax was applied to medicines, the amount charged varied from 4% to 15%.

Interpretation

Overall, public and private sector prices for originator and generic medicines were substantially higher than would be expected if purchasing and distribution were efficient and mark-ups were reasonable. Policy options such as promoting generic medicines and alternative financing mechanisms are needed to increase availability, reduce prices, and improve affordability.

Funding

None.

Introduction

Medicines account for 20–60% of health spending in developing and transitional countries,1 compared with 18% in countries of the Organisation for Economic Co-operation and Development.2 Up to 90% of the population in developing countries purchase medicines through out-of-pocket payments,3 making medicines the largest family expenditure item after food. As a result, medicines are unaffordable for large sections of the global population and are a major burden on government budgets.

The organisation of a country's pharmaceutical sector can have implications for medicine availability, price, and affordability. In fully public systems, medicines are financed, procured, and distributed by a centralised government unit; in mixed systems, public funding from central budgets or social health insurance is used to reimburse patients or private pharmacies, or medicines are supplied through government medical stores and health facilities but paid for by patient fees; in fully private systems, patients or private insurance systems pay the entire cost of medicines purchased from private pharmacies and drug sellers. Most countries use a combination of these approaches.4

In 2001, a resolution endorsed by Member States of WHO called for the development of a standardised method for measuring medicine prices,5 which resulted in the launch of the WHO/Health Action International (HAI) Project on Medicine Prices and Availability. The project aims to contribute to target 17 of the Millennium Development Goals: “in cooperation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries”.

Before the WHO/HAI project, only a few small studies had been done in low-income and middle-income countries to measure medicine prices and make international comparisons.6, 7, 8, 9 Lack of consistent or reproducible methodologies restricted the comparability of these studies, and left them open to criticism.10 As such, the WHO/HAI project's initial focus was on the development of a standardised method for measuring medicine prices, availability, affordability, and price components. After pilot testing in nine countries,11 the methodology was launched in 2003.12

More than 50 WHO/HAI medicine pricing surveys have been done,13, 14, 15 and results are available on the HAI website.13 Other activities have included validation studies, secondary analyses of survey data by region and disease group,16 investigations into country price variations, and development of a methodology for routine medicine price monitoring. In addition to the WHO/HAI pricing surveys, other class-specific studies of medicine prices across countries have also been done.17

This paper presents a secondary analysis of medicine availability, price, affordability, and price components in 45 national and subnational surveys done using the WHO/HAI methodology.

Section snippets

WHO/HAI survey methodology

The WHO/HAI methodology has been published as a manual.12 In the typical survey, data for the availability and price of a specific list of medicines are collected in at least four geographic or administrative areas in a sample of public health facilities, registered private retail medicine outlets, and optionally in medicine outlets in other sectors (eg, mission hospitals). Data are also collected on government procurement prices, generally at the central level. The methodology also includes

Results

In the public sector, the availability of the basket of 15 generic medicines was low, ranging from 9·7% in Yemen to 79·2% in Mongolia (table 3). Regional availability ranged from 29·4% in Africa to 54·4% in the Americas; mean availability in the public sector was lower than in the private sector in all regions.

Even in the private sector, availability of generics was low, ranging from 50·1% in the western Pacific to 75·1% in southeast Asia. High private sector availability of generics was

Discussion

The WHO/HAI survey methodology allows for the measurement of medicine prices and availability in a standardised way, with multiple steps to ensure data quality. The common list of core medicines with specified dosage forms and strengths allows for more reliable international comparisons, whereas supplementary medicines identified at the country level ensure local relevance.

The survey's target medicine list and outlet sample approach have been validated in a medicine prices survey done in Peru

References (32)

  • D Beran et al.

    Diabetes care in sub-Saharan Africa

    Lancet

    (2006)
  • The World Medicines Situation

    (2004)
  • Drug spending in OECD countries up by nearly a third since 1998, according to new OECD data

  • Equitable access to essential medicines: a framework for collective action

    (March 2004)
  • Public-private roles in the pharmaceutical sector: Implications for equitable access and rational drug use

    (1997)
  • Resolution WHA 54.11. WHO Medicines Strategy. In: Fifty-fourth World Health Assembly, Geneva, May 14–22, 2001. Volume 1

    Resolutions and decisions, and list of participants

    (2001)
  • K Bala et al.

    Retail drug prices: the law of the jungle

    Hainews

    (1998 April)
  • K Sagoo et al.

    HIV/AIDS: Improving access to essential drugs

    Hainews

    (December 1999/January 2000)
  • K Bala et al.

    Patents and prices

    Hainews

    (April/May 2000)
  • K Myhr

    Comparing prices of essential drugs between four countries in East Africa and with international prices. Geneva: Médecins Sans Frontières

  • F Andersson

    Methodological aspects of international drug price comparisons

    Pharmacoeconomics

    (1993)
  • J Madden

    Comparing pilot survey results from different countries

    Essential drugs monitor

    (2003)
  • Medicine Prices. A new approach to measurement. 2003 edn. Working draft for field testing and revision. World Health Organization and Health Action International

  • Health Action International Medicine Prices

    (2007)
  • ZUD Babar et al.

    Evaluating drug prices, availability, affordability, and price components: implications for access to drugs in Malaysia

    P LoS Med

    (2007)
  • S Mendis et al.

    The availability and affordability of selected essential medicines for chronic diseases in six low- and middle-income countries

    Bull World Health Organ

    (2007)
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