E-DRUG: New publication on Medicines affordability
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Can I bring to the attention of E-Druggers a new paper published in PLOS Medicine that addresses the issue of affordability of medicines. As many of you will know, the standard WHO/HAI method for measuring the price, availability and affordability of medicines measures affordability in the number of days wages for the Lowest Paid Unskilled Government worker to purchase a course of treatment for an acute disease or a months treatment for a chronic disease, This metric has been criticised because in many countries most people earn less or a lot less than this government worker and so this metric may overestimate the affordability of medicines for most of the population.
To address this problem the WHO/HAI pricing project approached the Erasmus University in Rotterdam that has a strong Health economics department after receiving a request from Laurens Niëns to do a research internship with us. We laid out the issue to their department and a programme of work was initiated. Firstly Laurens did an extensive literature review of how other people had measured affordability in other areas such as transport, housing, food, education etc. Then once it became clear what the two possible approaches were he went to HAI in Amsterdam and worked with staff there to extract data from their data bases to do the analysis. Then he came to Geneva to work on the analysis and report writing with assistance from staff in the Health Financing as well as the Essential Medicines department. He did all of this work in six months and deserves a great deal of credit for pushing the margins of methodology in analyzing medicine affordability.
I would encourage E-Druggers to read the paper and consider how the methods he developed could be applied in different national situations.
The full article is available at
http://www.plosmedicine.org/article/info%3Adoi%2F10.13712Fjournal.pmed.1000333
You can contact Laurens Niëns for more information or his thesis report at
Erasmus University Rotterdam
Room L3-084 (J-building)
Burgemeester Oudlaan 50, 3062 PA Rotterdam
PO Box 1738, 3000 DR Rotterdam
The Netherlands
phone: +31-10-4088550
fax: +31-10-4089081
email: niens@bmg.eur.nl
web: www.imta.nl
Here is the abstract and the Editors Summary.
Research Article
Quantifying the Impoverishing Effects of Purchasing Medicines: A Cross-Country Comparison of the Affordability of Medicines in the Developing World. Laurens M. Niëns 1*, Alexandra Cameron 2, Ellen Van de Poel 1, Margaret Ewen 3, Werner B. F. Brouwer 1, Richard Laing 2 https://gva1swmikan07.who.int/exchange/laingr/Drafts/RE:%20Paper%20published.EML/1_text.htm
1 Institute for Medical Technology Assessment and Institute for Health Policy & Management, Erasmus University Rotterdam, The Netherlands, 2 Essential Medicines and Pharmaceutical Policies, World Health Organization, Geneva, Switzerland, 3 Health Action International Global, Amsterdam, The Netherlands
Abstract
Background
Increasing attention is being paid to the affordability of medicines in low- and middle-income countries (LICs and MICs) where medicines are often highly priced in relation to income levels. The impoverishing effect of medicine purchases can be estimated by determining pre- and postpayment incomes, which are then compared to a poverty line. Here we estimate the impoverishing effects of four medicines in 16 LICs and MICs using the impoverishment method as a metric of affordability.
Methods and Findings
Affordability was assessed in terms of the proportion of the population being pushed below US$1.25 or US$2 per day poverty levels because of the purchase of medicines. The prices of salbutamol 100 mcg/dose inhaler, glibenclamide 5 mg cap/tab, atenolol 50 mg cap/tab, and amoxicillin 250 mg cap/tab were obtained from facility-based surveys undertaken using a standard measurement methodology. The World Bank's World Development Indicators provided household expenditure data and information on income distributions. In the countries studied, purchasing these medicines would impoverish large portions of the population (up to 86%). Originator brand products were less affordable than the lowest-priced generic equivalents. In the Philippines, for example, originator brand atenolol would push an additional 22% of the population below US$1.25 per day, whereas for the lowest priced generic equivalent this demographic shift is 7%. Given related prevalence figures, substantial numbers of people are affected by the unaffordability of medicines.
Conclusions
Comparing medicine prices to available income in LICs and MICs shows that medicine purchases by individuals in those countries could lead to the impoverishment of large numbers of people. Action is needed to improve medicine affordability, such as promoting the use of quality assured, low-priced generics, and establishing health insurance systems.
Citation: Niëns LM, Cameron A, Van de Poel E, Ewen M, Brouwer WBF, et al. (2010) Quantifying the Impoverishing Effects of Purchasing Medicines: A Cross-Country Comparison of the Affordability of Medicines in the Developing World. PLoS Med 7(8): e1000333. doi:10.1371/journal.pmed.1000333
Copyright: © 2010 Niëns et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
* E-mail: niens@bmg.eur.nl
Editors' Summary
Background
In recent years, the international community has prioritized access to essential medicines, which has required focusing on the accessibility, availability, quality, and affordability of life-saving medicines and the development of appropriate data and research agendas to measure these components. Determining the degree of affordability of medicines, especially in low- and middle-income countries, is a complex process as the term affordability is vague. However, the cost of medicines is a major public health issue, especially as the majority of people in developing countries do not have health insurance and medicines freely provided through the public sector are often unavailable. Therefore, although countries have a legal obligation to make essential medicines available to those who need them at an affordable cost, poor people often have to pay for the medicines that they need when they are ill. Consequently, where medicine prices are high, people may have to forego treatment or they may go into debt if they decide to buy the necessary medicines.
Why Was This Study Done?
The researchers wanted to show the impact of the cost of medicines on poorer populations by undertaking an analysis that quantified the proportion of people who would be pushed into poverty (an income level of US$1.25 or US$2 a day) because their only option is to pay out-of-pocket expenses for the life-saving medicines they need. The researchers referred to this consequence as the "impoverishing effect of a medicine."
What Did the Researchers Do and Find?
The researchers generated "impoverishment rates" of four medicines in 16 low- and middle-income countries by comparing households' daily per capita income before and after (the hypothetical) purchase of one of the following: a salbutamol 100 mcg/dose inhaler, glibenclamide 5 mg cap/tab, atenolol 50 mg cap/tab, and amoxicillin 250 mg cap/tab. This selection of drugs covers the treatment/management of three chronic diseases and one acute illness. The cost of each medicine was taken from standardized surveys, which report median patient prices for a selection of commonly used medicines in the private sector (the availability of essential medicines in the public sector is much lower so many people will depend on the private sector for their medicines) for both originator brand and lowest priced generic products. If the prepayment income was above the US$1.25 (or US$2) poverty line and the postpayment income fell below these lines, purchasing these medicines at current prices impoverishes people.
According to the results of this analysis, a substantial proportion (up to 86%) of the population in the countries studied would be pushed into poverty as a result of purchasing one of the four selected medicines. Furthermore, the lowest priced generic versions of each medicine were generally substantially more affordable than originator brand products. For example, in the Philippines, purchasing originator brand atenolol would push an additional 22% of the population below US$1.25 per day compared to 7% if the lowest priced generic equivalent was bought instead. In effect, purchasing essential medicines for both chronic and acute conditions could impoverish large numbers of people, especially if originator brand products are bought.
What Do These Findings Mean?
Although the purchasing of medicines represents only part of the costs associated with the management of an illness, it is clear that the high cost of medicines have catastrophic effects on poor people. In addition, as the treatment of chronic conditions often requires a combination of medicines, the cost of treating and managing a chronic condition such as asthma, diabetes, and cardiovascular disease is likely to be even more unaffordable than what is reported in this study. Therefore concerted action is urgently required to improve medicine affordability and prevent poor populations from being pushed further into poverty. Such action could include: governments, civil society organizations, and others making access to essential medicines more of a priority and to consider this strategy as an integral part of reducing poverty; the development, implementation, and enforcement of sound national and international price policies; actively promoting the use of quality assured, low-cost generic drugs; ensuring the availability of essential medicines in the public sector at little or no charge to poor people; establishing health insurance systems with outpatient medicine benefits; encouraging pharmaceutical companies to differentially price medicines that are still subject to patent restrictions.
Richard Laing (Coordinator)
Medicine Information and Evidence for Policy,
Department of Essential Medicines and Pharmaceutical Policies
World Health Organization
CH-1211 Geneva 27, Switzerland
Tel 41 22 791 4533
Fax 41 22791 4167
E-mail laingr@who.int