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Towards a Medicines Transparency Alliance (MeTA)

Richard Laing and Ali Cameron with slides prepared by Michael Borowitz, DfID

WHO Technical Briefing SeminarOctober 2007

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Problem: poor cannot access essential medicines

Total Market Approach: public, private, and 3rd sector• Availability: Low availability in public sector• Price: High prices in private sector• Quality: Concerns about quality particularly of

generics

Manufacturer Procurement Agent (s)•Public•Private•mission

Wholesaler

Medical Stores

Distributor Retailer

Informal Sector/ Primary careHospital

Patient

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Example: complexity of medicines supply in Kenya

Contra-ceptives and

RHequipment

STIDrugs

EssentialDrugs

Vaccinesand

Vitamin ATB/Leprosy

BloodSafety

Reagents(inc. HIV

tests)

DFID

KfW

UNICEF

JICA

GOK, WB/IDA

Source offunds for

commodities

CommodityType

(colour coded) MOHEquip-ment

Point of firstwarehousing KEMSA Central Warehouse

KEMSARegionalDepots

Organizationresponsible

for delivery todistrict levels

KEMSA and KEMSA Regional Depots (essential drugs, malaria drugs,

consumable supplies)

ProcurementAgent/Body

CrownAgents

Governmentof Kenya

GOK

GTZ(procurement

implementationunit)

JSI/DELIVER/KEMSA LogisticsManagement Unit (contraceptives,

condoms, STI kits, HIV test kits, TBdrugs, RH equipment etc)

EU

KfW

UNICEF

KEPI ColdStore

KEPI(vaccines

andvitamin A)

Malaria

USAID

USAID

UNFPA

EUROPA

Condomsfor STI/

HIV/AIDSprevention

CIDA

UNFPA

USGov

CDC

NPHLS store

MEDS(to Mission

facilities)

PrivateDrug

Source

GDF

Government

NGO/Private

Bilateral Donor

Multilateral Donor

World Bank Loan

Organization Key

JapanesePrivate

Company

WHO

GAVI

SIDA

NLTP(TB/

Leprosydrugs

Commodity Logistics System in Kenya (as of July 2006) Constructed and produced by Steve Kinzett, JSI/Kenya - please communicateany inaccuracies to skinzett@cb.jsikenya.com or telephone 2727210

Anti-RetroVirals

(ARVs)

Labor-atorysupp-lies

GlobalFund forAIDS, TB

and Malaria

PSCMC(CrownAgents,GTZ, JSI

and KEMSA)

BTC

MEDS

DANIDA

Mainly District level staff: DPHO, DPHN, DTLP, DASCO, DPHO, etc or staff from the Health Centres,Dispensaries come up and collect from the District level

MEDS

Provincial andDistrictHospital

LaboratoryStaff

Organizationresponsible fordelivery to sub-district levels

KNCV

MSF

MSF

JSI/DELIVER

KEMSA

JSI

WHO

Source: SSDS Inc for the World Bank

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Transparency and Accountability in Medicines

• Market Failure– Complex chains of information asymmetry– Principal-agent problems– Response: government intervention

• Government Failure– Health systems failure: accountability– Lack of state capacity– Unregulated private sector– Government/regulatory capture

• Setting new equilibrium through transparency and accountability– Accountability system in drugs:

• Consumer organisations• Professional organisations• 3rd party purchasers

– Transparency changes the rules of the game

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Lessons from the Extractive Industries Transparency Initiative

• Increase transparency and accountability in revenue flows from extractives companies to governments

• Government led – multistakeholder – civil society• 5 stages: coming together, pilots, consolidating the rules

of the game, expansion, new governance arrangements• Key strengths:

– multi-stakeholder– accounting issues are matched with accountability– clear and narrow focus

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The MeTA ProposalIncrease transparency and accountability in medicines

procurement and supply, by:

• Securing high level political commitment • Global public goods: activities on transparency using Global development funds: • Country-led process focusing on transparency and accountability

– Multi-stakeholder forum: Getting the right people around the table – business, civil society and government – to agree how to disclose price, availability and quality data into the public domain – from both public and private sectors.

– Transparency in pricing, availability, quality– Drilling down in therapeutic classes– Builiding capacity

• Capacity of the state to regulate• Capacity of civil society to hold government to account

• Research Observatory– Evidence-based policy

• DFID funding £2mill for design, £25 million contribution

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Total Market Analysis semi-standardised approach

– WHO/HAI pricing survey: what explains the results• Components analysis• Global reference prices (MSH, IDA, etc.)

– Micro: Household survey data on medicines• WHA• Southampton survey review: LSMS, etc• Next wave? Dennis/WHO

– Macro: Health financing: NHA– Private sector: Supply Chain mapping:

• competition in different components• IMS-like data on price/volume• Informal sector

– Public sector• Public procurement: extension of WHO/WB• Tracking: PETS, other tools

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Observatory/Info-mediary

• What should you do?• Research observatory to bring together best practice

(e.g. price controls)• Standardised reports on the pharma sector• Info-mediary role: e.g. GPRM database• Support evaluation of interventions• Support operation research• Partners:

– Harvard, BU, Hopkins, LSTHM, LSE, Imperial, DFID RPC, NORAD/Cochrane Centre… more developing countries

• Scoping

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Generic and Brand ARV Prices:ranges much greater for brands

0.205 0.2130.319

0.425

0.175 0.1580.267 0.278

0.444

0.279

0.108

0.600

0.428 0.463

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

G 32x B 83x G 33x B 37x G 21x B 33x G 61x B 168x G 31x B 81x G 41x B 125x G 227x B 137x

ddI 100mg ddI 200mg ddI 50mg EFV 200mg IDV 400mg NFV 250mg NVP 200mg

Pri

ce p

er s

mal

lest

un

it (

$)

$1.945 $1.713 $1.356

Prices shown are per tablet

Every dosage form tells a different story

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Phase I pilot countries for MeTA

• Covering all regions: begin with one and spread out– Latin America: Peru (Bolivia)– East Asia: Phillipines (Vietnam, Cambodia, China)– EE/fSU: Kyrgyzstan– Middle East: Jordan– South Asia: India (Bangladesh, Pakistan)– Africa: Uganda, Kenya, Ghana (Zambia, Francophone)

• Linked to WHO/WB/HAI

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How MeTA might work

PoliticalCommitment

Establish multistakeholder

group (MSG)

Reviewexisting data /

research

Agree key deliverables - identify blocks

Disseminate, debate,

act

Disclose data

Draw on scoping study, Including e.g.

HAI Pricing surveyGlobal Fund data etc

Identify technical assistance

required:Procurement, regulatory

Medicines policy etc

Release MeTA report

Evaluate results, develop

recs

Scoping study:Full market analysisDrivers of change

Disclosure and report production

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Early info on pilots• Jordan:

– strengthening accountability: pricing survey not disseminated• Uganda

– Putting price and regulatory data on website• Zambia

– Price survey• Kyrgyzstan

– Examination of diabetes/psychotropics– Transparency in hospital procurement

• Phillipines– Dissemination of price information

• Ghana– Disseminate existing data– Strengthen data collection and dissemination on medicines quality

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Supporting infrastructure for transparency and accountability

• State capacity– Strengthening regulation– Strengthening insurance purchasers– Policy advice on regulating medicine prices

• Civil society capacity– Strengthening NGOs—HAI– Strengthening professional societies

• Equity and poverty lenses

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Next steps• Consultation• Pilots• Principles• MeTA Forum• Global public goods

– Observatory– Info-mediary

• Governance– Secretariat– Governance structure