August 27th 2008 1

Availability, Pricing and Affordability of Cardiovascular Medicines 2001-2006

Draft report for comments

Maaike S.M. van MourikUniversity Medical Center UtrechtIntern with Department of Medicine Access and Rational Use (MAR)

Supervisors:Alexandra CameronRichard Laing

August 27th 2008 2

Outline

Introduction & Background Methodology Results

Availability Pricing Affordability

Discussion & Policy options

August 27th 2008 3

Introduction & Background Cardiovascular diseases: 30% of deaths worldwide,

80% of which in developing countries

WHO-PREMISE study Many patients did not get medicines needed for adequate

management. Non-WHO studies

Problems with availability, pricing and affordability WHO report on chronic disease medicines

(30 surveys) Poor availability and affordability

Aim: Secondary analysis of price, availability and affordability of CVD medicines in 36 developing countries that have undertaken WHO/HAI surveys

August 27th 2008 4

Methodology

WHO/HAI data Standardized data collection Prices as Median Price Ratios (MPRs) Medicines: Atenolol 50mg, Captopril 25mg,

Hydrochlorothiazide (HCT) 25mg, Losartan 50mg and Nifedipine retard 20mg.

Secondary analysis Adjustments for inflation and purchasing power Analysis by World Bank Income Groups and WHO

regions.

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Surveys included

Low incomeChad (2004)Ethiopia (2004)Ghana (2004)India-Chennai (2004)India-Haryana (2004)India-Karnataka (2004)India-Maharashtra 12 districts (2004)India-Maharashtra 4 regions (2005)India-Rajasthan (2003)India-West BengalKenya (2004)Kyrgyzstan (2005)Mali (2004)Mongolia (2004)Nigeria (2004)Pakistan (2004)Sudan-Gadarif (2006)Sudan-Khartoum (2005)Sudan-Kordofan (2006)Tajikistan (2005)Tanzania (2004)Uganda (2004)

Uzbekistan (2004)Yemen (2006)

Lower-middle incomeArmenia (2001)Cameroon (2002)China-Shandong Province (2004)China-Shanghai (2006)El-Salvador (2006)Fiji (2004)Indonesia (2004)Jordan (2004)Morocco (2004)Peru (2005) Philippines (2005)Sri Lanka (2001)Syria (2003)Tunisia (2004)

Upper-middle incomeBrazil-Rio de Janeiro (2001)Kazakhstan (2004)Lebanon (2004)Malaysia (2004)South Africa - Kwazulu Natal (2001)

High IncomeKuwait (2004)United Arab Emirates (2006)

p.21 of the report

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Results: Availability (%)

0

10

20

30

40

50

60

70

80

Atenolol Captopril Hydrochloro-thiazide

Losartan Nifedipine All

Pe

rce

nta

ge

av

ail

ab

ilit

y

Public sector LPG Public sector OB Private sector LPG Private sector OB

August 27th 2008 7

Results: Availability by WBIG

Public sector percentage availability (weighted)

Atenolol Captopril Hydrochloro-

thiazide Losartan Nifedipine All

LPG OB LPG OB LPG OB LPG OB LPG OB LPG OB

LI 40.7 0.8 18.6 1.4 15.0 0.4 2.2 0.0 24.5 0.2 20.8 0.6

LMI 17.8 3.8 59.4 8.7 51.3 0.0 8.6 12.1 20.4 21.5 32.6 9.0 UMI 5.0 3.3 5.0 66.7 33.3 0.0 0.0 30.0 35.0 0.0 14.4 21.4

HI 93.0 10.5 81.3 5.6 46.9 0.0 0.0 72.2 50.0 100.0 60.3 38.1

All 38.9 2.3 31.5 9.1 27.7 0.5 3.7 10.4 26.0 11.7 26.3 6.8

Private sector percentage availability (weighted)

Atenolol Captopril Hydrochloro-

thiazide Losartan Nifedipine All

LPG OB LPG OB LPG OB LPG OB LPG OB LPG OB

LI 79.7 32.5 25.9 24.0 35.5 1.7 46.0 5.7 74.8 13.0 52.3 17.0

LMI 59.1 38.9 83.5 39.4 64.3 8.9 37.8 42.9 45.6 38.6 58.8 33.9 UMI 72.3 66.8 68.5 84.4 55.5 21.7 15.0 66.7 82.1 36.9 60.1 57.7

HI 76 98.0 16.7 94.0 50.0 0.0 0.0 100.0 34.8 98.0 39.4 85.0

All 73.3 42.8 59.4 36.5 45.9 6.7 38.6 29.8 65.6 26.5 57.3 29.2

August 27th 2008 8

Results: Procurement pricing

Public sector procurement

Procurement vs. public sector patient pricing Mark-up Taxes Procurement at a different price Cross-subsidizing

0

2

4

6

8

10

12

14

16

Atenolol Captopril HCT Nifedipine All

CP

I ad

just

ed M

PR

Generic Brand

MPR = 1

August 27th 2008 9

Results: Patient pricing

0

20

40

60

80

100

120

140

160

Atenolol Captopril Hydrochloro-thiazide

Nifedipine All

CP

I an

d P

PP

ad

just

ed M

PR

Public sector LPG Public sector OB Private sector LPG Private sector OB

Price ratio's in the public & private sector

August 27th 2008 10

Results: Patient pricing by WBIG

Patient MPRs (MSH2003, CPI and PPP adjusted) for the LPG (weighted averages) in the public and private sector. Atenolol Captopril Hydrochloro-

thiazide Nifedipine All

Public Private Public Private Public Private Public Private Public Private

LI 15.7 21.0 7.2 12.4 40.5 85.2 9.8 11.8 15.9 35.6

LMI 40.2 41.5 6.9 14.7 12.0 66.6 9.5 27.8 15.3 45.7 UMI 13.2 8.9 15.2 36.0 9.5 11.1 12.4 22.4

HI 26.8 10.7 55.2 13.9 38.5

All 23.0 25.8 7.0 12.7 25.0 73.0 9.7 15.0 15.5 30.2

August 27th 2008 11

Results: Private sector brand premiums

0.0

1.0

2.0

3.0

4.0

5.0

6.0

Atenolol Captopril Nifedipine All

Rel

ativ

e b

ran

d p

rem

ium

LI LMI UMI HI All

August 27th 2008 12

Results: Affordability

Number of day's wages the lowest-paid government worker needed to purchase one month of chronic treatment Large variations, on average 1.8 day's wages for

single medicine Most affordable: atenolol 50mg (1.1 day's wages) High income areas more affordable than low income

Note: Average income often below lowest government

wage Need for multiple medicines

August 27th 2008 13

Discussion & Policy options

Availability Focus on small group of medicines from national STG Increase public sector funding for NCD medicines

Procurement Some countries: can improve on procurement prices Differential pricing for public & private sector

Patient prices Lower taxes & tariffs Promote the use of generics Reduce mark-ups

August 27th 2008 14

Thank you

Please send any comments to:

M.S.M.vanMourik@students.uu.nl