Overview of 2000 Survey of TB Drug Supply Experiences in Low- and Middle-Income

WHO Member States

Diana WeilSenior Public Health Specialist

World Bank/United States

Appreciation

With appreciation to National TB Control Program Managers, Ariel Pablos-Mendes and the Rockefeller Foundation, the World Bank, Lauren Mueenuddin, Rajedra Shukla, Mario Raviglionne, Jacob Kumaresan, Arata Kochi, Christy Hanson, Fabio Luelmo, Dan Bleed, Richard Laing, Peter Evans, Ian Smith, WHO regional offices and representatives, KNCV, and IUATLD and Dr. Pierre Chaulet

National TB Drug Supply Experiences, 1999–2000 Survey Objectives

• Inform Stop TB and DOTS expansion efforts

• Provide evidence base for assessment of need for a Global TB Drug Facility

• Provide background information on public tender market for the “pharmacoeconomics analysis” for the GATD

Approach

• Modified version of 1992 WHO survey (see Weil, in TB: Back to the Future, 1993), focusing on full drug cycle

• Distributed through WHO regional offices & the Africa IUATLD 2000 meeting to NTP managers or counterparts

• Used online and hard copy formats (online responses minimal)

• Allowed online entry of database

• Performed first analyses 2000/2001—GDF prospectus

• Performed price analysis 2002

• Reported all results based on respondents’ answers, without independent validation

Two Surveys

1992• 74 respondents

31/45 AFRO 14/36 AMRO 9/22 EMRO 5/11 SEARO 15/23 WPRO

2000• 75 respondents

27 AFRO 16 AMRO 12 EMRO 13 EURO 3 SEARO 4 WPRO**Only 4 high-burden WPRO countries

asked for responses.

• 17 of 22 high-burden countries

Drug Planning: Percentage of NTPs That

44%

88% 92%

0%10%20%30%40%50%60%70%80%90%

100%

Estimate need Use standardformula*

Include buffer stocks

*29% past year consumption; 40% past year TB cases; 27% estimated TB cases

Percentage of NTPs Responsible for Preparing Estimated Budget for TB Drugs,

1992 and 2000 Average

37%

63%50%

62%

100%

50% 51%

0%

20%

40%

60%

80%

100%

120%

AFR AMR EMR EUR SEAR WPR Average,1992

Region

Percentage of NTPs That Have Secure Financing for 2001: TB Drug Needs vs. 1992 Results

44%

88% 92%

69%

100%

75%

39%

0%

20%

40%

60%

80%

100%

120%

AFR AMR EMR EUR SEAR WPR Average,1992

Region

Percentage of NTPs with One or More Reported National-level TB Drug Stock Out: 1999 vs. 1992

39%

31%

15%

31% 33%

0

49%

0%

10%

20%

30%

40%

50%

60%

AFR AMR EMR EUR SEAR WPR Average,1992

Region

Proportion of $115 Million Reported Public TB Drug Purchasing, by Region

11%

17%

7%

18%20%

27%AFRAMREMREURSEAWPR

Note: A number of major countries are missing from the database.

Estimated $120–$145 Million Annual Sales through Public Tender Market

Governments73%

External Finance

27%

Source: Economics of TB Drug Development, GATDD, 2002.

Percentage of NTPs Using Open International Tendering for at Least Some Drug Purchases

33%

12.50%25% 23%

67%

100%

0%

20%

40%

60%

80%

100%

120%

AFR AMR EMR EUR SEAR WPR

Region

Price Differences and Relevance to Treatment Regimen Price

Regimen 1A—Comparison of Prices (SE Asia)

$18.37$21.22$20.92

$68.87

14% 16%

275%

0%0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

WHO/IUATLD India Bangladesh Thailand

Pri

ce i

n U

S$

0%

50%

100%

150%

200%

250%

300%

% D

iffe

ren

ce

Price in US$

% Difference

Price Comparisons (2)Regimen 1A—Comparison of Prices (AMRO)

$18.37$15.48 $17.22 $18.08

$25.39

$30.92 $32.08

$46.64

0%

38%

68% 75%

154%

–2%–6%–16%

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00

50.00

Pri

ce i

n U

S$

-40%-20%0%20%40%60%80%100%120%140%160%180%

% D

iffe

ren

ce

Price in USD

%Difference

Price Comparisons (3)

Regimen 1A—Comparison of Prices (EMR)

$18.37$22.66 $23.62

$34.73

$62.05

$87.52

0%23% 29%

89%

238%

376%

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

WHO/IU

ATLD

Leban

onSyr

ia

Moro

cco

Oman

Jord

an

Pri

ce i

n U

S$

0%

50%

100%

150%

200%

250%

300%

350%

400%

% D

iffe

ren

ce

Price in USD

%Difference

Price Comparisons (4)

Regimen 1B—Comparison of Prices (W. Pacific)

19.02

24.6626.37

0%

29.65%

38.64%

0

5

10

15

20

25

30

Pri

ce i

n U

S$

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

% D

iffe

ren

ce

Regimen 1B

% Diff 1B

Regimen 1B 19.02 24.66 26.37

% Diff 1B 0% 29.65% 38.64%

WHO/IUATLD Vietnam Cambodia

Percentage of Countries with National Mechanisms for Drug Quality Control, 1992 and 2000

17

69 75

40 4056 63 58 62

100

75

0

20

40

60

80

100

120

AFR AMR EMR EUR* SEAR WPR

Region

1992 2000

* Note: No question 1992 on measurement of the quality of quality control

Percentage of NTPs Using Fixed-dose Combinations

85%

56%67%

54%

100%

25%

41%

0%

20%

40%

60%

80%

100%

120%

AFR AMR EMR EUR SEAR WPR Avg.1992

Region

Percentage of NTPs Using Blister Packs

15%

38%33%

15%

67%

50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

AFR AMR EMR EUR SEAR WPR

Region

Percentage of NTPs with TB Drug Distribution Using a “Pull” Approach

(Based on Requests Received from Districts)

42% 44%

70%62%

67%

50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

AFR AMR EMR EUR SEAR WPR

Region

Percentage of NTPs Stating TB Drugs are Free-of-Charge to Patients in Health Services

42%

94%

69%77%

68%

50%

0%10%20%30%40%50%60%70%80%90%

100%

AFR AMR EMR EUR SEAR WPR

Region

Percentage of NTPs Reporting That Private Sales of TB Drugs Are Restricted

31% 31%

39%

23%

0

50%

0%

10%

20%

30%

40%

50%

60%

AFR AMR EMR EUR SEAR WPR

Region

Conclusions

• NTPs are more involved in the drug supply cycle. (But what about training & time burden?)

• Drug financing is still too often insecure.

• Average prices are low, but there are inefficient outliers caused by lack of competitive tendering.

• Use of fixed-drug combinations has increased.

• Quality control is still feeble.

Revisiting Recommendations from 1993 Survey Analysis

There is progress!1. Increasing awareness of governments, donors, and producers of burden

& C/E of control to increase financing and production +

2. Training NTP staff in drug management +

3. Fostering collaboration to develop new procurement mechanisms that increase availability of financing and volume of orders, and reduce delays in procurement and supply +++

4. Disseminating treatment guidelines so that rational use of drugs is improved +++

5. Conducting research to develop new drugs, depot preparations, and regimens that increase ease of drug administration, reduce length of regimen, and reduce risk of spreading drug-resistant strains ++