Survey shows low availability and high prices impede access to medicines in developing nations

For developing and middle-income countries, public sector medicine availability is low, leading patients to purchase medicines in the private sector where prices are substantially higher than would be expected if purchasing and distribution were efficient and mark-ups were reasonable. A range of policy options, such as promoting the use of generics, regulating mark-ups and removing taxes, could be used to target this inequity. These are the conclusions of an Article published in an upcoming edition of The Lancet, written by Alexandra Cameron, in charge of Essential Medicines and Pharmaceutical Policies at the World Health Organisation, and colleagues.

The authors looked at medicine prices from 45 WHO/Health Action International surveys in 36 countries*, which were adjusted for inflation or deflation and purchasing power parity which accounts for differences in buying power of local currencies. They were then compared with international reference prices. The results presented are for 15 medicines included in at least 80% of surveys and four specific medicines used to treat asthma, diabetes, infections and hypertension.

They found that 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, however low procurement prices did not always translate into low public sector 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%.

The authors conclude: “Data from the WHO/HAI Project on Medicine Prices and Availability confirm that substantial opportunities exist to increase availability, lower prices, and improve affordability of medicines in all regions and at all levels of country development. Using such data, countries should develop and implement national policies to improve the availability and affordability of essential medicines. The evaluation of such policies, including measuring progress against predetermined benchmarks and timelines, is crucial. Medicine prices, availability, affordability, and price components should be surveyed at least every 2 years using the WHO/HAI methodology, and should be routinely monitored and reported on a more frequent basis. Currently, evidence is limited on the effect of various policy options to make medicines more affordable; regular monitoring will be needed to assess whether policies are effective.”

In an accompanying Comment, Dr Ashwin Vasan, London School of Hygiene and Tropical Medicine, UK and Partners in Health, Boston, USA, and Dr Jim Yong Kim, Partners in Health, Boston, USA, say: “The shift in focus to chronic-care delivery systems should galvanise the global public-health community to reprioritise access to general essential medicines. As championed by WHO Director-General Margaret Chan and many others, comprehensive primary health care is now the only appropriate global health goal. If we can match our efforts in HIV, tuberculosis, and malaria with a robust effort to make all essential medicines affordable and accessible, that goal may just be in reach.”

*36 countries: Armenia, Brazil, Cameroon, Chad, China, El Salvador, Ethiopia, Fiji, Ghana, India, Indonesia, Jordan, Kazakhstan, Kenya, Kuwait, Kyrgyzstan, Lebanon, Malaysia, Mali, Mongolia, Morocco, Nigeria, Pakistan, Peru, Philippines, South Africa, Sri Lanka, Sudan, Syria, Tajikistan, Tanzania, Tunisia, Uganda, United Arab Emirates, Uzbekistan, Yemen.