Drugs and Money - Prices, Affordability and Cost Containment
(2003; 158 pages) View the PDF document
Table of Contents
View the documentIntroduction
Open this folder and view contentsPart I: Problems and approaches to a solution
Close this folderPart II: Selected experiences with policy options
View the documentChapter 6: Measures relating to use of drug subsidy lists and to regulation
View the documentChapter 7: Experiences with budgets
View the documentChapter 8: Experiences with reference pricing
View the documentChapter 9: Experiences with patient charges
View the documentChapter 10: Switching to non-prescription status
View the documentChapter 11: Experiences with generics
View the documentChapter 12: Experiences with pharmacy benefit management programmes in the USA
View the documentChapter 13: Experiences with professional education
View the documentChapter 14: Providing affordable medicines in transitional countries
View the documentChapter 15: Access to medicines in low-income countries
View the documentList of Contributors
View the documentBack cover
 

Chapter 15: Access to medicines in low-income countries

Marthe Everard

1. Introduction

The World Bank classifies countries by per capita Gross National Product (GNP). “Low-income” countries are regarded as those with a national income per capita of US$ 755 or less and “middle-income” countries as those with per capita income lying between US$ 756 and US$ 9265 [12]. Both these groups are generally referred to as “developing” countries. “High-income” countries or “developed” or “industrialized” countries are classified as those with per capita income of US$ 9266 or above [12]. The distinction between these three classes of countries thus reflects differences in the levels of income and standards of living of their populations. In low and middle-income countries a large proportion of the population live in poverty and their condition is characterized by high rates of mortality, morbidity and disability, as well as limited access or none to health care and services. The bulk of the population in high-income countries, on the other hand, have better standards of living and health and enjoy extensive access to health services, while their countries also have the ability to develop health technologies [5].

Notwithstanding these differences, the governments of developing and industrialized countries share an interest in health and health care. Irrespective of their level of development or national income, people desire better health status and greater access to health care including appropriate pharmaceutical services. It is clearly in the national interest that health budgets be allocated effectively so as to maximize the contribution made to attaining national health objectives and advancing social welfare [1].

A global analysis shows that world consumption of pharmaceutical products increased dramatically from US$ 70 billion to US$ 317 billion in the period between 1975 and 2000 [10]. During this period the world’s per capita consumption of medicines increased from US$ 17 to US$ 53. Yet more than 80% of all pharmaceutical products are consumed by the 15% of the world population living in industrialized countries, a figure which reflects a grossly uneven distribution of pharmaceutical consumption across the world [3,13,16].

Despite the increased world consumption, problems remain in ensuring the availability and affordability of medicines, including those which are essential for treating the majority of common diseases prevailing in low and middle-income countries. The reasons for this are complex. They are not only related to financial constraints, but also to the attitudes of key actors in the health sector - a sector which comprises a network of relationships between the government, public and private providers in the health and pharmaceutical sectors, an important volume of industrial activity and the consumer.

This chapter will provide a general overview of the situation in developing countries regarding access to essential medicines, and especially their problems in ensuring affordability and possible strategies to overcome them.

In this overview traditional medicines will not be considered, although their role should not be underestimated.

2. Access to essential medicines: Four components

After immunization for common childhood diseases, appropriate use of medicines is one of the most cost-effective components of modern health care but that is not to say that all are equally necessary across the board; where means are limited, priorities can and must be set. Decisions on the range of medicines which one must strive to make available throughout a nation have to be taken in the face of challenging political, social, ethical, economic, and medical difficulties and developments. Governments, non-governmental organizations, and households in many low-income countries struggle continuously to ensure and secure access to even the most basic life-saving medicines, especially in rural areas. In low-income countries therefore, the most urgent concerns relate to the need to attain affordability and equity of access with respect to these vital pharmaceuticals, and beyond that to attain the same for a somewhat wider range of “essential medicines”, a concept developed by the World Health Organization in 1977.

The description of essential medicines is as follows: Essential medicines are those that satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness. Essential medicines are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford. The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations; exactly which medicines are regarded as essential remains a national responsibility” [25].

The term “essential medicines” is usually applied to those medicines that are listed on the World Health Organization (WHO) Model List of Essential Medicines, most of which are off-patent; many countries have developed their own lists.

WHO has developed a global framework for “Access to Essential Medicines” which has been adopted by United Nations’ agencies and consists of (1) rational selection and use; (2) affordable prices; (3) sustainable financing; and (4) reliable health and supply systems [19]. Different stakeholders have differing roles to play in developing these components positively and seeking both to remove old obstacles and create new opportunities.

2.1. Rational selection and use

Medicines are one of the important elements in the provision of health care. While advanced methods of treatment for major infectious diseases and related conditions tend to become ever more complex and costly, many highly effective medicines are - or can be - made available at very low cost. Commonly, therefore, fully acceptable and affordable treatments can be found if one chooses well. Rational selection of medicines includes defining which medicines are most needed, identifying the most cost-effective treatments for particular conditions while taking full account of quality and safety as well, and then ensuring that they are used effectively.

Appropriate use of medicines by health professionals and mid-level health workers is being pursued by introducing evidence-based national treatment guidelines and protocols. Based on these treatment guidelines a national list of essential medicines and key pharmaceuticals can be prepared and disseminated.

In-service training programmes and availability of unbiased drug information are needed to update the knowledge and skills of clinicians, pharmacists and nurses in effective drug use. Encouraging rational drug use by patients is of equal importance.

2.2. Affordable prices

Affordability of medicines by individual patients in low-income countries is an important factor influencing access to care and treatment. Seeking care is more commonly a question of buying medicines than of consulting a qualified health worker. Drug prices, which are sometimes actually higher than those in high-income countries, often have to be met entirely by sick persons or their households; it is estimated that some 50-90% or more of pharmaceutical expenses are out-of-pocket purchases [16]. The bulk of the out-of-pocket health expenses which have to be met by the individual or household commonly relate to medicines [15]. Various ways of reducing this burden on the family will be considered below, but an important one is clearly to ensure that prices are brought to the lowest attainable level. That can be ensured variously by promoting competition among quality generic medicines where off-patent items are concerned, negotiation of prices, and therapeutic competition for on-patent medicines, use of the provisions stipulated under the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS) where necessary to increase affordability of medicines still under patent [24], reduction of duties and taxes, and reduced wholesale and retail margins. It is equally important to provide transparent price information for healthcare providers and consumers so that the community knows how to find the most affordable products when they are needed.

2.3. Sustainable financing

This third component of access must be viewed in the context of overall funding of health care, including financing for prevention and treatment of priority infectious diseases with a high public health impact.

For decades, the public health sector in developing countries was mainly financed by the government, and the public health sector commonly provided medicines free of charge. Over the years, diminishing budgets have increasingly led to drug shortages in the national health system, particularly in rural areas, and to a widespread collapse of free drug supply. This is the principal reason why, as already pointed out, health care in low-income countries is today predominantly financed privately. This is illustrated in Fig. 1, contrasting the sources of health financing in eleven low-income countries with those in nine high-income countries [20].

By far the most common form of private finance is out-of-pocket payment, made at the time when people seek care and treatment, rather than through a prepayment scheme. Figure 2 shows that out-of-pocket payment in the high-income areas of the world seldom exceeds 20% of the total while it exceeds 90% in some low-income countries. Out-of-pocket payment for health care tends to be both inequitable and inefficient when it plays a major role in health financing; there is clear evidence that the burden of payment for health care falls heavily on the poorest households at the time when a family member is sick; at these times, income may actually be reduced by illness and it is likely that the medicines which will be needed will be bought in insufficient quantities or not at all.

In this respect, change is underway, though it still has far to go. Thirty-three of the 37 Sub-Saharan African countries in which public health services were previously free-of-charge and funded by domestic tax revenues have introduced health financing strategies based largely on private financing in the form of fee schemes or co-payment [2].


Fig. 1. Public and private shares in health financing differ in high- and low-income countries.


Fig. 2. Out-of-pocket payment as % total health expenditure is more important in low-income countries.

Health insurance schemes are another option, though it may be difficult to implement them in low-income countries. Whereas social insurance schemes are common in Europe and are on the increase in Latin America and Asia, one finds that in Sub-Saharan Africa, protection by social insurance coverage provides for less than 8% of the population [15,21].

Sustainable financing can also be achieved by a combination of several viable financing mechanisms, including, in addition to the above, reallocation of public funds, better use of out-of-pocket spending, and international financing through grants, donations, and loans under appropriate circumstances.

2.4. Reliable health and supply systems

Health systems should provide a certain minimal level of health care which has the capacity to treat major infectious diseases and related conditions effectively with essential medicines and when necessary with key pharmaceuticals. Improvements to existing drug supply systems are usually central to health sector development.

Tackling the overall cost of health care became high on the political agenda of governments from both developing and developed countries because of increasing health and pharmaceutical expenditures. Governments had to look for new ways of financing and delivering health services in a cost-effective way. Mechanisms for cost-containment introduced by industrialized countries and relating to medicines have been, among others, national drug formularies, non-reimbursable drug lists, restricted reimbursement schemes, price regulation, promotion of generic prescribing and substitution, and surveillance of prescribing costs [14].

In 1993, the World Bank published its report “Investing in Health” and encouraged governments from developing countries to set priorities in health services and to allocate resources efficiently by promoting an approach based on “the burden of disease” and the cost-effectiveness of interventions so to design an “essential national package” of health services. That would comprise a “minimum package” of public health (preventive care) and clinical (curative care) services, including the provision of essential medicines. Governments should ensure universal access to their national packages and allocate a certain amount of resources to satisfy the needs of the poor and other target groups [11].

Drug supply systems must serve to ensure continuous availability of essential medicines and medical supplies of assured quality. Supply should be well planned and dependable so that shortages and stock-outs are rare, and the total costs for a given level of service should be low. In order to meet increasing drug demands and the expectations which the public have of the public health services, and to improve on failing public drug supply systems, governments have looked for new - and cost-effective - ways of financing and managing drug supplies [11]. In many low-income countries, creative mechanisms and an efficient mix of public, private, and NGO sectors in national drug supply and distribution systems have evolved [15]. It is particularly important that effective national drug legislation and regulations, including drug quality assurance and control systems be in place for monitoring both imported and locally produced medicines circulating in the local market. In addition regulatory control is needed to determine which health professionals are authorized to prescribe and dispense medicines (an essential part of ensuring the quality of medical care), to assure the quality of drug supplies, to combat counterfeit products, and to contain drug resistance in both public and private sectors [15].

Despite all the efforts which have been made in developing countries in advancing both general health policy and the performance of the pharmaceutical sector, it is an unhappy fact that the access problem is far from being solved. Two thirds of all deaths of children under 15 are due to seven diseases for which effective prevention and therapies exist, as shown in Fig. 3 [17]. Vulnerable groups of society are still dying because of lack of access to these essential treatments. It is an unhappy fact that the world’s poorest people too often are served by the most inefficiently performing health systems [20]. Their health status is below what is attainable, and health and supply systems are unresponsive and unfairly financed.

3. Strategies to increase affordability of medicines and reduce expenditure

Throughout this volume, alternative methods of rendering medicines more affordable and containing overall expenditure have been presented, and experience with them reviewed. Some of those methods are simple to apply while others demand considerable resources and may not be feasible in developing countries where the input to policies is constrained in terms of staffing, finance and technical abilities. The best known of these methods are summarized in Table 1, and certain of these will be discussed further in this section.


Fig. 3. Two out of three deaths among children and young adults in Africa and South East Asia are due to seven causes (age group: 0-44 yrs).

Table 1
Examples of measures for controlling drug expenditure

Examples

Explanation/comments

Bulk purchasing

E.g., by Government Medical Stores, generally with extensive use of tenders

 

May include pooled procurement (by several institutions or even several countries)

Capping of expenditures

Ceiling of pharmaceutical expenses per insured patient or

 

Limits on expenditure allowed per treatment episode

Drug selection

Positive lists, such as essential medicines lists, based on criteria for inclusion (public health needs, therapeutic value, cost) or Negative lists, excluding certain products

Restrictions on marketing and advertising expenditure

Advertising and promotion can make up a significant portion of ex-factory drug costs and are intended to raise consumption.

 

Limitations are thus intended both to reduce price and help rationalize consumption

Prescribing controls or incentives

Intended to reduce consumption and/or shift prescriptions towards cheaper or generic medicines

Price control

Mainly on ex-factory or retail prices or on distribution margins

Promotion of rational use

Strategies include national drug formularies, post-graduate education, lists of non-reimbursable medicines, substitution, and surveillance of prescribing costs

Use of generic products

Substitute for brand name products, providing cheaper alternatives

User fees and co-payments

May discourage excessive consumption but can have negative consequences for affordability and equity of access

3.1. Factors determining prices: The role of competition

In order to design programmes which will render medicines more affordable, one needs to understand how the prices of medicines are normally determined. It is well known that in a competitive market for goods of any type, where there are no barriers to entry, and a large number of buyers and sellers are active, prevailing prices are close to producers’ cipline of the competitive market prevents any individual producer from raising prices very far above production cost.

That general market rule does apply to a limited extent to pharmaceuticals, namely to generic products, where a particular medicine is available from various competing sources. Here, price determination responds to competitive pressure in the way the economic theory predicts. However, barriers to entry are common in the rest of the pharmaceutical market. Essentially these are economic barriers, in the form of the large initial investments which are required to develop a drug and maintain the activities of a multinational corporation.

Secondly, there are legal barriers. The originating firm will go to great lengths to secure and retain a monopoly of production and sale for a long period, making use of patent legislation to do so. Where patent rights exist, drug prices can be many times the marginal cost and manufacturers have a substantial amount of freedom to set prices for their patented medicines, varying these from country to country to secure the highest income which the market will bear. It is only as a patent nears the end of its term that competition begins to play a major role in price determination. The only element of price competition before that time comes will be competition across therapeutic groups, where two or more drug substances having similar therapeutic effects may battle with one another for the market. Although the research-based manufacturing industry claims that its often high prices are justified by its costs and the need to take risks, this claim is in fact impossible to assess in detail, since information on manufacturing costs is not publicly available. It is however certain that a large margin exists for many patented medicines between the costs of production and the manufacturers’ to demonstrate how the very large sums earned from medicines may to a substantial extent be used to provide profit or finance advertising rather than to conduct innovative research [4,8]. It is also clear that where a firm finds it commercially attractive to reduce a price it can and will do so. The art of the policy maker often lies in creating a situation in which, particularly through increased competition but also through other means, a company can be induced to reduce prices of its own initiative.

One of the main options available to governments is, in short, to steer the market towards greater price competition [16]. Figure 4 illustrates the effects of price competition concerning medicines for HIV/AIDS in Brazil over a period of 5 years [9]. The prices of each of the six medicines listed declined over this period, but the decline was only slight for the two medicines which had no generic competition whereas it was dramatic for the four where such competition was introduced.

Many developing countries have to date not succeeded in following this course. Often poorly informed as to the possibilities which exist to obtain better prices, not endowed with an efficient national purchasing system and commonly not having large markets of interest to international manufacturers, such countries all too frequently find themselves obliged to pay whatever prices manufacturers ask. According to findings by Médecins Sans Frontières (MSF) and in other studies, many low-income countries pay generally higher prices than necessary, and as pointed out above the prices may even be higher than in the industrialized world [16].


Fig. 4. Effective price competition.

Source: UNAIDS, B. Samb, 2000


3.2. The role of reliable price information

National agencies in some drug-importing countries have discovered that reliable information on drug pricing across the world is an important tool in seeking to tackle the pricing issue in their own country. As explained in earlier chapters, well organized public purchasing agencies, e.g., in Canada, and New Zealand, or social insurance schemes in Europe acting on behalf of very large populations, are aware of prices paid by bulk purchasers elsewhere, and therefore negotiate directly with manufacturers to obtain prices which are at least as favourable. In some countries, as described in Chapter 8, prices are deliberately set with reference to prices in other countries (e.g., Bulgaria, The Netherlands, Canada). In such countries, a high proportion of patented drug are thus negotiated, rather than simply manufacturer-set [22].

Even developing countries have access to some important sources of data showing the prices at which reliable medicines can be obtained across the world. A vital tool is the “MSH International Drug Price Indicator Guide”, published regularly by Management Sciences for Health in Boston, MA, in collaboration with WHO, and available both in printed form and through the Internet. This shows for most essential medicines a range of dependable sources and the prices which they charge [6]. A country can also determine the prices at which international agencies such as UNICEF have succeeded in purchasing certain types of medicines and can set out to attain comparable prices. A further alternative is to purchase medicines through international low-cost supply agencies which provide a guarantee of quality.

Once a drug has entered a national market, availability of pricing information remains equally important. Policy-makers, health professionals, wholesalers, retailers and distributors, and consumers all need complete, accurate and up-to-date information on drug prices. For example, in India, Pakistan and other parts of Asia, the requirement that the maximum retail price be printed on drug packages means that the system not only regulates retail prices, but also provides price information directly to the consumer [15]. Price information is increasingly being included in national drug formularies, in therapeutics manuals and clinical guidelines. Price information may be given as relative price levels (such as the relative price bands in the British National Formulary and the French Dictionnaire Vidal), as price comparison bar charts for selected therapeutic categories (such as the Kenyan or Zimbabwean Clinical Guidelines or the Dutch Pharmacotherapeutic Compass), or simply as the current price for each drug.

3.3. The question of differential pricing

It is clear that, viewed globally, the burden of drug costs should not be equally shared between rich and poor nations; the only fair approach is for a country to pay the prices which it can reasonably afford and no more. Drug firms have always to some extent adjusted their prices from one country to another, but generally only to a minor extent and primarily with the intention of setting for each country the highest prices which the market will bear [8]. This traditional concept of “tiered pricing”, as it is known, is not helpful in developing a constructive approach for developing countries, since it tends to shift prices upwards rather than downwards. WHO has called for a more systematic form of “differential pricing”, structured so as to ensure that much lower prices are charged in countries with a weak economy. There are some indications that the appeal for change is being heard by parts of the research-based pharmaceutical industry, though consumer critics have argued that the response is too meagre. A gesture by five international pharmaceutical manufacturers to cut prices of antiretrovirals for Sub-Saharan African countries at all events reflects industry recognition that current pricing of patented medicines is unfair for low-income countries and politically unsustainable [23]. In fact, the industry has made it clear on several occasions that differential pricing is an acceptable mechanism, provided there is no parallel importing back to the higher priced markets. Such mutually satisfactory arrangements have been achieved, for example, with vaccines (see below) and with oral contraceptives sold through international agencies at a tiny fraction of their normal prices [8].

One might add that the more general concept of “equity pricing”, which WHO has advocated [23], is not essentially different to that of “differential pricing”. To attain prices which are equitable for a given population and compatible with equity one will necessarily have to adjust them to the wide variations in income which exist between countries, and this will involve marked differentiation. The concept of differential pricing is illustrated in Fig. 5.

3.4. Exploiting the use of generic medicines

Means to ensure that low-cost generic (off-patent) medicines are used to the greatest extent possible have been reviewed in Chapter 11. Most of those methods can be used to a greater or lesser extent in developing countries. It is particularly crucial to ensure that the generic medicines on sale are of assured quality and that the population is emphatically made aware of this fact; too often people who cannot afford high prices have nevertheless paid them in order to secure a branded speciality in the belief that it is in some way superior to the generic equivalent.

3.5. Large-scale competitive procurement

For a large pharmaceutical firm, it is hardly rewarding to negotiate extensively with a mass of small procurement agencies, each requesting better prices yet each offering only a minuscule market. One important step is to bundle the procurement process into larger units. Within a country, for example all hospitals may do well to procure jointly. Public procurement for an entire public health service should as far as possible be centralized nationally; decentralization of government administration may be a laudable aim, but if it means that drug purchasing will henceforth be handled by twenty or more inexperienced and small provincial bodies the quality of procurement can hardly be expected to improve. A remarkable price reduction was experienced in Delhi State when the annual needs of approx. 300 medicines for hospitals and health centres, were pooled and procured in bulk. Even an entire nation may represent only a tiny market for a multinational corporation, and there can be very good reason for several small countries to act together in a pooled purchasing arrangement. Examples of pooled procurement are bulk purchasing mechanisms of the Maghreb countries; joint drug purchasing is also undertaken by the countries of the Eastern Carribean and by the Gulf States [22].


Fig. 5. Schematic example of differential pricing. Option 1: smaller amounts are sold in high priced markets (D and E), while Option 2: larger amounts are sold to low priced markets (A/B) and greater volumes can provide the same total revenues, though with lower profit margins, at a lower tiered price. The multiple bands for C reflect the fact that market forces will determine the price in these situations.

Table 2
Use of price controls in high and low-income countries

Countries

Sample size
(# countries)

With price control

Without price control

   

Limited

Substantial

 

High-income

23

48%

52%

0%

Low-income

33

24%

55%

21%

While there is some place for price negotiations and closed tenders, by far the most successful means of obtaining fair prices is for a large purchasing agency to buy medicines through an open tendering system.

3.6. Price controls

Price controls are another important option for government intervention to adjust price levels with the intention of maximizing affordability or minimizing overall drug expenditures. Table 2 shows that this is a very commonly used option throughout the world [16].

Price controls involve not only the setting of the initial or current price of a drug, but also the regulation of price increases and sometimes also the power to reduce existing prices which have been found to be excessive. Controls may relate primarily to the prices paid to producers or importers, insofar as these are not kept in hand by a tendering system, or they may relate to the ultimate purchase price. In the latter case it will be necessary to obtain a grip on the margins earned throughout the drug supply system; distribution margins are important, not only because they often account for 50% of the consumer price of a drug, but also because the structure of distribution margins provides economic incentives for dispensing. Reduction and control of distribution and retail margins often needs to be better regulated than is currently the case [15].

The various forms of price control are further discussed in Chapter 3.

3.7. Prices of new essential medicines and vaccines

While the problem of prices needs to be tackled for all essential and useful drug items, there are two class of products for which a special effort is needed. The one comprises “new” essential medicines as defined as - important new medicines which represent a substantial advance in the treatment of major diseases yet which are still under patent and therefore expensive. The other class comprises vaccines, especially those used in national vaccination programmes.

For new essential medicines it is not acceptable for low-income countries and poor populations to pay the same price as the industrialized countries. The poor simply cannot be expected to contribute equally to research, marketing, and shareholder returns, especially as it is unlikely that the return will be used for drug research and development for neglected diseases; the prices will in any case render these vital items largely inaccessible. During 2000, the endeavour known as “Accelerating Access to Care and Treatment”, in which UNAIDS and other partners are involved, has stimulated discussions with five pharmaceutical companies to achieve “equity” or “differential” pricing of new essential medicines for low-income countries [20].

As the vaccine industry is a largely fixed cost business, increases in production scale and increased experience in production of a specific vaccine (the “learning curve”) can drive costs down. Thus, additional production volume has a value when sold at lower prices, even if the revenues per dose resulting from this marginal volume are low. Revenue per dose is, however, a more important driver of profitability. When new vaccines are produced, production costs have to be spread over a smaller volume, and thus prices are higher. Increasing volume can lower production costs and increase profits. New high-priced products have a limited market: if markets of low-income countries can be accessed as well, economies of scale can be increased [7].

3.8. Elimination of tariffs, duties and taxes

WHO, the World Trade Organization and other partners advocate the elimination of import duties (still over 30% in some countries) for essential medicines including HIV-related medicines, and the abolition of value-added and other national and local taxes (still over 20% of the final consumer price) for essential medicines [20].

3.9. The role of domestic production

WHO and other partners support local production of essential medicines, manufactured in accordance to good manufacturing practices (GMP), where this results in lower prices. This can be facilitated by voluntary licensing, transfer of technology by the originator companies, and other suitable mechanisms [15]. It must be recognized however that local production will not always result in lower prices and it may run into considerable problems where technical experience is lacking; establishment of a new production plant in a country where none existed before is a step to be undertaken only after careful consideration.

3.10. Application of TRIPS safeguards

Essential medicines are a public good and not simply just another commodity. Patents for pharmaceuticals should be managed in a balanced manner, protecting the interest of the patent holder yet safeguarding public health principles. Measures consistent with the TRIPS agreement which may be used under specific circumstances to reduce drug prices and increase access include prompt availability of generic medicines through “early workings” (“Bolar provision”), compulsory licensing, and parallel importing [24]. These are specialized issues which cannot be dealt with in detail in this chapter, particularly since developments in the interpretation and application of TRIPS are still under way.

4. Conclusions

The challenge for governments of developing countries is to find a balance between the need to attain national health objectives, the effort to respond to the health needs of the population, the political climate, the capacities existing in the public and private health and pharmaceutical sectors, and the economic realities of these countries.

As the governments of developing countries seek to achieve their public health goals they will find it necessary to ensure equitable access to “old” and “new” essential medicines, probably using innovative approaches with which successful experience has been gained elsewhere. It is to be hoped that governments of developed countries will provide ongoing technical and financial assistance to the developing world in its effort to implement this facet of health policy. At the global level, too, suitable strategies in support of these efforts can be developed and endorsed so as to ensure a significant increase of access of essential medicines among the world’s poorest

References

[1] B. Abel-Smith, An Introduction to Health: Policy, Planning and Financing, Longman, London, United Kingdom, 1994.

[2] L. Gilson and A. Mills, Health sector reforms in Sub-Saharan Africa: lessons of the last 10 years, Health Policy 32 (1995), 215-243.

[3] IMS Health, IMS Health reports 10% growth in 2000 audited pharmaceutical sales to $317.2 billion, 6 March 2001, http://www.imshealth.com.

[4] R.D. Laing, Health and pharmacy systems in developing countries. Paper delivered to the WHO/WTO Workshop on Differential Pricing and Finance of Essential Drugs, Høsbjør, Norway, 2001.

[5] K. Lee and A. Mills, Developing countries, health, and health economics, Chapter 1, in: The Economics of Health in Developing Countries, K. Lee and A. Mills, eds, Oxford University Press, Oxford, United Kingdom, 1985.

[6] MSH, International Drug Price Indicator Guide, Management Sciences for Health, Boston, Mass., USA, 2001.

[7] J. Milstien and A. Batson, Accelerating availability of new vaccines: role of the international community, Drug Information Journal 32(1) (1998), 175-182.

[8] E. Mossialos and M.N.G. Dukes, Affordably priced drugs for poor populations: Approaches for a global solution, Int. J. Risk and Safety in Medicine 14 (2001), 1-29.

[9] B. Samb, Travel report, UNAIDS, Geneva, Switzerland, March 2000.

[10] SCRIP, No. 2609, 17 January 2001, p. 16.

[11] World Bank, World development report 1993: Investing in health, Oxford University Press, New York, USA, 1993.

[12] World Bank, World development report 2000/2001: Attacking poverty, Oxford University Press, New York, USA, 2000.

[13] World Health Organization, The world drug situation, World Health Organization, Geneva, Switzerland, 1988.

[14] World Health Organization, Evaluation of recent changes in the financing of health services, Report of a WHO study group, WHO technical report series 829, World Health Organization, Geneva, Switzerland, 1993.

[15] World Health Organization, Public-private roles in the pharmaceutical sector. Implications for equitable access and rational drug use, Health economics and drugs, DAP series no. 5. WHO/DAP/97.12, World Health Organization, Geneva, Switzerland, 1997.

[16] World Health Organization, Health reform and drug financing, Selected topics, Health economics and drugs, DAP series no. 6, WHO/DAP/98.3, World Health Organization, Geneva, Switzerland, 1998.

[17] World Health Organization, Report on infectious diseases: Removing obstacles to healthy development, World Health Organization, Geneva, Switzerland, 1999.

[18] World Health Organization, The use of essential drugs, WHO Technical Report Series 895, World Health Organization, Geneva, Switzerland, 2000.

[19] World Health Organization, WHO medicines strategy: framework for action in Essential Drugs and Medicine Policy 2000-2003, World Health Organization, Geneva, Switzerland, 2000.

[20] World Health Organization, World Health Report 2000, Health systems: improving performance, World Health Organization, Geneva, Switzerland, 2000.

[21] World Health Organization, Global comparative pharmaceutical expenditures, EDM/PAR/2000, World Health Organization, Geneva, Switzerland, 2000.

[22] World Health Organization, Strategies to increase affordability of medicines and diagnostic supply, Briefing note for the European Commission Roundtable discussion, September 2000.

[23] WHO, More equitable pricing for essential drugs: What do we mean and what are the issues? Background paper for the WHO-WTO Secretariat Workshop on Differential Pricing and Financing of Essential Drugs, Høsbjør, Norway, World Health Organization Secretariat, Geneva, Switzerland, 2001.

[24] World Health Organization, Globalization, TRIPS and access to pharmaceuticals, WHO Policy Perspectives on Medicines, number 3, World Health Organization, Geneva, Switzerland, 2001.

[25] World Health Organization, The Selection of Essential Medicines, WHO Policy Perspectives on Medicines, number 4, World Health Organization, Geneva, Switzerland, 2002.

Further reading

World Health Organization, The World Health Report. Bridging the gaps. Report of the Director-General, World Health Organization, Geneva, Switzerland, 1995.

Management Sciences for Health, Managing Drug Supply, Second edition, revised and expanded, Kumarian Press, West Hardford, Conn., USA, 1997.

World Health Organization, Globalisation and access to drugs: Perspectives on the WTO/TRIPS Agreement, Health economics and drugs, DAP Series No. 7, revised. WHO/DAP/98.9 revised, World Health Organization, Geneva, Switzerland, 1998.

World Health Organization/World Trade Organisation, Differential pricing and financing of essential drugs, a WHO/WTO Secretariat Workshop, Høsbjør, Norway, 2001.

World Health Organization, Globalization, Patents and Drugs, an Annotated Bibliography, 2nd edn, Health Economics and Drugs, EDM series no. 10, 2001.

World Trade Organisation, http://www.wto.org.

 

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