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The World Medicines Situation
(2004; 151 pages) View the PDF document
Table of Contents
View the documentContributors
View the documentIntroduction
View the documentChapter 1. World medicine production
View the documentChapter 2. Research and development
View the documentChapter 3. Medicines in international trade
View the documentChapter 4. World pharmaceutical sales and consumption
View the documentChapter 5. Global trends in medicines spending and financing
View the documentChapter 6. National medicines policies
View the documentChapter 7. Access to essential medicines
View the documentChapter 8. Rational use of medicines
View the documentChapter 9. Medicines regulation
View the documentConclusion
View the documentStatistical annex notes
Open this folder and view contentsStatistical annex
 

Chapter 7. Access to essential medicines

SUMMARY

• Although the percentage of the world’s population without access to essential medicines has fallen from an estimated 37% in 1987 to around 30% in 1999, the total number of people without access remains between 1.3 and 2.1 billion people.

• Lack of access is particularly concentrated in Africa and India.

• Access to essential medicines appears closely correlated with other indicators of health system performance, such as disability-adjusted life expectancy.

• The majority of low- and middle-income countries use essential medicines lists in selecting their medicines and are more likely to use these to limit procurement choices than are high-income countries.

• Generic competition and differential pricing can contribute substantially to the affordability of medicines in low-income countries.

• Bulk purchasing, careful price comparison, compulsory licensing and differential pricing schemes may help countries obtain better purchasing prices for medicines.

• Greater scope for domestic price regulation exists in many low-income countries.

7.1 CURRENT ESTIMATES OF ACCESS TO ESSENTIAL MEDICINES

Inequities in access to medicines reflect failures in health systems and medicines policy. Access to essential medicines remains a major objective of people everywhere, and is widely featured as an objective of countries’ national medicines policies. In a strategy document for 2000-20031, WHO considers better access to essential medicines a priority health issue. WHO’s ongoing World Medicines Survey asks a local medicines expert in each country to estimate the percentage of the population who have access to a minimum list of 20 essential medicines, which are continuously available and affordable at a health facility or medicines outlet, within one hour’s walk from the patients’ home. Responses to this question form the basis for the access figures reported here and in the statistical annex. Because of the complexity of the access concept and the difficulty of validating respondents’ estimates, the statistical annex also uses ranges around each respondent’s estimate.

In 1975, less than half the world’s population were estimated to have regular access to essential medicines.2 New estimates from the 1999 World Medicines Survey show that this fraction has fallen to around one-third. However, the absolute number of people without access has remained almost unchanged, at about 1.7 billion. Getting the right medicines to the people who need them at the time they need them remains a major challenge.

In the 1999 survey, 183 of 193 countries responded to this question. Table 7.1 shows the distribution of countries by WHO region according to reported levels of access to essential medicines.

TABLE 7.1 Range of access to essential medicines by WHO region, 1999

WHO Region

Percentage of population with regular access to essential medicines

 

Very low access
(< 50%)

Low to medium access
(50%-80%)

Medium to high access
(81%-95%)

Very high access
(<95%)

 
 

Number of countries

Number of countries

Number of countries

Number of countries

Total Countries

Africa

14

23

5

3

45

Americas

7

14

7

7

35

Eastern Mediterranean

2

7

5

8

22

European

3

12

6

25

46

South-East Asia

2

4

3

0

9

Western Pacific

1

8

8

9

26

Total countries*

29

68

34

52

183

Even from these broad groupings the regional extremes are clear. In Europe, 25 of the 46 countries reporting were in the “very high” access group and only three countries were in the “very low” access group, whilst in the African region only 3 of the 45 countries were in the “very high” but 37 countries (over 80%) were in the “very low” and “low to medium” groups.

Table 7.2 illustrates access in relation to population size.

TABLE 7.2 Number of people without access to essential medicines, by WHO region, 1999

WHO Region

Number of countries

Total population (million) % of total

Estimated numbers, ranges and percentages of population without regular access to essential medicines

       

Population without access (millions)

Percentage of WHO regional population without access

Percentage of world population without access

African

45

566

10

267
(200-334)

47
(35-59)

15
(11-19)

American

35

813

14

179
(134-224)

22
(16-27)

10
(8-12)

East Mediterranean

22

485

8

143
(107-179)

29
(22-36)

8
(6-10)

European

46

832

14

114
(85-142)

14
(10-17)

7
(5-9)

South-East Asia

9

486

8

127
(95-159)

26
(19-32)

7
(5-9)

India

1

998

17

649
(487-811)

65
(49-81)

38
(28-47)

West Pacific

26

380

7

55
(41-69)

14
(10-17)

3
(2-4)

China

1

1274

22

191
(143-239)

15
(11-19)

11
(8-14)

Total all countries

183

5834

100

1725
(1294-2156)

30
(22-37)

100

Table 7.2 shows that about 30% of the world’s population, or between 1.3 and 2.1 billion people, are estimated not to have access to the essential medicines they need. In India, an estimated 499-649 million people (50% to 65% of the population) do not have regular access to essential medicines. Throughout Africa, a further 267 million people (almost half the population or 15% of the world total) also lack access.

Classifying access according to countries’ level of income, as in preceding chapters, shows a clear relationship between economic level and access to medicines, as seen in Tables 7.3 and 7.4. Table 7.3 shows the medians and ranges of reported access figures from countries by income level.

TABLE 7.3 Country income level and access to essential medicines

Country income group

Median reported access level (%)

Minimum reported %

Maximum reported %

Low-income

60

10

93

Middle-income

85

30

100

High-income

100

98

100

Table 7.4 shows that the percentage of the population estimated to lack adequate access to essential medicines is less than 1% in high-income countries, 39% in low-income countries and 24% in middle-income countries. The 1.3 billion people in low-income countries estimated to lack access account for almost 80% of the total number of people in the world who lack essential medicines.

TABLE 7.4 People without access to essential medicines, by countries’ level of income

Country income group

Number of countries

Population

Population without access to essential medicines

   

Number (million)

Number (million)

As % of country income group

As % of global total without access

Low-income

63

3548

1369

38.6

79.4

Middle-income

86

1447

350

24.2

20.3

High-income

34

859

5

0.6

0.3

Total countries and population

183

5854

1724

n.a

100

7.2 FACTORS INFLUENCING ACCESS TO MEDICINES

Lack of access to medicines is symptomatic of wider problems relating to the way health services are organized, financed and delivered. However, the measurement of overall health systems performance is still in its infancy. Measures proposed in The World Health Report 20003 are now undergoing extensive refinement, revision and consultation. Nevertheless, health outcomes, as measured in disability-adjusted life expectancy (DALE) do correlate with the questionnaire-based judgements made in the World Drug Survey on access levels. Well-performing health systems offer high levels of access, and poorly performing ones result in large numbers of people being excluded from medicines as well as other forms of treatment, prevention and care. Table 7.5 shows the relationship between health outcomes in DALEs and access to medicines.

TABLE 7.5 Access to essential medicines and life expectancy (DALE),i 1999

Level of DALE

Percentage of population estimated to have regular access to essential medicines

 

Number of countries

%

Number of countries

%

Number of countries

%

Number of countries

%

Total Countries

Below 50 years

18

62.0

22

42.3

9

21.4

1

1.7

50

50-59 years

5

17.0

13

25.0

12

28.6

5

8.6

35

60 years and over

6

21.0

17

32.7

21

50.0

52

89.7

96

Total countries

29

100

52

100

42

100

58

100

181

 

i DALE. Disability-adjusted life expectancy.


Table 7.5 shows that most countries reporting low access to medicines also had very low disability-adjusted life expectancy. At the other end of the spectrum, almost 90% of countries with very high access to medicines also had the highest level of health outcome.

7.3 KEY FACTORS INFLUENCING ACCESS TO ESSENTIAL MEDICINES

In addition to the general problem of health systems performance, four medicines-specific factors have to be in place to ensure that medicines are accessible to people whenever and wherever they are needed (Figure 7.1).


FIGURE 7.1 The access framework

Source: WHO, 2000


As Figure 7.1 makes clear, rational medicines selection processes should be in use, based on national or local essential drugs lists and treatment guidelines; prices should be at levels affordable by governments, health care providers and consumers; fair and sustainable financing for the medicines component of health care should be ensured through adequate funding levels and equitable prepayment mechanisms, such as government revenues or social health insurance, to ensure that poor people do not face proportionally higher costs than the better off; and finally, reliable health and supply systems need to be in place, incorporating an efficient and locally-appropriate mix of public and private service providers. Failure in any one of these processes will jeopardize people’s access to medicines.

The financing aspects of access were discussed separately in Chapter 5. The remaining sections of this chapter examine in turn the evidence on each of the other three components of access.

7.4 RATIONAL SELECTION

Rational selection of medicines means choosing medicines appropriate to the country’s health situation on the basis of their safety and cost-effectiveness. Institutionalizing rational choice involves using essential medicines lists (EMLs), based on the best available evidence on local disease burden, efficacy, safety and cost of treatment for those diseases. However, there is a significant difference between having an EML and using it effectively. WHO has developed model lists of essential medicines since 1977, which have served as a reference for countries in the establishment of their own national EML. The first Model List, published one year before the Alma Ata Declaration of Health for All, contained around 200 active substances. Approximately every two years, WHO updates the List on the basis of evidence presented to a committee of experts. Following the revision in March 2003, the Model List now contains 316 active substances.4,5,6

Figure 7.2 indicates that the number of countries which revised their national EML increased from 1985 to 1999: from 5 to 60 among low-income countries; from 2 to 62 among middle-income countries; and from 0 to 9 among high-income countries.


FIGURE 7.2 Cumulative number of countries with a national essential medicines list revised within the last five years

Source: World Drug Situation Survey (1999)


Table 7.6 shows that there is a clear relationship between a country’s EML status and its level of income. Less than 10% of low- and middle-income countries had not established an EML in 1999, compared with over two-thirds of high-income countries. However, institutional use of EMLs, by hospitals or health insurers is often widely practised in high-income countries and likely to be under-represented in these figures.

TABLE 7.6 Essential medicines list and countries’ level of income, 1999

Status of EML

Low-income

Middle-income

High-income

 

No. Countries

%

No. Countries

%

No. Countries

%

EML updated within 5 years

47

75

70

74

11

31

EML updated over 5 years

13

21

17

18

0

0

No EML /not known

3

4

8

8

24

69

Total

63

100

95

100

35

100

 

Source: World Drug Situation Survey (1999)


Table 7.7 shows that the number of items on a national EML tends to be associated with the level of a country’s income: the median list size is 276 medicines in low-income countries, 420 in middle-income countries and 903 in high-income countries.

TABLE 7.7 Average size of essential medicines list by countries’ level of income, 1999

Level of income

Total Countries

Median number of medicines

Minimum number of medicines

Maximum number of medicines

Standard deviation

Low-income

45

276

134

6000

911

Middle-income

49

420

35

2348

450

High-income

5

903

531

3280

1036

 

Source: World Drug Situation Survey (1999)


The following chapter analyses experiences, challenges and approaches to ensuring the rational use of medicines, once they have been selected and purchased.

7.5 AFFORDABLE PRICES

The price of medicines plays an essential role in access to medicines. When a course of treatment for peptic ulcer costs almost twice the monthly wage of a government employee, as in Cameroon,7 it is clearly not generally affordable. Several strategies are available to countries to influence price, and they fall into two main categories: (i) obtaining the best possible price through the selection and purchasing process and (ii) ensuring price regulation throughout the supply chain from manufacturer or importer to patient.8 Many countries use combinations of these two approaches in their attempt to keep medicine prices down, though responses to the World Drug Survey indicate that almost 40% of respondent countries (53/135) implement no price regulation policy at all.

A policy focus on cost-effective selection and purchasing is likely to be based on an EML, and to use competitive purchasing methods for medicines available from multiple manufacturing sources. Major economies in the national medicines bill can also be made by ensuring that public procurement focuses on generic medicines of assured quality wherever possible, rather than innovator brand products with patent protection and higher prices.

Table 7.8 shows that, of the 121 countries responding to this question in the World Medicines Survey, low-income countries are more likely to restrict procurement to items on the national EML than middle- or high-income countries.

TABLE 7.8 Public medicines procurement and country income level, 1999

Level of income

Limitation to EML

 

Number

%

Low-income

37

77

Middle-income

25

43

High-income

2

13

Total countries

64

47

 

Source : World Drug Situation Survey (1999)


Estimates of the proportion of procurement done by international tender also indicate that this mechanism is somewhat more used by low-income countries.

TABLE 7.9 Percentage of procurement done by international competitive tender

For patented medicines, international competitive tenders are seldom possible and purchases have to be negotiated on a country-by-country and medicine-by-medicine basis. The price offered by the manufacture is likely to vary according to the size of the country, its level of income and local manufacturing capacity. Many countries lack the ability to negotiate medicine prices in a professional, evidence-based way. In this situation, access to price information by purchasers in all sectors may have a crucial role to play in successful negotiated purchases. Prices of therapeutic competitors, where these exist, can help purchasers assess value for money. In addition, prices paid in other markets may provide useful evidence as to what a particular manufacturer is getting elsewhere for a particular medicine with patent protection. A number of countries use international reference prices systematically in their medicines purchasing and a number of price information services, both national and international, are now available.i Pricing practice in Greece, for example, takes account of prices for the same medicine in the three lowest-priced countries in the European Union. Prices for the most clinically effective new medicines in France are set with reference to prices in four other European countries.9 Eight other OECD countries take formal account of prices elsewhere.10,11Figure 7.3 shows some of these price information links.

i A regularly updated list of this can be consulted on the WHO website: http://www.who.int/medicines/organization/par/ipc/drugpriceinfo.shtml


FIGURE 7.3 International reference pricing arrangements, 2001

In a small but growing number of mainly high-income countries, systematic use is made of pharmacoeconomic analysis in assessing and negotiating medicine prices. This entails rigorous comparison of the clinical effectiveness of a new medicine, and its price, with the effectiveness and price of the closest existing alternative medicine. In this way, public purchasing bodies can assemble the evidence on cost-effectiveness in a systematic manner, and judge whether the therapeutic advantage of a new medicine offsets its additional cost. The Australian government’s Pharmaceutical Benefits Scheme pioneered the use of this approach, and since 1993 has used it to determine which new medicines will qualify for insurance reimbursement. Countries including the Netherlands, UK and France employ similar techniques in evaluating new medicines for public purchase and reimbursement.

As Chapter 4 illustrates, generic medicines, particularly unbranded generics, are usually much less expensive than newer patented medicines, and in both high- and low-income countries many governments encourage their use to control overall costs. In value terms, the USA is the leading consumer of generic medicines in the world, as Chapter 4 shows. But the use of generic medicines offers important opportunities for low-income countries, where over the half of households live below the poverty threshold, to maintain affordable access to medicines.

A study carried out in Ghana and Cambodia highlights the “brand premium” or gap between prices of generic and brand medicines. Systematic surveys of the price of generic and brand medicines were carried out in public health, private for-profit facilities, private not-for-profit facilities (NGOs/religious missions) and private retail outlets (private pharmacies). These surveys were based on 30 essential medicines (20 essential medicines selected for diseases that are common throughout the world and 10 medicines that each country selected according to the local disease situation). Figure 7.4 indicates that prices vary greatly between generic and brand medicines. In Ghana, brand medicines are much more expensive than generic medicines by a factor of 18 in public facilities, 11 in private facilities, and 10 in private pharmacies but by only 50% more in the pharmacies of NGOs and religious missions.12 In Cambodia, price differences between brand and generic medicines are higher in private pharmacies than others: a two to threefold brand premium in private pharmacies, and in private facilities, and about 100% in public facilities and in the pharmacies of NGOs and missions.


FIGURE 7.4 Price differences between generic and brand medicines for standard treatments in Ghana and Cambodia

Using a slightly different approach but based on systematic surveys, brand and generic prices for a fixed list of essential medicines were also compared in five other low- and middle-income countries. Figure 7.5 shows that for one diuretic medicine, furosemide, local retail prices ranged from a high of over 100 times the international reference price (South Africa and Kenya, brand) to slightly below it (Sri Lanka, generic). For the full set of medicines compared, generic prices were close to international reference prices in Kenya, Sri Lanka and Armenia, while half of the innovator medicines in South Africa cost from 11 to 62 times the reference prices.

Clearly, big price differences exist not only between generic and innovator medicines, but also between prices for the same brand or generic in different countries. Many countries thus have considerable scope for taking steps to ensure that they are not paying more than necessary for their essential medicines. National, regional or even global bulk purchasing schemes greatly improve the prospect for achieving lower prices. Regional medicine purchasing schemes exist in francophone West Africa, in the Caribbean, in Latin America through the WHO/PAHO revolving drug fund, and in the countries of the Gulf


FIGURE 7.5 Brand and generic furosemide prices in relation to international generic price, five countries, 2001

Source: http://www.haiweb.org/medicineprices


Cooperation Council. Global purchasing arrangements exist for vaccines through UNICEF and GAVI and for contraceptives through UNFPA; for tuberculosis, the Green Light Committee purchases medicines for multi-drug resistant forms of the disease and the Global Drug Facility purchases first-line tuberculosis drugs. Most recently established, the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria is currently evolving its procurement and price monitoring arrangements for medicines for these three diseases.

The high price of medicines for common diseases has been highly publicized in recent years. At the national level in high-income countries such as the USA and Switzerland there is widespread concern about high medicine prices. At the international level, the debate has centred on the high price of patented medicines used to treat HIV/AIDS and AIDS-related opportunistic infections - many of them life-saving medicines which have to be taken for life. At prevailing high-income country prices they are beyond the reach of governments and the great majority of people in low-income countries.

7.5.1 Voluntary price discounts and approaches to “equity pricing” for new essential medicines

Manufacturers’ discounts on selected medicines under patent are occasionally offered to approved buyers in low-income countries. Novartis, in a framework established with WHO, offers public sector purchasers in developing countries a special price for its antimalarial medicine Coartem (artemether + lumefantrine). For HIV/AIDS medicines, an “Accelerated Access Initiative” focused on Africa was launched by several UN agencies and five pharmaceutical companies in May 2000. A detailed history of treatment price levels and a database of current prices for these medicines is maintained by Médecins Sans Frontières.i Treatment costs with the innovators’ medicines have fallen from over US$ 10 000 a year to around US$ 730 a year, although generic medicines are available at less than half of these prices and one participating manufacturer has made no price reduction on one key medicine, which is still over US$ 3000 for one year’s supply.

i http://www.accessmed-msf.org/prod/publications.asp


This voluntary approach has had only a modest impact on peoples’ access to care. Although about 60 000 patients in Africa are reported to be receiving medicines through the programme, they represent less than 1% of the HIV-infected population in need of treatment. Moreover, demand from countries for medicines under this initiative is limited, as cheaper generic sources of supply are increasingly available.13 Finally, countries have little control over voluntary price discounts in terms of which medicines are available, over what period, through which channels, and in what volume.

An alternative gesture by patent-holding manufacturers is to offer patent waivers. Commitment by the patent holder not to prosecute low-income countries for patent infringement would open the door to differential pricing. Such waivers have, in fact, already been granted for African countries by at least one company for a limited range of products. The WTO Ministerial Declaration on the TRIPS Agreement and Public Health has in effect given a limited patent waiver for the least-developed countries by extending their transition period with respect to pharmaceutical products to at least 2016.i

i Declaration on the TRIPS Agreement and Public Health. Ministerial Conference, Fourth Session. Doha, 9-14 November 2001, WT/MIN(01)/DEC/W/2, 14 November 2001. It should be noted, however, that the 48 Least Developed Countries, as specified by the United Nations, account for less than 650 million people, less than half of the world’s poor, and only one major pharmaceutical production country (Bangladesh).


A more systematic approach to lower prices for the poorer countries might be achieved by low- and high-income country governments working together with manufacturers and consumer groups through an explicit differential pricing framework, as outlined in recent publications.ii The common concern in these has been to establish more thorough market segmentation between high-income and an identified group of low-income countries, entailing the cooperation of manufacturers and governments in both high- and low-income countries. Prices related to countries’ purchasing power would be the target for new essential medicines, and measures (by both manufacturers and governments) established to prevent exportation of differentially priced medicines to higher price regions would be necessary. Regulatory mechanisms in high-income countries already exist to prevent such reimportation. Mechanisms such as bulk purchasing could help to guarantee both financing and volume for manufacturers.

ii http://www.who.int/medicines/library/edm_general/who-wto-hosbjor/who-wto-hosbjor.html and Report to the Prime Minister: UK working group on increasing access to essential medicines in the developing world. Department for International Development, London, November 2002.


7.5.2 Domestic price regulation

Prices increase between the factory or importer and the patient due to transportation costs, tariffs and taxes, and the mark-ups of distributors, wholesalers and retailers. Since these can easily double the ex-factory price of a medicine, some governments try to control these add-ons.

Yet a surprisingly high number of countries do not attempt to control local elements of medicine prices. Table 7.10 shows that, of the 135 countries responding to the World Drug Survey questionnaire:

• over 40% have no regulation of medicine prices

• 8% use a combination of regulation on the producer price with control of wholesale and retail mark-up

• 16% apply regulation on wholesale and retail mark-ups

• 12% regulate only through a maximum retail mark-up.


TABLE 7.10 Price regulation in WHO Member States, 1999

Type of regulation

None

Producer price

Retail mark-ups

Wholesale mark-ups

Retail + wholesale mark-ups

Producer price + retail mark-ups

Producer price + retail + wholesale mark-ups

Total number of respondents and percentage

Number of countries

54

10

15

7

20

6

10

122

Percentage

44.3

8.2

12.3

5.7

16.4

4.9

8.2

100

 

Source: World Drug Situation Survey (1999)


When the data are analysed by country income level (Table 7.11), only 22% (4 of 18) of high-income countries responding use no price regulation, whereas around half of low-and middle-income countries (50/104) do not regulate prices. Proportionally twice as many high-income countries (22%) as low- and middle-income respondents (10%) use all of the identified regulatory approaches and combinations surveyed to control domestic prices. In both purchasing practices and in domestic price regulation measures many low-and middle-income countries appear to be missing opportunities to ensure that medicine prices are affordable.

TABLE 7.11 Price regulation according to countries’ level of income, 1999

Level of income

None

Producer price only

Retail mark-ups

Wholesale mark-ups

Retail and wholesale mark-ups

Producer price + retail mark-ups

All

Total

Low-income

20

2

8

0

6

1

2

39

Middle-income

30

4

7

4

12

4

4

65

High-income

4

4

0

3

2

1

4

18

Total

54

10

15

7

20

6

10

122

 

Source: World Drug Situation Survey (1999)


7.6 RELIABLE HEALTH AND SUPPLY SYSTEMS

Reliable medicine supply systems have two components: procurement and distribution. Procurement patterns have been described above in section 7.5. Distribution is the process which delivers medicines from their origin to their destination. A good distribution system ensures the timely availability of essential medicines at all levels of the health system. Information available through recent studies in several low-income countries14 shows that physical accessibility of medicines outlets or health facilities remains a problem for many people. In Ghana, the majority (62%) of the rural population have to travel more than 30 minutes to a health facility, compared with only 20% of the urban population. In Rajasthan (India), only 45% and 55% of households respectively are within 20 km of a public health centre and a public or private hospital. Yet in Tanzania, 73% of households are within 5 km of a health facility and 86% within the same distance of a pharmacy.

Timely distribution of medicines means that they must be distributed and dispensed within their expiry date. Figure 7.6 shows the percentage of unexpired items in a defined set of important medicines in the stock at dispensing facilities in four countries, with separate data for each sector (public, NGO, private health facilities and private dispensaries). All sectors in each country had expired items in stock, with the lowest level of expired stock (16%) at NGO facilities in Tanzania and the highest, also at NGO facilities (82%), in Rajasthan. All sectors in Rajasthan compared poorly with those in Tanzania. Private health facilities (hospitals, clinics) compared poorly: in three of the four countries they had the lowest percentage of unexpired key items in stock, though private pharmacies everywhere appeared to have better distribution systems.


FIGURE 7.6 Percentage of a set of unexpired key items in stock

Source: MSH


FIGURE 7.7 Percentage of prescribed items presented for dispensing that are dispensed

Another indicator of the performance of the supply system is the percentage of prescribed items which are actually dispensed. A low percentage of dispensing of prescribed items may result from either out-of-stock facilities or unaffordable prices. Figure 7.7 uses limited survey data from public, private for-profit and private not-for-profit facilities in four countries and in one state in India to show the percentage of prescribed items actually dispensed at facilities in each sector. The findings indicate that in Ghana, Tanzania and Rajasthan, India, the public facilities perform less well than those in other sectors, while in Cambodia the reverse is true. In Cambodia, NGO and private facilities are able to dispense only 50% and 59% respectively of prescribed medicines.

REFERENCES

1 WHO medicines strategy: framework for action in essential drugs and medicines policy 2000-2003. Geneva, World Health Organization, 2000.

2 The world drug situation. Geneva, World Health Organization, 1988.

3 The world health report 2000. Health systems: improving performance. Geneva, World Health Organization, 2000.

4 Laing R, Waning B, Gray A, Ford N, ‘t Hoen E. 25 years of the WHO essential medicines lists: progress and challenges. Lancet 2003, May 17:1723-9.

5 WHO model list of essential medicines, 13th list (April 2003), (http://www.who.int/medicines/organization/par/edl/eml.shtml).

6 The selection and use of essential medicines. Report of the WHO Expert Committee, including the Model List of Essential Drugs, thirteenth list (WHO Technical Report Series 920) in press, (http://www.who.int/medicines/organization/par/edl/expertcomm13.shtml).

7 Are medicine prices a problem? Essential Drugs Monitor No. 33, Geneva, World Health Organization, 2003.

8 Cost-containment mechanisms for essential medicines, including antiretrovirals, in China. Geneva, World Health Organization, 2003.

9 French outline new pricing policy. SCRIP, No. 2814, 2003.

10 Pharmaceutical price regulation: the current debate. London, Institute for Fiscal Studies, (http://www.ifs.org.uk).

11 Jacobzone S. Pharmaceutical policies in OECD countries: reconciling social and industrial goals. Paris, OECD, 2000. DEELSA/ELSA/WD(2000)1.

12 Strategies for enhancing access to medicines. Boston, Management Sciences for Health, (http://www.msh.org/seam/3.1.3.htm).

13 Grace C. Equitable pricing of newer essential medicines for developing countries. Geneva, World Health Organization, 2002, (available electronically at: http://www.who.int/medicines/library/par/equitable_pricing.doc).

14 Quick JD, Rankin JR, Laing RO, O’Connor RW, Hogerzeil HV, Dukes MNG, Garnett A, eds. Managing drug supply. West Hartford, CT, Kumarian Press, 1997.

 

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