PARTICIPANTS judged the first in a series of regional training work- shops on the WHO/HAI pricing methodology a great success. Held in Cairo from 20 - 22 October 2003, the event was opened by Dr Zuhair Hallaj, WHO Representative in Egypt, who delivered a message to participants from Dr Hussein Gezairy, Regional Director of WHO Eastern Mediterranean Region. Dr Gezairy emphasised the continuing challenge of medicine prices and noted that as many as 100 million people in the region still lack regular access to essential drugs. He referred to the 54^th World Health Assembly resolution requesting WHO's Director-General to explore the feasibility and effectiveness of implementing systems for voluntary monitoring of drug prices and reporting global drug prices, with a view to improving equitable access to affordable medicines.

Framework for assessing affordability

Dr Abdel Aziz Saleh, WHO/EMRO Special Adviser, Medicines, stressed the importance of pricing issues and recommended the new WHO-HAI manual as an excellent starting point, offering a framework for assessing affordability of medicines. He hoped that surveys would provide valuable information on the difficult questions of the real cost of a medicine and what a drug is really worth. Dr Saleh also observed that each country's situation is different, and that a single framework might not be adequate to capture all situations. In Egypt, for example, there was a problem with smuggling, and there were likely to be difficulties in obtaining some tender price data because of confidentiality. The WHO and HAI staff present responded that the manual and database could not answer all of the challenging questions involved, but that it offered a step towards greater clarity and transparency about local and international price differences. Sound information, produced in a standard fashion, offers a necessary base for better understanding and policy action on medicine prices.

Participants briefly identified some price issues in their own country, and considered how a medicine price survey might assist them in their work. For example, in Egypt the pricing system was felt to be relatively simple and acceptable for generic drugs, and the level of access to these is also acceptable. How to price innovative medicines remains problematic. In Jordan, median prices in other countries (sometimes in a drug's country of origin, but particularly in neighbouring countries) are used systematically for reference purposes. As in Egypt and some other countries in the region, retail prices are fixed and monitored throughout the country. Lebanon has also undertaken recent international price comparisons of key medicines, and is currently implementing regulation to give pharmacists the right to substitute generic medicines for originator brands. Several countries acknowledged that official prices and actual prices in the retail market place may differ, because of discounts or ineffective price regulation.

Syria imports only about 10% of its drug requirements and has a price setting and regulating policy in place. Yemen, on the other hand, imports over 90% of requirements and has a free market for pricing. Some of its prices are the same as those paid in higher-income neigh-bouring countries in the region. In Oman, the Ministry of Health purchases imported drugs by a centralised tender process undertaken jointly with other Gulf Cooperation Council countries. Retail prices are controlled by Government, and comparisons are made with other countries before prices in Oman are set. Health care is free of charge. A number of methodological issues were raised, for example how to deal with prices under insurance systems with reimbursement, and with subsidy elements in public sector prices. Clearer guidance will be given in the revised version of the manual, due out by the end of 2004.

Technical focus

WHO and HAI representatives discussed the pricing project's background and the technical focus of the methodology. They were followed by Dr Anita Kotwani, who gave details of the price survey recently completed in Rajasthan State, India. Following preparatory briefings on the data collection forms and computerised workbook, and an exercise with data entry, five working groups of participants made visits to nine pharmacies in the Cairo area. A shortened version of the Medicine Price Data Collection Form was used on these visits, which were arranged by the Egyptian Ministry of Health.

Following the data collection exercise, working groups exchanged their data for entry into the Workbook by another group, all the results were consolidated and were presented back to the plenary for discussion. Results were illustrative as the clinics were selected for their convenience and were not identified using the recommended sampling method from the manual. The database of results from previous studies on the HAI website was demonstrated. Based on her experience in Rajasthan, Dr Kotwani outlined a number of important tips for survey managers:

• Read the manual thoroughly and several times to ensure that the method is fully understood.

• Decide who will be the principal investigator, co-investigators(s) and advisory committee.

• Make sure the area supervisors know the area to be surveyed, contact MOH people and pharmacists in the area to ensure their understanding and engagement

• Choose reliable data collectors. Data collectors working in pairs for four areas is more costly than individual data collectors for each study area, but probably much more reliable. Try to use pharmacists working in the public sector or qualified pharmacy assistants from a pharmacy institute.

• Give clear written guidelines to data collectors and make sure that they have the principal investigator's contact details. Make sure that everyone understands the importance of the survey.

• The Rajasthan study entailed long distance travel for the principal investigator and so it was more expensive than the average, but the budget was a little over US$3,000.

Planning surveys

Participants from the countries attending the workshop then looked at organizing their own surveys, discussing feasibility and details of when, where and by whom these could be done. Any such surveys may receive support from EMRO and from the WHO-HAI project. Facilitators at the workshop indicated their willingness to exchange ideas and suggestions with participants in the early stage of their thinking about a price study. A post-survey workshop, to help participants with a completed study through the data analysis and interpretation, was outlined. Its timing, location and participants will depend on how individual studies develop over the coming months.

Acknowledgements

Zaheer U. Baber is a lecturer in the School of Pharmacy, University College Sedaya International (UCSI), 56100, Kuala-Lumpur, Malaysia.

Kumariah Balasubramaniam is Adviser and Coordinator, Health Action International Asia - Pacific.

Andrew Creese is a health economist working in the Policy, Access and Rational Use Team, Department of Essential Drugs and Medicines Policy, WHO, Geneva. He is a co-coordinator of the WHO/HAI pricing project.

Margaret Ewen co-coordinates the HAI/WHO project on medicine prices and is the co-director (projects) at Health Action International (HAI) Europe, Jacob van Lennepkade 433T, 1053 NJ Amsterdam, The Netherlands. Tel: +31 20 683 3684, fax: +31 20 685 5002, e-mail: marg@haiweb.org

M. Izham M. Ibrahim is Associate Professor in the School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Penang, Malaysia.

Isaac Kibwage is a Professor in the Department of Pharmacy, University of Nairobi, Kenya.

Dr Anita Kotwani is a Scientist in the Department of Pharmacology, Maulana Azad Medical College, New Delhi 110002, India, and represented the Delhi Society for Promotion of Rational Use of Drugs in her work on medicine prices.

Richard Laing, Medical Officer in the Department of Essential Drugs and Medicines Policy, WHO, Geneva, is Editor of the Essential Drugs Monitor.

Libby Levison is a public health consultant based in Boston, USA; this work was done as part of her MPH at Boston University. E-mail: llevison@alum.bu.edu

Jeanne Madden is a Post-Doctoral Research Fellow at the Harvard Medical School and Harvard Pilgrim Health Care, Boston, USA. She reviewed pilot field data for the pricing project.

Kirsten Myhr is principal author of the Medicine Prices manual. She is a pharmacist and head of the Regional Centre for Medicines Information and Adverse Drug Reaction Monitoring in Oslo, Norway. Her experience in drug management comes from working in Africa and central Europe, and in the regulatory sector and hospital pharmacy in Norway.

Principal Investigators of Field Tests:

Movses Aristakesyan, Armenia
André Luis de Aleida dos Reis, Brazil
Meinolf Kuper, Cameroon
Charles Allotey, Ghana
Isaac Kibwage, Kenya
Javier Olivas, Peru
Aldrin Santiago, the Philippines
Aarti Kishuna, South Africa
Rajitha Wickremasinghe, Sri Lanka

The manual can be downloaded from the WHO and HAI web sites, and hard copies are available from: Department of Essential Drugs and Medicines Policy, WHO, 1211 Geneva 27, Switzerland.