1. August 27th 20081 Availability, Pricing and Affordability of Cardiovascular Medicines 2001-2006 Draft report for comments Maaike S.M. van Mourik University Medical Center Utrecht Intern with Department of Medicine Access and Rational Use (MAR) Supervisors: Alexandra Cameron Richard Laing

2. August 27th 20082 Outline Introduction & Background Methodology Results Availability Pricing Affordability Discussion & Policy options

3. August 27th 20083 Introduction & Bac k ground Cardiovascular diseases: 30% of deaths worldwide, 80% of which in developing countries WHO-PREMISE study Many patients did not get medicines needed for adequate management. Non-WHO studies Problems with availability, pricing and affordability WHO report on chronic disease medicines (30 surveys) Poor availability and affordability Aim: Secondary analysis of price, availability and affordability of CVD medicines in 36 developing countries that have undertaken WHO/HAI surveys

4. August 27th 20084 Methodology WHO/HAI data Standardized data collection Prices as Median Price Ratios (MPRs) Medicines: Atenolol 50mg, Captopril 25mg, Hydrochlorothiazide (HCT) 25mg, Losartan 50mg and Nifedipine retard 20mg. Secondary analysis Adjustments for inflation and purchasing power Analysis by World Bank Income Groups and WHO regions.

5. August 27th 20085 Surveys included Low income Chad (2004) Ethiopia (2004) Ghana (2004) India-Chennai (2004) India-Haryana (2004) India-Karnataka (2004) India-Maharashtra 12 districts (2004) India-Maharashtra 4 regions (2005) India-Rajasthan (2003) India-West Bengal Kenya (2004) Kyrgyzstan (2005) Mali (2004) Mongolia (2004) Nigeria (2004) Pakistan (2004) Sudan-Gadarif (2006) Sudan-Khartoum (2005) Sudan-Kordofan (2006) Tajikistan (2005) Tanzania (2004) Uganda (2004) Uzbekistan (2004) Yemen (2006) Lower-middle income Armenia (2001) Cameroon (2002) China-Shandong Province (2004) China-Shanghai (2006) El-Salvador (2006) Fiji (2004) Indonesia (2004) Jordan (2004) Morocco (2004) Peru (2005) Philippines (2005) Sri Lanka (2001) Syria (2003) Tunisia (2004) Upper-middle income Brazil-Rio de Janeiro (2001) Kazakhstan (2004) Lebanon (2004) Malaysia (2004) South Africa - Kwazulu Natal (2001) High Income Kuwait (2004) United Arab Emirates (2006) p.21 of the report

6. August 27th 20086 Results: Availability (%)

7. August 27th 20087 Results: Availability by WBIG

8. August 27th 20088 Results: Procurement pricing Public sector procurement Procurement vs. public sector patient pricing Mark-up Taxes Procurement at a different price Cross-subsidizing MPR = 1

9. August 27th 20089 Results: Patient pricing Price ratio's in the public & private sector

10. August 27th 200810 Results: Patient pricing by WBIG

11. August 27th 200811 Results: Private sector brand premiums

12. August 27th 200812 Results: Affordability Number of day's wages the lowest-paid government worker needed to purchase one month of chronic treatment Large variations, on average 1.8 day's wages for single medicine Most affordable: atenolol 50mg (1.1 day's wages) High income areas more affordable than low income Note: Average income often below lowest government wage Need for multiple medicines

13. August 27th 200813 Discussion & Policy options Availability Focus on small group of medicines from national STG Increase public sector funding for NCD medicines Procurement Some countries: can improve on procurement prices Differential pricing for public & private sector Patient prices Lower taxes & tariffs Promote the use of generics Reduce mark-ups

14. August 27th 200814 Thank you Please send any comments to: M.S.M.vanMourik@students.uu.nl