1. Access to essential drugs: staggering inequities - unparalleled opportunities Jonathan D. Quick, MD, MPH Director, Essential Drugs and Medicines Policy Health Technology and Pharmaceuticals Cluster World Health Organization Presented at SEAM Conference, Washington, DC 27-29 November 2001

2. 2 WHO SEAM Access.ppt (10-Oct-15) Opportunities InequitiesInequities Access to essential drugs: staggering inequities - unparalleled opportunities

3. 3 WHO SEAM Access.ppt (10-Oct-15) Economic inequity Economic inequity - percent of population below the poverty line has changed little in 2 decades Inequities Source: WHO/HFA (1997)

4. 4 WHO SEAM Access.ppt (10-Oct-15) Health status inequity Health status inequity - infant mortality still varies 10-fold among regions of the world Source: WHO/HFA (1997) Inequities

5. 5 WHO SEAM Access.ppt (10-Oct-15) R&D inequity R&D inequity - expenditures grow, new drugs are launched, few specific for tropical diseases New chemical entities launched (number) R&D expenditure (US$ billions - top companies) Between 1975 and 1997 - ä ä 1,223 new compounds launched ä ä only 11 for tropical diseases Sources: D. Gannaway and PriceWaterhouseCoopers (1999) R&D, NCE data; P. Trouiller et al (1999) tropical research data Inequities

6. 6 WHO SEAM Access.ppt (10-Oct-15) Therapeutic inequity Therapeutic inequity - growing resistance is affecting prevalent infectious diseases n Malaria ä chloroquine resistance in 81/92 countries n Tuberculosis ä 2 - 40 % primary multi-drug resistance n Gonorrhoea ä 5 - 98 % penicillin resistance in N. gonorrhoeae n Pneumonia and bacterial meningitis ä 12 - 55 % penicillin resistance in S. pneumoniae n Diarrhoea: shigellosis ä 10-90+ % amp, 5-95% TMP/SMZ resistance Source: DAP, EMC, GTB, CHD (1997)

7. 7 WHO SEAM Access.ppt (10-Oct-15) Inequities Source: D. Gannaway (1999), World Development Report (1997), WHO/DAP (1998), WHO/EDM (1999) Health literacy inequity Health literacy inequity - information explosion for some people, information poverty for others n Among high income countries - ä 300+ million world-wide internet users by 2000 ä 2/3 of users search for health information ä 43% of 700,000 US doctors or their staff browse the Web ä 67% of doctor’s patients have Internet information n Among low and middle income countries - ä available information often under-utilized ä 1/2 of drugs with sufficient information for safe, effective use ä only 1/4 of drug packets in Asia contain inserts ä 25-45% of adult women illiterate - over 90% in some countries

8. 8 WHO SEAM Access.ppt (10-Oct-15) Inequities Pharmacists per one million population Europe, N. America (150 to 940 per million) Asia (10 to 70 per million) Africa (1 to 30 per million) Pharmaceutical care inequity Pharmaceutical care inequity - a 100-fold variation in pharmacists per million population Source: WHO/HST/GSP/94.1 (1994)

9. 9 WHO SEAM Access.ppt (10-Oct-15) Based on average worldwide price and national per capita income. Source: WHO/EDM Affordability inequity Affordability inequity - number of working hours to pay full treatment course Inequities

10. 10 WHO SEAM Access.ppt (10-Oct-15) Source: Azerbaijan - UNICEF-Bamako Technical Report No. 35 ; Bangladesh 1995 - National Accounts 1996/97 Mali (1986) - Diarra K and Coulibaly S. Financing of recurrent health costs in Mali. Health Policy and planning; 1990, 5(2);126-138 Drugs are the largest health expenditure for poor households Financing inequity Financing inequity - the burden falls heaviest on those least able to pay Inequity in health and pharmaceutical financing: ä äHigh income countries: 50-90 % publicly funded ä äLow/middle income countries: 50-90 % out-of-pocket Inequities

11. 11 WHO SEAM Access.ppt (10-Oct-15) Access inequity Access inequity - financing, delivery, and other constraints still limit access to essential drugs 1/3 of world’s population lacks regular access 320 million in Africa have <50% Problem worsens with economic pressures Source: WHO/DAP (1998) Percentage of population with regular access to essential drugs (1997) 1 = <50% (36) 2 = 50-80% (68) 3 = 80-95% (33) 4 = >95% (41) 5 = No data available (1) Inequities

12. 12 WHO SEAM Access.ppt (10-Oct-15) People are needlessly suffering and dying - drugs unavailable, unaffordable, unsafe, or wrongly used In Africa and S.E.Asia: ä ä1/2 of deaths among children, young adults due to 6 diseases ä äprompt diagnosis and treatment could save over 3 million lives per year Inequities

13. 13 WHO SEAM Access.ppt (10-Oct-15) OpportunitiesOpportunities Inequities Access to essential drugs: staggering inequities - unparalleled opportunities

14. 14 WHO SEAM Access.ppt (10-Oct-15) Ensuring access to essential drugs - framework for collective action 1. Rational selection 4. Reliable health and supply systems 2. Affordable prices 3. Sustainable financing ACCESS 1. Rational selection and use 4. Reliable health and supply systems 2. Affordable prices 3. Sustainable financing ACCESS

15. 15 WHO SEAM Access.ppt (10-Oct-15) Essential drugs concept nearly universal - lists and guidelines put the concept into practice Selection Affordability Financing Health systems Treatment guidelines (only) Essential drugs lists (only) (75) (7) Essential drug list & guidelines (83) 158 countries with essential drugs lists 90 countries with treatment guidelines 83 countries with both

16. 16 WHO SEAM Access.ppt (10-Oct-15) Standard treatment guidelines (STGs) - save lives when effectively implemented Source: WHO/CDS/CSR/DRS/2001.9 Selection Affordability Financing Health systems

17. 17 WHO SEAM Access.ppt (10-Oct-15) Getting mothers and clinicians to talk - reducing injection use in Indonesia Source: Long-term impact of small group interventions, Santoso et al., 1996 Interactive group discussion Seminar (both groups) District-wide monitoring (both groups) Selection Affordability Financing Health systems

18. 18 WHO SEAM Access.ppt (10-Oct-15) UN Drug Access Initiative Domestic production Accelerated access initiative Generic offers Advocacy, corporate responsiveness, & competition have reduced prices 95% in 3 years ?? Selection Affordability Financing Health systems

19. 19 WHO SEAM Access.ppt (10-Oct-15) Source = UNAIDS, B. Samb, 2000 Competition (2 to 6 producers per product)No competition Competition is highly effective in reducing prices - the example of antiretrovirals Selection Affordability Financing Health systems

20. 20 WHO SEAM Access.ppt (10-Oct-15) Drug benefits in public health insurance - access and risk-sharing Drugs covered by public health insurance (71) Selection Affordability Financing Health systems

21. 21 WHO SEAM Access.ppt (10-Oct-15) Global Fund to fight AIDS, Tuberculosis and Malaria - pledges from May to August 2001 US $ millions ? $ 1.5 billion Selection Affordability Financing Health systems

22. 22 WHO SEAM Access.ppt (10-Oct-15) Shopkeeper training - helping households get the best value for their health spending Source: Marsh et al, 2001 Southern zoneNorthern zone Training Selection Affordability Financing Health systems

23. 23 WHO SEAM Access.ppt (10-Oct-15) Reliable health and supply systems - successful examples exist in all regions Direct delivery system - privatized, decentralized Primary distributor system - privatized, centralized Autonomous medical stores - partly private, centralized Selection Affordability Financing Health systems

24. 24 WHO SEAM Access.ppt (10-Oct-15) India - state essential drugs programmes developed through an NGO Components n n State drug policy n n Essential drugs lists by level of care n n Pooled procurement n n Efficient distribution n n Quality assurance n n Information--patients & prescribers n n Training in rational prescribing n n Studies on drug use, pharmacoeconomics 13 states - total population 580 million Andhra Pradesh Bihar Punjab Rajasthan Maharashtra Delhi State Haryana Himachal Pradesh West Bengal Madhya Pradesh Goa Tamil Nadu Gujarat Selection Affordability Financing Health systems

25. 25 WHO SEAM Access.ppt (10-Oct-15) Unparalleled opportunities exist - to build on local successes to expand access for those in need Unparalleled opportunities exist - to build on local successes to expand access for those in need Staggering inequities exist - in income, health status, R&D, pharmaceutical care, and access Staggering inequities exist - in income, health status, R&D, pharmaceutical care, and access Conclusion 1. Rational selection & use 4. Reliable health systems 2. Affordable prices 3. Sustainable financing ACCESS