1. WHO/EMP TBS | 02 November 2011 1 |1 | 1 Financing Essential Medicines in Low- and Middle-income Countries: Cameroon Case Study Dr Dele Abegunde (MAR) & Mrs Helen Tata (MCP/MAR)

2. WHO/EMP TBS | 02 November 2011 2 |2 | 2 Inequalities (or inequities) access to medicines: growing with needs  Access to pharmaceuticals essential to healthcare  25 -70% of health spending in the developing countries,  10-18% in OECD countries  Marginal cost of consumption at point of need:  for most consumers in the developing countries is way greater than zero.  Less that 3% of population in low-income countries have some forms of insurance cover  Total pharmaceutical expenditure:  0.2 – 3.8% of GDP  TPE / Total Health expenditure:  25 – 36% OECD countries. Likely higher in LIMC countries?  Share of TPE from external sources  increased from 12% in 2000 to 17% in 2006 in LMIC, 22% in the 49 least developed countries.

3. WHO/EMP TBS | 02 November 2011 3 |3 | 3 Inequality in access = poor access to medicines 80% global TPE spent on 18% of population: May suggest regressive global financing scenario Medicines financing remain regressive in LMIC: Medicines are largely financed through OOP – only about 3% have access to some forms of insurance mechanism Market failures justify public intervention: global economic recession threatening to dry up traditional funding sources

4. WHO/EMP TBS | 02 November 2011 4 |4 | 4 Dimensions to medicines financing Providers (Supply of medicines) –National governments –Collaborating & Development partners (NGOs) –Health care systems and direct provides Consumers (Demand for medicines) –General needs consumers –Special needs consumers Nearly all the global financing efforts to increase access to medicines is actively focused on Supply of medicines

5. WHO/EMP TBS | 02 November 2011 5 |5 | 5 Government health expenditure (as source) is Increasing

6. WHO/EMP TBS | 02 November 2011 6 |6 | 6 Official Development Assistance (ODA) and Health ODA Source: OECD

7. WHO/EMP TBS | 02 November 2011 7 |7 | 7 Source Of Funds ESSENTIAL MEDICINES ARVsMALARIATBOI ARVs Ped REAGENT Blood safety (+ HIV test) VACCINESCONDOMSCONTRACEPTIVES MEDICAL SUPPLIES GOVERNMENT MULTILATERAL DONOR BILATERAL DONOR NGO/PRIVATE GOVERNMENT WBWB GLOBAL FUND SIDASIDA PEPFARPEPFAR USAIDUSAID UNICEFUNICEF OMSOMS ABBOTTABBOTT CSSCCSSC COLUMBIACOLUMBIA PFIZERPFIZER JICAJICA CL I N T O N UNITAIDUNITAID CIDACIDA CDCCDC GAVIGAVI CUAMMCUAMM HAVARDHAVARD NORADNORAD AXIOSAXIOS Tanzania: Funding by Supply Type (2006-2007 Data) 315,17053,85917,7343,90517,30037,0273,7224,70054,20156,85365,869$ ‘000 100%17.1%5.6%1.2%5.5%11.7%1.2%1.5%17.2%18.0%20.9% Source: Supply management, WHO/EMP/MAR

8. WHO/EMP TBS | 02 November 2011 8 |8 | 8 Source: Helen Tata, WHO

9. WHO/EMP TBS | 02 November 2011 9 |9 | 9 82,156 1,8620.61,305010,8891,4952,9840.311,71845,3355,666$ ‘000 100% 2%1%2%0%13%2%4%0.5%14%55%7% Zambia: Funding by Supply type Source Of Funds WORLD B A N K PEPFARPEPFAR DFIDDFID USAIDUSAID UNICEFUNICEF WHOWHO CHAZCHAZ CHAICHAI JICAJICA WORLD VISION UNFPAUNFPA ZABARTZABART ESSENTIAL MEDICINES ARVsMALARIATBOI ARVs Ped REAGENT Blood safety (+ test HIV) VACCINESCONDOMSContraceptives MEDICAL Supplies Category of Products Color GOVERNMEN T BILATERAL DONOR MULTILATERAL DONOR NGO/PRIVAT E BGATESBGATES ITN AXIOSAXIOS UNITAIDUNITAID GLOBAL FUND CDCCDC GLASERGLASER MOHMOH Source: Supply management, WHO/EMP/MAR

10. WHO/EMP TBS | 02 November 2011 10 | 10 Players and Partners?

11. WHO/EMP TBS | 02 November 2011 11 | 11 What is happening in countries? Increased funding, more investment to improve access to medicines Access to medicines improving in some disease areas? Impact on health systems and unfavoured diseases areas Pharmaceutical work force challenges Uneven development of the procurement, supply and systems Demand for medicines is increasing in scale and scope Hardly any active planning budgeting for medicines in countries Is optimal and equitable access to medicines being achieved?

12. WHO/EMP TBS | 02 November 2011 12 | 12 Challenges Distorted view of total medicines financing with inputs to specific disease programs by donors Reduced government contributions to health and medicines Constrained technical capacity in countries Political will Global economic (financial) crisis Human resources Healthcare systems. Weak tax systems – large informal sector

13. WHO/EMP TBS | 02 November 2011 13 | 13 Innovative financing mechanism galore hypotheticated taxes, e.g. 'sin taxes' for tobacco and alcohol national and state lotteries dedicated to health public-private partnerships between governments and the private sector to co- fund health care. Other mechanisms are internationally focused, such as: –the (recently proposed) International Finance Facility (IFF). This would front-load development assistance by selling government bonds secured by future aids flows debt for health swaps, in which external government debt is converted into domestic debt, thereby resulting in less pressure to generate foreign exchange for debt service. A debt-for-health swap also represents an opportunity for a foreign donor to increase the local currency equivalent of a donation. the use of public-private partnerships to develop new products using capital markets.

14. WHO/EMP TBS | 02 November 2011 14 | 14 Financing demand for medicines Mechanisms to empower consumers such that economic considerations diminishes in making the decision to use medicines rationally to restore or improve health. –Insurance & reimbursement systems –Prepayment mechanisms –Market system manipulation and affordability

15. WHO/EMP TBS | 02 November 2011 15 | 15 Global Picture: Medicines reimbursement Low- Income Lower Middle- Income Upper Middle- Income High-Income Number of countries n = 40 (%)n = 54 (%)n = 46 (%)n = 50 (%) Number of countries with any insurance coverage 18 (45.0%)31 (57.4%)35 (76.1%)47 (94.0%) Number (%) of countries with medicines reimbursement 18 (45.0%)19 (35.2%)27 (58.7%)46 (92%) Total population 0.88e+093.97e+091.03e+091.10e+09 Population coverage ratio: Health insurance 13.8%24.8%54.18%93.2% Coverage for medicines reimbursement 14.1%19.8%47.2%92.7% Health insurance coverage and medicines reimbursement coverage by countries’ 2011 World Bank income classification

16. WHO/EMP TBS | 02 November 2011 16 | 16 Global Picture: Medicines reimbursement Health Insurance coverageReimbursement for medicines

17. WHO/EMP TBS | 02 November 2011 17 | 17 Global Picture: Medicines reimbursement Health Insurance coverageReimbursement for medicines

18. WHO/EMP TBS | 02 November 2011 18 | 18 Persisting Situation Medicines reimbursement reflects comparable coverage with health insurance coverage in countries with universal, or tax financed insurance systems. Drug Revolving Funds are often precursors of community health insurance schemes in the developing countries and may explain the slightly higher medicines cover in low-income countries. Community health insurance is growing in low- and middle-income countries, –but majority of countries and populations have no access to health insurance compared to high-income countries.

19. WHO/EMP TBS | 02 November 2011 19 | 19 CHI Community finance schemes –This market is evolving in the contest of: Government failure to organize taxes, public finance, provision of social protection to vulnerable populations and to exercise oversight over the health sector. Market failure to offer effective exchange between demand and supply –Strength Social capital Pre existing community institutions Interconnectivity between local communities –Limitations to overcome to serve the community well Lack of insurance and reinsurance mechanisms to spread risk over larger population Isolation from formal financing and provider networks Have difficulties in mobilizing enough resources to cover costs of priority health services for the poor Limited ability to encourage prevention or use of therapies effectively Rely on management staff with limited professional training.

20. WHO/EMP TBS | 02 November 2011 20 | 20 Community Health Insurance and Access to Medicines: Evidence from Cameroon

21. WHO/EMP TBS | 02 November 2011 21 | 21 Supported by GTZ and Cameroon government in 3 regions  North West  South West  Littoral An effective medicines supply system on cost-recovery basis Hosted by Provincial Special Funds for Health (the FUNDs) Strong community participation Essential Medicines Program

22. WHO/EMP TBS | 02 November 2011 22 | 22 Public Medicines Supply System in Cameroon

23. WHO/EMP TBS | 02 November 2011 23 | 23 Community Mutual Health Organisation (Mutuelle) A subsidiary of the Fund. Built on well mobilized community platform of the EMP Not-for-Profit community-based health financing schemes Provides a viable alternative health financing mechanism  Pulls resources together from households  Risk sharing  Affordable health care to the rural poor

24. WHO/EMP TBS | 02 November 2011 24 | 24 AIM of study Evaluate the impact of the community health insurance schemes on supply and distribution of essential medicines to public health care facilities in 3 regions in Cameroon.

25. WHO/EMP TBS | 02 November 2011 25 | 25 Methodology (1) Medicines selection  Antimalarial  Antibiotic  Maternal health  Chronic ailments (diabetes and hypertension) Detailed supply records kept at regional medical stores (RMS) –Supply details to Health Facilities of 8 essential medicines (aminophyline, amoxicillin, co-trimoxazole, folic acid in combination with ferrous sulphate, metformin, nifedipine paracetamol and quinine)

26. WHO/EMP TBS | 02 November 2011 26 | 26 Analysis Two-by-two Analysis mean monthly quantity of orders per facility –(Ho): zero mean difference between the comparative groups (across the two partitions), rejected at 95% degree of confidence student t test used to evaluate the significance of the mean difference after and before CMHO.

27. WHO/EMP TBS | 02 November 2011 27 | 27 Littoral South West North West Health Centres Before vs After CHMO CHMO vs Non- CHMO Before vs After CHMO CHMO vs Non- CHMO Before vs After CHMO CHMO vs Non- CHMOMedicines 60 (0.30)-19 (0.83)14 (0.30)-3 (0.83)31 (0.10)19 (0.29)Aminophylline 0 (0.88)8 (0.01)-2 (0.03)4 (0.00)2 (0.09)4 (0.00)Amoxicillin 78 (0.39)-132 (0.35)-25 (0.67)141 (0.00)65 (0.42)588 (0.00) Co- trimoxazole -522 (0.59)855 (0.54)--705 (0.00)608 (0.00)Fafs ---119 (0.09)200 (0.00) - 8 6 (0.18) 331 (0.00)Metformin -479 (0.16)-179-68 (0.28)259 (0.00)55 (0.35)488 (0.00)Nifedipine -411 (0.06)338 (0.33)-73 (0.31)250 (0.00)43 (0.16)373 (0.00)Paracetamol -176 (0.13)82 (0.63)123 (0.00)45 (0.09)-38 (0.01)85 (0.00)Quinine Results: Mean Differences (Total Supply)

28. WHO/EMP TBS | 02 November 2011 28 | 28 Results: North West

29. WHO/EMP TBS | 02 November 2011 29 | 29 Results: South West

30. WHO/EMP TBS | 02 November 2011 30 | 30 Results: Littoral Region

31. WHO/EMP TBS | 02 November 2011 31 | 31 Summary of Results Regularly supply sustained in all centres - including non provider centres Increased consumption of medicines and utilization of associated services Evidently sustainable financing of medicines Indications or demand for quality of medicines and care

32. WHO/EMP TBS | 02 November 2011 32 | 32 Conclusion A well designed and positioned mutual health insurance systems can have a positive impact on access to medicines and associated health services. A well designed and functioning medicines supply system is essential for community health insurance to function.

33. WHO/EMP TBS | 02 November 2011 33 | 33