Figure 1: Countries included in the essential asthma medicines survey 2011

ESSENTIAL MEDICINES: PRICING AVAILABILITY, AND AFFORDABILITY

Although effective treatment for asthma exists, many people, especially in low- and middle-income countries, are unable to access the medicinesneeded to manage this chronic condition. Poor availability of medicines is one barrier, another is price - many medicines are unaffordable for patients who have to purchase them out-of-pocket.

Providing affordable essential medicines for developing countries is a target within goal 8 of the Millennium Development Goals and a particular focus of the World Health Organization (WHO).

Measuring and understanding the price of medicines is the first stage in developing pricing policies that can improve both the availability and affordability of medicines. However, data on medicine prices and availability are still limited in low- and middle-income countries.

Essential asthma medicines: A survey in 2011

A cross-sectional ‘snapshot’ survey was conducted by The Union and the University of Auckland’s School of Pharmacy to measure the availability and prices in low- and middle-income countries of three essential asthma medicines: beclometasone 100 μg/puff inhaler, salbutamol 100 μg/puff inhaler, and budesonide 200 μg/puff inhaler (all with 200 doses and HFA i.e., CFC-free). For each of these inhalers, the price and availability of both an innovator or reference product and the lowest-priced generic product was sought. Qvar® from 3M was used as the reference medicine for beclometasone; Pulmicort® from Astra Zeneca as the innovator for budesonide. For salbutamol, innovator brands from GlaxoSmithKline (such as Ventolin®, Aerolin®, or Salbutan®) were sought. Union contacts in 50 countries collected data by making one visit to a public hospital, a public sector national procurement centre and two private retail pharmacies in the capital or main provincial city of each country during the months of May-July 2011.

The price ratios of each medicine were calculated by comparison with the Management Sciences for Health 2010 International Reference Prices (IRPs). IRPs are the medians of recent procurement or tender prices offered by predominantly not-for-profit suppliers to developing countries for multi-source products. Affordability for patients was calculated using the surveyed price of each inhaler and the daily wage of the lowest-paid unskilled government worker of the particular country.

Survey results

Pricing of medicines

International Reference Prices (IRPs) were used to assess pricing and procurement efficiency and some pricing information is provided in Appendix B. However, this approach should be taken with some caution, as IRPs are only indicators. In addition, these IRPs appear to be on the higher side, for example, the IRP for beclometasone (US$ 8.06) is much higher than the current price obtained by the Asthma Drug Facility (ADF) (US$ 1.28 FCA price). Likewise the IRP for budesonide (US$ 10.55) is much higher than ADF’s price (US$ 2.60). Therefore, public sector procurement agencies and other sectors should definitely aim to obtain prices significantly lower than the IRPs for these products. Median prices of the surveyed inhalers are shown below in US$ (Table 1).

Availability of medicines (Table 2)

Beclometasone 100μg/dose was on the national Essential Medicines List (EML) of only 10 countries (20%). Others listed only 50μg and 250μg strengths, despite the fact that 250μg is no longer in the WHO EML. Generic beclometasone was available in 41% of private pharmacies, 15% of national procurement centres and 17% of public hospitals.
Salbutamol 100μg/dose was on the EML of almost all countries. Generic salbutamol was available in 82% of private pharmacies, 54% of national procurement centres and 57% of public hospitals.
Budesonide 200μg/dose was on the EML of 9 countries (18%). In at least 20 countries, neither the innovator nor generic brand was available. Generic budesonide was available in 31% of private pharmacies, 12% of national procurement centres and 17% of public hospitals.

Affordability of medicines purchased from private pharmacies

Affordability was based on inhaler prices and a generalised daily minimum wage. Affordability in private pharmacies is presented here (see Figure 2) and in Appendix A (Figures 3 and 4). It should be noted that in some of these countries, medicines may be provided free in the public sector, and social insurance may exist in the private sector. The tables do, however, show what patients would have to pay out-of-pocket, if they have no alternative.

Given that a patient with severe asthma needs about 16 beclometasone inhalers per year and 8 salbutamol inhalers per year, all prices per inhaler need to be multiplied to estimate the cost of a year’s supply. For example, to purchase one reference brand inhaler of beclometasone in Cambodia and in El Salvador, more than 10 days’ wages are needed (160 days’ wages per year for severe asthma). For one generic beclometasone inhaler, less than 5 days’ wages are needed (less than 80 days’ wage/year) in all countries except Ethiopia, Madagascar and Malawi.

One generic salbutamol inhaler requires 4 or less days’ wages (32 days’ wages/year) in all countries. Innovator brands of salbutamol are less than 8 days’ wages per inhaler in all countries, except the Republic of Guinea.

Affordability of budesonide demonstrates wider extremes: for generic budesonide, it ranges from less than one day’s wage (16 days’ wages/year for severe asthma) in Iran, Jordan and Malaysia to more than 50 days’ wages (800 days’ wages/year) in Mozambique. In the Republic of Guinea, the innovator brand costs 107 days of wages (1712 days’ wages/year).

Using results to improve access

This preliminary analysis reveals issues around the pricing, availability and affordability of essential medicines recommended by the WHO. It is of concern that beclometasone 100μg and budesonide 200μg are absent from so many Essential Medicines Lists (EMLs). The integration of these essential medicines into national EMLs is an important first step for improving the availability of these products in the public sector.

The fact that corticosteroid prices continue to remain so high in many countries is reflected in the International Reference Prices (IRPs): IRP for beclometasone is 6 times higher than the ADF’s current price; IRP budesonide is 4 times higher. Hopefully this preliminary report and the upcoming detailed analysis will alert policymakers and health services to the disparities that exist within and between countries. Most health systems are spending much more than they need, and there are many examples of an acute lack of affordability for patients.

-Zaheer-Ud-Din Babar, Charon Lessing, Karen Bissell, Cécile Macé

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