Access to Medicines-I

In this chapter we’ll be looking at access to essential medicines. Very clearly the introduction of life-saving drugs has made a great deal of contribution to improving life expectancy as well as reducing disability. And when we are looking at global health, the access to medicines becomes a very important element of universal health coverage[1]. Essential medicines are those that satisfy the priority healthcare needs of the population. Obviously there are several medicines, some of which are taken for relief of very temporary conditions, some are often taken as supplements to diet, some are taken for example to relieve cough or something like that. But essential medicines are those that are really required for protecting the health by reversing disease and reducing disability They’re selected with due regard to public health relevance, evidence on efficacy and safety and comparative cost effectiveness. Clearly there can be a wide range of medicines for treating the same condition but you need to be very sure that they’re effective, safe, at the same time, cost effective. Essential medicines are also intended to be available to the health system so that we are not uncertain about their regular availability for being provided in various healthcare facilities as needed. They should be available at all times in adequate amounts and in appropriate dosage forms with assured quality. Now quality is going to be an absolutely important criterion because without that, you cannot be sure either of effectiveness or of safety. And there should also be adequate information available about each of these drugs, not only for the physicians but also for the patients who are receiving it. And they should be available at a price that the individual and the community can afford and certainly the health system also should be able to afford it as a part of the public financing. Access to medicines has become a worldwide challenge and the World Health Organization estimates that about 1.3 to 2.1 billion, depending upon the criteria that are employed, do not have access to medicines. Unfortunately many of these are in the countries where there’s the greatest need in terms of unmet health challenges that is Africa and India. Access to essential medicines is closely related with the other aspects of the health system performance. That is, we find wherever there is a high level of disability- adjusted life years lost because of major health disorders, there, access to medicines which ought to be assured is unfortunately deficient. In terms of inequities in production and utilization, we ought to be able to really look at where the population lies and where the actual money is being spent in terms of purchase and prescription of medicines. Whereas the largest populations lie in the low and middle income countries and the low income countries and a much lower proportion of the population, about 16% is in the high income countries, the actual expenditure on medicines at the global level is the highest in the high income countries that is about 78.5%. Whereas in the low income countries, the expenditure is only 1%. This is a huge inequity in terms of availability and affordability of medicines across the world, reflected in the utilization patterns. When we are really looking at access, there are four critical elements which promote access. The World Health Organization says firstly there should be rational selection based on first quantification of the medicines that are there in the overall pharmacopoeia and then trying to select among them according to the criteria of essential medicines and forecasting the need according to the disease burdens and the various health system priorities within that country. And rational selection of course goes as I said, on the basis of effectiveness or efficacy, safety, and cost effectiveness. That brings us to affordable prices because we need to really look at how affordable these medicines are, both for public procurement by the health system and also for personal purchase by an individual patient. So that becomes the second element of how we actually ensure that the prices are within easy reach. And then we actually look at the procurement process which then brings the medicines into the health system. And we definitely require reliable supply systems. Unfortunately many public procurement systems and distributions systems do not pay attention to regularity of supply and there are frequent stock-outs that means non-availability of medicines within the facilities. And that means that many of the people who actually go to these facilities do not have the opportunity to get them on a regular basis as needed. And similarly if they’re also not available on a predictable manner in the open market for purchase at affordable prices, that again deprives people of access. So having reliable supply systems is absolutely critical. Rational selection refers to choosing safe and effective medicines which are appropriate to the country’s health situation. Accordingly, essential list of medicines will have to be prepared by each country. The World Health Organization, since 1977, has been providing a reference list of essential medicines, which actually serves as a guideline for individual countries which will adapt it for their own use based on their own national requirements. So each country has to have its own national list of essential medicines. And sometimes within large countries, provinces or states also modify the national list to suit some of their regional priorities. The number of countries which have essential list of medicines is of course is fairly large. But the number of medicines that enter the lists varies based on the national income. Low income countries for example have much lower number of essential medicines on their lists as compared to middle income. But the high income countries have a far higher number. The low income countries have had on an average, 355 drugs. The middle income countries have 441. Whereas the high income countries have a total of 1700 drugs as a part of their armamentarium in their essential list. Sustainable financing is the next step that we need to really look at, and here we need to increase the public funding for health system in general, but especially for essential medicines. Unless public financing of health through universal health coverage programs increases to a level where essential medicines can be procured and distributed at no cost or low cost we will find that there will be a continuing barrier to essential medicines for most of the people in that country. So we need to raise public financing and use a substantial fraction of that for procurement of medicines. We also will get an added benefit in that because much of the out-of-pocket spending in many of the countries is related to private expenditure on purchase of medicines. Of course by expanding various forms of health insurance, particularly social insurance or government subsidized insurance, we will be able to provide greater coverage and we need to bring in medicines also into the ambit of insurance programs which frequently do not cover outpatient care or provision of medicines. And of course there are other financing mechanisms that we ought to be looking at, including debt relief as well as international supply by various donor agencies. Sustainable financing of course requires a fair amount of public expenditure, which is predictable. As a paradoxical situation, high income countries seem to be having a greater degree of public financing as compared to private financing. And this situation has remained unchanged or even worsened over the years, when you compare 1996 to for example, 2006. In the other categories of countries, which are in the middle income or the low income bracket, we find that the private expenditure on medicines is increasing, which is again, quite indicative of the fact that public financing is at low levels as a response to the needs of the people and certainly fall short of the objectives of universal health coverage. When we look at the overall global situation in relation to sustainable financing, out of the high income countries, categorized by the WHO, the share of pharmaceutical expenditure in high income countries is about 18.2%. Whereas in low and middle income countries, it’s about 26.6%. And the low income countries, it’s 29.5%. Which means that these countries, despite the fact that they’re unable to invest adequate amounts of public financing into the universal health coverage program, or even into the health system as it exists today, are still having to spend a fair amount of their health budget on medicines. Unless the overall health financing goes up as public financing for the health sector, we will be unable to raise within the limitations of the currently available funding the expenditure on medicines to meet the huge gap in access to medicines.

[1] http://www.unmillenniumproject.org/documents/TheLancetTrade.pdf, http://whqlibdoc.who.int/hq/2004/who_edm_2004.4.pdf, http://globalhealth.thelancet.com/2014/06/06/stepping-out-silos-integrating-global-health-trade-negotiations, http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001485,

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