Transcript Novartis Deck for External meeting

Prices of Antihypertensive
Medicines in Sub-Saharan Africa
(SSA) and Alignment to World
Health Organization’s Model List
Of Essential Medicines
Marc Twagirumukiza, MD, PhD
Clinical Pharmacology
Ghent University
Ghent, Belgium
Focus on SSA
47 countries (+ South Sudan since June 2011)
Total population (2010): 800 Million
−12.5% of the world population►1,2bn by 2025
−Wars, conflicts and instability
 Economy :
−Only <10 % of global GDP (2008 est)
−Farming for liverhood (75%) / Gender issues
−GNI per capita: 858 US$
 283 US$ in Burundi – 21 616 US$ in
Seychelles – WB, 2008 est
 Life expectancy at birth : 50.5 years
(36 in Zambia – 73 in Mauritius )
Inequality in health spending by
region (WHO, 2000)
EXTERNAL AID AS PERCENTAGE OF TOTAL
HEALTH SPENDING (2000)
SSA: Health and wealth, who pays?
4%
23%
38%
Gouvernements
(including
donors)
Patients' (outof-poket)
State health
insurances
1%
Private health
insurance
Other sources
34%
Source: WHO, 2004
Mortality worldwide: CVDs are responsible for
more than 30% of all deaths (WHO, 2005)
Global deaths
by causes,
2005
HT
7.1
Mio
• Morbidity worldwide:
• 972 Mio hypertensive →will rise to 1.6 bn (2025)
• 65% in developing countries (including SSA).
Source : WHO 2005: «Preventing Chronic Diseases: A Vital Investment»
• P.Kearney,The Lancet, 2005
HT in SSA
Prevalence, Gender and burden
From
population
studies, 19982008
2008 in SSA: 74,7 million


(38.3M
; 36.4M
)
people with hypertension
and prevalence of 16.2%
2025 in SSA:
125 million
people with
hypertension
and a
prevalence of
17.4%
Twagirumukiza M, J Hypertens. 2011 Jul;29(7):1243-52.
Hypertension prevalence in Africa Vs Western
countries
Twagirumukiza M, Journal of Hypertension 2007.
USA (3)
70
England (2)
60
Canada (6)
SSA (1)
50
40
30
20
10
0
15-24
25-34
35-44
45-54
55-64
Age-ranges (in years)
>=65
HT is a major Cardiovascular
(CV) risk factor
We can
consider
hypertension
as a disease
but at the
same time as a
risk factor
for other
CVDs.
coronary
heart
disease
Cerebrovascular
disease
Hypertension
heart
failure
peripheral
artery
disease
Stroke mortality rate
worldwide
Number of cases reaching hospitals are in last
stage of complications – dying at home.
Stroke worldwide : DALYs lost
Disability Adjusted Life Years : The sum of years of potential life lost due to premature
mortality and the years of productive life lost due to disability.
Access-to-medicines worldwide
 Documented worldwide: 1/3 of world’s population lacks
regular access-to-essential medicines.
(Source: WHO/DAP 1998 )
 Global response (1977): World Health Organization
Essential Medicines List (WHO/EML): a limited range of
medicines selected to meet better availability, better use of
financial resources, and in that way greater access to care.
 Many countries have developed their “National Essential Medicines
Lists” (NEMLs) from WHO model.
 Those NEMLs can play a role in standardization of the hypertension
treatment in SSA.
Access-to-medicines
Methods
Data on NEMLs and drug prices were collected from 65 public
and 65 private pharmacies (from 13 SSA countries).













Benin
Burundi
Cameroon
Congo
DRC
Ivory Coast
Kenya
Mozambique
Niger
Rwanda
Senegal
Tanzania
Uganda
Antihypertensive medicines on
WHO/EML
14-15th WHO/EML (2005, 2007)
Classes
Drug (ATC name)
Dosage
Duretics
Hydrochlorothiazide
25mg
Atenolol
50mg
100mg
β-blockers
2.5mg
ACE inhibitors
Calcium Channel
blockers
Enalapril
5mg
Amlodipine
NEMLs
All investigated countries had a NEML, and all advocated drug
classes were represented.
Overview of the situation
NEMLs in sampled countries
Data on National Essential Medicine
Lists (NEMLs) and drug prices were
collected from 13 SSA countries.
All surveyed countries had a NEML
but 38% were not updated in the last
5 years.
Advocated drugs in SSA countries: % of NEMLs
having advocated drugs on at least one of the
WHO/EML 2002, 2003, 2005, 2007
% of NEMLs
100.00
53.8%
61.5%
61.5%
46.2%
50.00
0.00
HCTZ
ATEN
ENAL/CAPTO
AMLO/NIFE SL
HCTZ=Hydrochlorothiazide, ATEN=Atenolol, ENAL=Enalapril, CAPTO= Captopril,
AMLO= Amlodipine, NIFE SL= Nifedipine sustained release.
Non advocated drugs on NEMLs
(Listed for HT Indications!)
 Diuretics: Furosemide (10 NEMLs)
 β-blockers: Propranolol (6 NEMLs), Labetalol, Carvedilol.
 ACE inhibitors: Ramipril, Lisinopril.
 CCBs: Nifedipine short acting (5 NEMLs), Verapamil,
Diltiazem, Nicardipine.
 Centrally acting drugs: Clonidine (5 NEMLs),
Reserpine.
DDD prices adjusted to PPP per capita
140
Income
adjusted
price
Enalapril
120
100
80
60
40
20
0
Uganda
Tanzania
Senegal
Rwanda
Niger
Mozambique
Kenya
Ivory coast
DRC
Congo
Cameroon
Burundi
Benin
Tropical Medicine and International Health, 2010; 15:350-361.
DDD prices adjusted to PPP per capita
•High prices :
→Amlodipine
→Burundi & DRC
25
20
15
Uganda
Tanzania
Senegal
Rwanda
Niger
Mozambique
Kenya
Ivory coast
DRC
Congo
Cameroon
10
5
0
MET
Burundi
AMLO
ATE
CAPTO
Benin
HCTZ
NIFE
Tropical Medicine and International Health, 2010; 15:350-361.
Components of price build up along the chain
Manufacturer’s
Selling Price
Import Tariffs
and other fees Insurance+ Freight
Wholesaler margins
Cost build up
Prashant Yadav, India, 2008
Retail margins
Price Components: Multi-country comparison
Hidden costs of medicines
Items
Manufacturer price
Import tariff
Port charges
Clearance and freight
Kenya
Rwanda Tanzania Nigeria
0
0%
8%
1%
0
7%
5%
8%
0
10 %
1%
2%
0
5%
0%
4%
Pre-shipment inspection
Pharmacy board fee
Importer's margins
VAT
Central government tax
State government tax
Wholesaler
Retail
2,75 %
-
30 %
10 %
20 %
25 %
11 %
25 %
1,20 %
2%
9%
2%
0%
50 %
22 %
18 %
1%
4%
3%
50 %
Total mark up
72 %
81 %
77 %
107 %
Sources: Levison and Laing 2003, Governments files, MoH in every country
Discussions, remarks and study
limitations:
•
The outlets surveyed were chosen in each
country from the capital city and data from
distanced rural areas could change according
to transport add-ons.
•
The survey was limited to drugs on NEMLs
which were on the WHO/EML between 2002
and 2007.
•
The present study ignored the price data from
informal channels, such as street vendors,
which should interact with the prices in SSA
countries.
Discussions, remarks and study
limitations:
•
Additionally, the present study is descriptive and not
explanatory (no analysis of reasons of price disparities)
•
The prices discussed are prices for monotherapy
whereas this does not necessarily reflect the cost of
the management of hypertension since a patient with
established hypertension requires more than one
antihypertensive drug.
•
Apart from the price, the quality of medicines, not
analysed here, is also of utmost importance in
treatment. The major weakness of all medicines price
comparisons is that they assume that all medicines on
the market are of equal quality and therapeutic value.
Assumption model : Cost of hypertension
treatment (estimates for SSA needs)
6.00
Cost per year for SSA
(bn $ US)
5.00
4.00
3.00
2.00
1.00
0.00
Conclusions
 SSA sampled NEMLs are partially in compliance with WHO/EML.
 Some still have less effective (Furosemide short acting) or
dangerous drugs (Nifedipine immediate release formulation)
 Prices of drugs advised by WHO/EML largely differ between drugs
and for each drug within and between countries.
 Adding advocated drugs on country's NEMLs nearly always
contributes to reduce prices.
 In general, hydrochlorothiazide is the cheapest drug and should be
the drug to be considered first.
Treatment strategies
J Hum Hypertens. 2011 Jan;25(1):47-56
www.nature.com/jhh
Prices of Antihypertensive Medicines in SubSaharan Africa (SSA) and Alignment to World
Health Organization’s Model List Of Essential
Medicines
“Although the nature tries classifying people
into richest and poorest, it is an ethical
obligation for scholars and scientists to find
how health care can reach everyone!”
Marc Twagirumukiza
Thanks for
your attention