Understanding access to medicines in low- and middle-income countries through the use of price and availability indicators

Abstract

Objectives: While it is generally understood that large sections of the population in low- and middle-income countries (LMICs) lack access to medicines, the concept of access is difficult to define and measure.Data on medicine prices and availability obtained through national facility-based surveys were examined through a variety of approaches to determine their usefulness in informing a global understanding of access to medicines. Methods: National and sub-national data on medicine price and availability were obtained from a database containing results of surveys conducted using a standard methodology (developed through a collaboration between the World Health Organization (WHO) and Health Action International (HAI)). In the surveys, the prices and availability of approximately 50 medicines are collected in a sample of facilities in the public and private sectors. Data are also collected on public procurement prices as well as the add-on costs applied through the supply and distribution chain. WHO/HAI data for 15 commonly-surveyed medicines were aggregated on a global level, taking several steps to improve the comparability of results. Similar analyses were also conducted for individual disease areas, namely cardiovascular disease and epilepsy. The availability of medicines used for acute and chronic conditions, respectively, were then compared. To further explore treatment affordability, medicine price data was used to quantify the impoverishment effects of medicine purchases in a subset of 17 countries. Finally, medicine prices were used in combination with consumption data to estimate potential savings which could arise from switching consumption from originator brands to generics. Findings: The secondary analysis of survey results for commonly-available medicines showed that medicine availability is generally low: 38.4% and 64.2% in the public and private sectors, respectively. Analyses for individual disease areas showed similar results: availability of generics medicines was only 26.3% for cardiovascular medicines and <50% for nearly all antiepileptics. When the availability of medicines for acute and chronic conditions was compared, it was found that medicines for chronic conditions were substantially less available than those for acute conditions (36.0% availability versus 53.5% in the public sector). Overall, private sector patient prices ranged from 9-25 times international reference prices for lowest-priced generic medicines. This was found to translate into poor affordability: for example, purchasing a month’s supply of the antidiabetic glibenclamide in generic form would push an additional 6% of populations below the international poverty line (US $1.25/day). Originator brand medicines were found to be consistently less affordable than their lowest-priced generic equivalents, which was illustrated in an analysis which showed that approximately 60% of private sector spending on medicines could be achieved by switching consumption from originators to lowest-priced generics. Conclusions: These analyses show that national-level data on medicine price and availability can be used to improve our understanding of access to medicines in low- and middle-income countries. While results vary across countries, global and regional trends raise concerns regarding access to medicines in these contexts. Given their role in informing advocacy efforts, investments, and policy and programmatic support related to access to medicines, ongoing efforts are needed to collect and report on medicine prices and availability.