103
Global status report on NCDs 2014
102
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34
■
周 e national health strategy should include access to health
technologies and essential medicines as an objective and should
specify a mechanism for monitoring, evaluation and review of
the availability and a ordability of basic health technologies and
NCD medicines.
■
Achieving this target requires sustainable health-care nancing,
to ensure adequate procurement of basic health technologies and
essential NCD medicines.
■
Country e orts to improve access should rst focus on basic
health technologies and essential medicines for NCDs, and
the national essential medicines list should be the basis for
procurement, reimbursement and training of health-care workers.
■
Reliable procurement and distribution systems are needed
to guarantee the supply of essential NCD medicines and
technologies to all levels of health care, including primary care,
and to regional and remote communities.
■
Mechanisms must be in place to ensure that quality-assured
generic medicines are procured; prescribers and consumers need
to have con dence in the generic medicines in circulation.
■
Evidence-based treatment guidelines and protocols should be
promoted and implemented, to support the appropriate use of
essential NCD medicines.
■
周 e attainment of this target will contribute to attainment of
targets on reducing the prevalence of hypertension, on improving
coverage of treatment for prevention of heart attacks and strokes
and, ultimately, on reducing premature mortality from NCDs.
Key points
38
105
Availability and aff ordability of
basic technologies and medicines
Eff ective delivery of individual interventions for NCDs requires strengthening of
the health system at all levels of care. Weaknesses and ine ciencies are currently
encountered in all components of health systems, including supply of essential med-
icines and technologies (1−4). Priority actions for addressing the NCD crisis include
delivering cost-eff ective and aff ordable essential medicines and technologies for
all priority disorders, and strengthening health systems to provide patient-centred
care across diff erent levels of the health system, starting with primary care (4,5).
is target includes the basic requirement of medicines and technologies for
implementing cost-eff ective primary care interventions and for addressing car-
diovascular disease, diabetes and asthma (6). e core essential medicines include
at least aspirin, a statin, an angiotensin-converting enzyme inhibitor, a thiazide
diuretic, a long-acting calcium-channel blocker, a beta-blocker, metformin, insulin,
a bronchodilator and a steroid inhalant. e basic technologies include, at least, a
blood pressure measurement device, a weighing scale, height measuring equipment,
blood sugar and blood cholesterol measurement devices with strips, and urine strips
for albumin assay. ese are minimum requirements for implementing essential
NCD interventions in primary care. Availability is de ned as the percentage of
public and private primary health-care facilities that have all of these medicines
and technologies, indicated above.
Cancer medicines are not included in this indicator because of the di culty of
implementing treatment interventions for cancer in primary care in resource-con-
strained settings. However, this should not undermine eff orts to improve access
to essential medicines for treating cancer. Treatment interventions and protocols
for cancer should be identi ed, specifying the level of care at which these cancer
medicines can be safely administered.
Progress achieved
Substantial information exists on availability and aff ordability of essential medi-
cines, particularly in low- and middle-income countries. A large number of country
studies have been conducted using a standard validated methodology developed by
9
Global target 9: An 80% availability of the
affordable basic technologies and essential
medicines, including generics, required to
treat major noncommunicable diseases in
both public and private facilities
92
Global status report on NCDs 2014
106
WHO and Health Action International (HAI) (7).
周 e availability and prices of medicines are inves-
tigated through visits to public and private-sector
facilities in each country, and availability is reported
as the percentage of facilities where a product is
found on the day of data collection.
A summary of the results of medicine-availability
studies conducted between 2007 and 2012 using
WHO/HAI survey methods is shown in Fig. 9.1 (8).
周 ere is a consistent pattern of lower availability of
medicines in public sector facilities compared to the
private sector, and lower availability in low-income
and lower-middle-income countries. While the bas-
ket of medicines surveyed in each country is not the
same, the basket of medicines in each case is a mix
of medicines used to treat communicable diseases
and NCDs, as well as to provide symptomatic and
pain relief.
Further analysis of these WHO/HAI studies in 40
low- and middle-income countries has compared
the availability of 15 medicines used for acute
Fig. 9.1 Median availability of selected lowest-priced generic medicines, in the public and private sector, by World
Bank income group, 2007−2012
—
median
100
90
80
70
60
50
40
30
20
10
0
Median % availability
54.1
max
min
68.0
56.1
70.0
59.7
69.1
70.0
60.0
Upper-middle-income
HIgh-income
Lower-middle-income
Low-income
Source: World Health Organization/Health Action International, using data from medicine price and availability surveys conducted
between 2007 and 2012 using the WHO/HAI methodology (http://www.haiweb.org/medicineprices).
n = number of countries. Baskets of survey medicines differ between countries.
Public
(n = 10)
Private
(n = 12)
Public
(n = 14)
Private
(n = 14)
Public
(n = 11)
Private
(n = 11)
Public
(n = 2)
Private
(n = 3)
conditions with 15 medicines for chronic diseases
(see Table 9.1) (9).
周 ese summary measures across a selection of 15
medicines conceal the extent of some of the prob-
lems of availability of speci c medicines for the
prevention and treatment of NCDs.
An analysis of the availability of selected cardiovas-
cular medicines (atenolol, captopril, losartan and
nifedipine) in 36 countries concluded that availabil-
ity in the public sector was poor (26.3%) compared
to the private sector (57.3%) (10).
A survey of the availability of asthma medicines
listed on the WHO model list of essential medicines
(11) found that, while salbutamol inhalers were
available in 82.4% of private pharmacies, 54.8% of
national procurement centres and 56.3% of public
hospitals, the availability of beclometasone 100 μg
pu inhalers, a cornerstone of the management of
asthma, was much lower (41.7%, 17.5% and 18.8%
respectively) (12).
90
Chapter 9. Global target 9
107
Table 9.1 Mean availability of medicines used for acute and chronic conditions in 40 low- and middle-income
countries
Sector and product type
(number of countries)
Mean availability (%) of medicines
Diff erence (%) in
mean availability
(95% CI)
P
Acute conditions
(95% CI)
Chronic conditions
(95% CI)
Public sector
Generic products (n = 35)
53.5 (46.2–60.8)
36.0 (27.4–40.6)
17.5 (6.5–28.6)
0.001
Private sector
Generic products (n = 40)
66.2 (60.4–72.1)
54.7 (47.6–61.9)
11.5 (2.4–20.6)
0.007
CI: confi dence interval.
Source: see reference (9).
Access to insulin is problematic in many countries,
complicated by the cost of syringes and diagnostic
tools for initial diagnosis and follow-up that are
essential for monitoring and adjusting treatment
(13). Gaps in availability and aff ordability of basic
technologies and medicines are particularly severe
at the primary care level (14) and are major barriers
to implementation of essential NCD interventions.
e results of these studies demonstrate the lower
availability of key NCD medicines in the public
sector. e consequence is that patients are forced to
obtain medicines in the private sector, where prices
are generally higher and may be unaff ordable for
many. WHO/HAI surveys have also addressed the
prices patients must pay for medicines and whether
these are aff ordable (8). e measurement of aff ord-
ability is not straightforward (15). e approach
used in the WHO/HAI surveys is to use the salary
of the lowest-paid unskilled government worker to
establish the number of days’ wages needed to pur-
chase courses of treatment for common conditions.
Because chronic diseases need ongoing treatment,
the aff ordability of a 30-day supply of medicines is
used to indicate monthly medicine expenditures.
Data from WHO/HAI surveys between 2007 and
2012 (8) were used to compare the aff ordability of
two medicines used in managing NCDs – salbu-
tamol inhaler 100 μg per dose for asthma (assum-
ing one inhaler per month) and captopril tablets
for hypertension (assuming 25 mg twice daily per
month). e results (see Fig. 9.2) illustrate wide
variability between studies. If one day’s salary is
deemed a measure of aff ordability of a medicine,
then, in many cases, medicines are unaff ordable.
e situation is o en worse in countries where a
large proportion of the population earns much less
than the lowest-paid government worker.
Monitoring the availability
and aff ordability of
basic technologies and
essential medicines
e indicator for monitoring this target in the
global monitoring framework (see Annex 1) is the
availability and aff ordability of quality safe and e -
cacious essential noncommunicable disease medi-
cines, including generics and basic technologies in
both public and private facilities.
Many countries have already collected ad
hoc facility-based information about prices and
availability, using the WHO/HAI methodology
(8,9). However, assessing progress towards targets
requires regular measurement and the collection
of valid and reliable data.
Routine monitoring systems should be estab-
lished, in order to provide regular facility-based
assessments of the availability of key medicines and
health technologies. ese systems need to provide
information from the public and private sectors
and from urban and rural locations, so that equity
of access to these essential commodities can be
assessed. For routine monitoring to be feasible, data
60
Global status report on NCDs 2014
108
Fig. 9.2 Number of days’ wages needed by the lowest-paid unskilled government worker to pay for 30 days’
treatment for hypertension and asthma, private sector, 2007–2012
Q
Captopril tablets*
Q
Salbutamol inhaler*
Republic of Moldova LPG
Republic of Moldova OB
Afghanistan LPG
Afghanistan OB
United Republic of Tanzania LPG
Iran (Islamic Republic of)
China (e) LPG
China (e) OB
India (d) LPG
Oman LPG
Bolivia (Plurinational State of) OB
Bolivia (Plurinational State of) LPG
Nicaragua LPG
Congo LPG
Congo OB
Mauritius LPG
Mauritius OB
Colombia LPG
Colombia OB
Haiti LPG
Haiti OB
Russian Federation (c) LPG
Russian Federation (c) OB
Ecuador LPG
Ecuador OB
Brazil (b) OB
Mexico (a) LPG
Kyrgyzstan OB
Kyrgyzstan LPG
Indonesia OB
Burkina Faso LPG
Burkina Faso OB
Sao Tomé and Principe OB
Democratic Republic of the Congo LPG
Democratic Republic of the Congo OB
Number of days’ wages**
30
25
20
15
10
5
0
***
35
Source: World Health Organization/Health Action International, using data from medicine price and availability surveys conducted between 2007 and 2012 using
the WHO/HAI methodology (http://www.haiweb.org/medicineprices).
* Captopril 25mg tab x 2/day; Salbutamol 100 mcg/dose inhaler, 200 doses.
** Number of days’ wages needed by the lowest-paid unskilled government worker to pay
*** If one days’ wages of a lowest-paid government worker is deemed as a measure of aff ordability of medicine, then in many cases medicines are unaff ordable.
(a) Rio Grande do Sul State, (b) Tatarstan Province, (c) Delhi (National Capital Territory), (d) Shaanxi Province.
OB=Originator Brand, LPG= Lowest-Priced Generic
90
Chapter 9. Global target 9
109
collection needs to be simple, focusing on a smaller
number of key medicines and adding minimal cost
to the health system. 周 is monitoring is important,
not only to assess progress towards the target of
80% availability, but also to identify potential prob-
lems in procurement and in-country distribution of
medicines and to develop interventions to address
any system failures identi ed.
WHO’s Service Availability and Readiness Assess-
ment (SARA) is another mechanism for assessing the
availability of key medicines and health commodities
(16). 周 is extensive survey uses statistically represen-
tative samples of country health facilities. Analyses
are strati ed by location (urban, rural) and facility
type (dispensary, clinic, health centre, hospital),
allowing detailed assessment of in-country di er-
ences in medicines availability. However, the scope
of SARAs and the large numbers of health facilities
surveyed make these surveys resource intensive and
expensive. To date, SARAs have largely been con-
ducted in Africa and, where SARA data exist, they
should be used to inform decision-making and to
identify areas where interventions are required to
improve access to medicines.
Assessing the a ordability of medicines requires
regular measurement of the prices patients must
pay for medicines in both public and private sec-
tors. A ordability can be computed by using the
daily wage of the lowest-paid unskilled government
worker for each country and the cost of a year’s
supply of medicines. In measuring a ordability,
financing arrangements for medicines in each
country may need to be considered. Some countries
may make medicines freely available in the public
sector or have health insurance systems in place.
周 e out-of-pocket costs for NCD medicines should
be monitored.
It is also important to consider those who are
unable to access care or purchase medicines. House-
hold surveys remain an important tool for under-
standing the sources of care in the community
and the barriers to accessing care and treatments,
including essential NCD medicines and health
technologies. WHO has standardized methods for
conducting household surveys to measure access to
and use of medicines (17).
Actions required
to attain this target
Commitment to this target, and regular public
reporting of progress – regionally, nationally and
globally – will hold governments accountable for
meaningful progress in improving access to, and
affordability of, essential NCD medicines and
health technologies (18).
Health-care fi nancing
Achieving this target requires adequate and sus-
tainable health-care nancing. 周 e ministry of
health has a pivotal role in promoting access to
quality-assured, affordable essential medicines
and should work with the ministry of nance to
secure adequate funding for health care in general,
and essential NCD medicines and technologies in
particular.
Regulatory systems
Strong regulatory systems are necessary to ensure
the availability of quality-assured NCD medicines.
E ective regulatory authority performance requires
an appropriate legislative framework, commitment
to good governance, administrative structures sup-
ported by technical capacity, and political commit-
ment to enforce compliance with established norms
and standards for manufacture, distribution and
supply of medicines and health technologies.
周 e a ordability of NCD medicines for both
government and patients depends heavily on the
use of generic products. Policies that promote the
use of a ordable generic medicines are important,
as is ensuring the quality of generic medicines in
circulation in the country. Quality-assurance sys-
tems and educational campaigns promoting the
use of generic medicines are needed to reassure
prescribers, patients and consumers that low price
does not mean inferior medicines.
Rational selection and use
In addition, there should be rational selection of
cost-e ective NCD essential medicines and tech-
nologies, e cient and e ective procurement and
distribution systems for quality-assured products,
76
Global status report on NCDs 2014
110
and implementation of evidence-based guidelines
to support rational use of these medicines and tech-
nologies at all levels of care. 周 ese essential medi-
cines should be available at the primary health-care
level. While treatment may be initiated at higher
levels of health care, patients need easy access to
these medicines if they are to adhere to long-term
treatment regimens.
E orts to improve the availability of quality-as-
sured products in the market should be supported
by programmes to promote their use. 周 e evi-
dence-based treatment guidelines and protocols for
primary care should be disseminated and imple-
mented (6,19). Relatively little is known of rational
use of medicines and adherence of prescribing to
national treatment protocols in the private sector,
so this is an important area for further research.
While attention o en focuses on procurement, sup-
ply, availability and pricing measures for essential
medicines (supply side), rational use of medicines
is critical to cost-e ective and appropriate use.
Health-care professionals and consumers need
accurate information on medicines. Setting-spe-
ci c studies are required to understand why pre-
scribers and consumers choose particular medi-
cines (demand side) and to assess the adherence of
prescribing practices to evidence-based treatment
guidelines.
Procurement systems and pricing policies
Along with e ective and e cient procurement
systems, pricing policies can promote a ordable
access to treatment. Countries need to consider
regulation of the mark-ups and fees in the pharma-
ceutical supply chain, not only for distributors and
wholesalers but also for retail outlets. Supported by
policies to allow generic substitution, dispensing
fees should encourage the use of low-price generic
medicines. Tax exemptions or reductions can be
considered – particularly for essential medicines
and health technologies – to enhance the a ord-
ability of medicines for consumers (20).
Multi-stakeholder action
Local stakeholders in the pharmaceutical sector
include the pharmaceutical industry, health-care
professionals and civil society. 周 e pharmaceutical
industry has the responsibility to produce and sup-
ply medicines, including those for NCDs, meeting
appropriate standards of quality, promoting use
in line with marketing approval, and providing
balanced and truthful information to health-
care professionals. Health-care professionals have
responsibility for the optimal care of patients and
for judicious use of scarce resources in managing
them. Medicines must be prescribed appropriately,
in accordance with evidence-based treatment pro-
tocols, and the costs of treatments should be con-
sidered. Consumers have a responsibility to use
medicines wisely and in accordance with recom-
mendations from health-care professionals.
In some settings, international stakeholders play
an important role in supporting the strengthening
of country health systems, through strengthening
of drug-manufacturing capacities of countries;
training and strengthening of procurement and
supply systems; monitoring of prices, availability
and a ordability of medicines; and promoting
interventions to improve access. Donations of med-
icines must be appropriate, targeted and consistent
with WHO guidelines. Medicines bene t packages
must include essential NCD medicines. Countries
may require support to develop sustainable nanc-
ing mechanisms, including targeted subsidies or
health insurance systems that ensure a ordable
access to NCD medicines and technologies.
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