Quantifying the Impoverishing Effects of Purchasing Medicines: A Cross-Country Comparison of the Affordability of Medicines in the Developing World

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1 Quntifying the Impoverishing Effects of Purchsing Medicines: A Cross-Country Comprison of the Affordbility of Medicines in the Developing World Lurens M. Niëns 1 *, Alexndr Cmeron 2, Ellen Vn de Poel 1, Mrgret Ewen 3, Werner B. F. Brouwer 1, Richrd Ling 2 1 Institute for Medicl Technology Assessment nd Institute for Helth Policy & Mngement, Ersmus University Rotterdm, The Netherlnds, 2 Essentil Medicines nd Phrmceuticl Policies, World Helth Orgniztion, Genev, Switzerlnd, 3 Helth Action Interntionl Globl, Amsterdm, The Netherlnds Abstrct Bckground: Incresing ttention is being pid to the ffordbility of medicines in low- nd middle-income countries (LICs nd MICs) where medicines re often highly priced in reltion to income levels. The impoverishing effect of medicine purchses cn be estimted by determining pre- nd postpyment incomes, which re then compred to poverty line. Here we estimte the impoverishing effects of four medicines in 16 LICs nd MICs using the impoverishment method s metric of ffordbility. Methods nd Findings: Affordbility ws ssessed in terms of the proportion of the popultion being pushed below US$1.25 or US$2 per dy poverty levels becuse of the purchse of medicines. The prices of slbutmol 100 mcg/dose inhler, glibenclmide 5 mg cp/tb, tenolol 50 mg cp/tb, nd moxicillin 250 mg cp/tb were obtined from fcilitybsed surveys undertken using stndrd mesurement methodology. The World Bnk s World Development Indictors provided household expenditure dt nd informtion on income distributions. In the countries studied, purchsing these medicines would impoverish lrge portions of the popultion (up to 86%). Origintor brnd products were less ffordble thn the lowest-priced generic equivlents. In the Philippines, for exmple, origintor brnd tenolol would push n dditionl 22% of the popultion below US$1.25 per dy, wheres for the lowest priced generic equivlent this demogrphic shift is 7%. Given relted prevlence figures, substntil numbers of people re ffected by the unffordbility of medicines. Conclusions: Compring medicine prices to vilble income in LICs nd MICs shows tht medicine purchses by individuls in those countries could led to the impoverishment of lrge numbers of people. Action is needed to improve medicine ffordbility, such s promoting the use of qulity ssured, low-priced generics, nd estblishing helth insurnce systems. Plese see lter in the rticle for the Editors Summry. Cittion: Niëns LM, Cmeron A, Vn de Poel E, Ewen M, Brouwer WBF, et l. (2010) Quntifying the Impoverishing Effects of Purchsing Medicines: A Cross- Country Comprison of the Affordbility of Medicines in the Developing World. PLoS Med 7(8): e doi: /journl.pmed Acdemic Editor: Joshu A. Slomon, Hrvrd School of Public Helth, United Sttes of Americ Received Mrch 10, 2010; Accepted July 23, 2010; Published August 31, 2010 Copyright: ß 2010 Niëns et l. This is n open-ccess rticle distributed under the terms of the Cretive Commons Attribution License, which permits unrestricted use, distribution, nd reproduction in ny medium, provided the originl uthor nd source re credited. Funding: No direct funding ws received for this study. The uthors were personlly slried by their institutions during the period of writing (though no specific slry ws set side or given for the writing of this pper). Competing Interests: The uthors hve declred tht no competing interests exist. Abbrevitions: EIU, Economist Intelligence Unit; GDP, gross domestic product; HAI, Helth Action Interntionl; HHFCE, household finl consumption expenditure; LIC, low-income country; LPG, lowest priced generic; LPGW, lowest pid government worker; MIC, middle-income country; OB, origintor brnd; WDI, world development indictor; WHO, World Helth Orgniztion * E-mil: niens@bmg.eur.nl PLoS Medicine 1 August 2010 Volume 7 Issue 8 e

2 Introduction In developing countries the cost of medicines ccounts for reltively lrge portion of totl helthcre costs [1 4]. As the mjority of people in developing countries do not hve helth insurnce [5] nd medicines provided free through the public sector re often unvilble [4], medicines re often pid for out of pocket t the time of illness. Consequently, where medicine prices re high, people my be unble to procure them nd therefore forego tretment or they my go into debt. For this reson, the World Helth Orgniztion (WHO) hs designted ffordble prices s determinnt of ccess to medicines (together with rtionl selection nd use, sustinble finncing, nd relible helth nd supply systems) [6]. In severl interntionl treties, ccess to helthcre hs been estblished s right [7,8]. Sttes hve legl obligtion to mke essentil medicines vilble to those who need them t n ffordble cost. Determining the degree of ffordbility of medicines, especilly in low- nd middleincome countries (LICs nd MICs), is n importnt, yet complex undertking s ffordbility is vgue concept. Medicine ffordbility hs been investigted in terms of the dys wges tht country s lowest pid unskilled government worker (LPGW) needs to spend on stndrd course of tretment [4,9]. However, this metric is limited becuse it does not provide insight into the ffordbility of medicines for the often lrge sections of the popultion tht ern less thn the LPGW [4,10]. Recently, Niëns et l. hve proposed two lterntive methods to gin insight into the ffordbility of medicines in the developing world [11]. A first method focuses on the ctstrophic impct of expenditures on medicines, while the second pproch consists of studying the impoverishing effect of these expenditures. Here we discuss the ppliction of the ltter pproch nd present the results of cross-country nlysis of the ffordbility of four medicines in 16 developing countries. Methods Our mesurement of the ffordbility of medicines is bsed on the pproch tken by Vn Doorsler et l. [3], who ressessed poverty estimtes in 11 Asin countries fter tking into ccount household expenditures on helth cre. The impoverishment pproch hs lso been used in other fields of study such s housing ffordbility [12,13] nd helth insurnce [14]. The impoverishing effect of medicine is defined in terms of the percentge of the popultion tht would be pushed below n income level of US$1.25 or US$2 per dy when hving to purchse the medicine. Although different income levels hve been used/proposed [3,15], the US$1.25 nd US$2 poverty lines were chosen becuse they re the most recent widely recognized poverty indictors s used by the World Bnk [16]. Thus, the pproch essentilly compres households dily per cpit income before nd fter (the hypotheticl) procurement of medicine. If the prepyment income is bove the US$1.25 (or US$2) poverty line nd the postpyment income flls below these lines, purchsing the medicine impoverishes people. We used this method to generte impoverishment rtes, which denote the percentge of the popultion tht would become impoverished. The unffordbility of medicine then refers to the percentge of the popultion tht either lredy is or would fll below the poverty line when hving to procure the medicine. First we consider the ffordbility of medicines in the totl popultion t risk of becoming ill. We lso indicte, using prevlence rtes for the three chronic diseses, the expected number of ptients ctully ffected. Dt To conduct the first nlysis, three types of dt were required per country: medicine prices, ggregted income dt, nd informtion on the income distribution. In clculting expected numbers of ptients ffected, prevlence dt re lso required. Medicine prices were tken from stndrdized surveys using the WHO/Helth Action Interntionl (HAI) price mesurement methodology, which report medin ptient prices for selection of commonly used medicines in the privte sector, for both origintor brnd (OB) nd lowest priced generic (LPG) products [17]. We focused on the privte sector becuse the vilbility of essentil medicines in the public sector is much lower [4]. In the countries studied here, therefore, mny people will depend on the privte sector for their medicines. The World Bnk s World Development Indictors (WDIs) provided Household Finl Consumption Expenditure (HHFCE) dt nd informtion on income distribution [18]. Although WDIs hve shortcomings (highlighted in the Discussion section), they hve the dvntge of being vilble for wide rnge of countries. Moreover, in this context commonly used household surveys re often not vilble on yerly bsis nd re not conducted in stndrdized wy, limiting the comprbility of results cross countries nd over time [3,19]. Here we use n ffordbility mesure tht cn be quite esily pplied in LICs nd MICs where the use of more detiled household survey dt my be limited. HHFCE ws selected s n ggregte income mesure rther thn gross domestic product (GDP) per cpit s it better reflects households resources [19], while GDP lso includes consumption, gross investment, nd net trde. Becuse the WDI did not provide ny informtion on HHFCE for Nigeri nd Yemen, the Economist Intelligence Unit (EIU) nominl privte consumption figure ws used for these countries [20]. For simplicity, we refer to income s mesured by HHFCE or nominl privte consumption. Aprt from verge income, the WDIs lso provide some informtion on country s income distribution by listing the proportion of totl income erned in seven income groups; five income quintiles, with the poorest nd richest quintiles split into deciles. At the time of nlysis, medicine price surveys were vilble for 53 countries. In lrge countries such s Indi nd Chin, price surveys were crried out on stte or provincil level [4]. Becuse the WDIs do not provide stte-level income distributions, HHFCE, nd popultion figures, these countries were excluded from the current study. To ensure cross-country comprbility, the nlysis ws limited to countries where income distributions (WDI dt) were vilble from the yer 2000 onwrds. We used WDI income dt from the sme yer s the WHO/HAI price dt. Dt on income distributions for the sme yer were used when possible, if not, the most recent income distribution dt prior to the yer of the price nd income dt were used. Tble 1 provides n overview of ll countries nd dt used in this study. When discussing results, countries were grouped into LICs nd MICs ccording to the 2008 World Bnk s clssifiction [21]. Sixteen countries were selected on the bsis of the vilbility of WHO/HAI dt. They re not representtive of the developing world s whole. However, s these countries vry substntilly in terms of economic development, helth cre infrstructure, nd medicine prices, they provide n interesting smple to study ffordbility of medicines. We selected four medicines for which price dt were vilble for the mjority of countries nd for which tretment regimens re reltively stndrd cross countries. While these my not led to results tht re in strict sense generlisble, they provide vluble PLoS Medicine 2 August 2010 Volume 7 Issue 8 e

3 Tble 1. Overview of countries studied nd yers of dt sources used. Countries Medicine Price Survey nd WDI Income Dt WDI Dt on Income Distribution LIC Kyrgyzstn Mli Nigeri Pkistn Tjikistn Tnzni Ugnd Uzbekistn Yemen MIC El Slvdor Indonesi Jordn Mongoli Peru Philippines Tunisi Nominl privte consumption from EIU ws used. doi: /journl.pmed t001 insight into the ffordbility of common medicines in the selected countries. Tble 2 lists the medicine, the ill helth conditions for which these medicines re used, the totl number of units per tretment course, nd the tretment durtion in dys [17]. Three of the four study medicines re used to tret chronic conditions (sthm, dibetes, nd hypertension). For ech of these, we lso clculted the expected numbers of ptients becoming impoverished, using the prevlence dt shown in Tble S1. We could not do this for dult respirtory infection becuse of unvilbility of comprble prevlence dt. The emphsis on medicines for chronic disese is justified by the fct tht these conditions require ongoing, usully lifelong expenditures, mking it more difficult for households to use finncing strtegies like borrowing nd selling ssets [22]. Tble 2 shows tht the tretment durtion for these medicines ws set t 30 d to represent the monthly tretment costs. The ffordbility of one cute condition (dult respirtory infection) treted with 7-d tretment course of moxicillin ws lso studied. Recently, the WHO incresed the guidelines for tretment of dult respirtory infection with moxicillin to dily regimen of three times 500 mg moxicillin. This chnge implies tht the ffordbility of this medicine is likely to be lower thn reported here [23]. Clcultion Methods Our method of estimting the impoverishing effect of procuring medicines ws bsed on the method used by Vn Doorsler et l. [3]. However, using ggregte dt requires some simplifying ssumptions bout the income distribution cross popultion groups. For detiled discussion of the method used to clculte the impoverishing effect of medicines, we refer to Niëns et l. [11]. The bsic ide is to compre poverty estimtes before nd fter (potentil) purchse of the medicines listed in Tble 1. Averge per cpit income within ech income group is estimted by combining informtion on the proportion of totl income erned cross income groups with dt on the HHFCE (s provided by the WDIs). As only dt on verge income in the different quintiles nd deciles were vilble, we ssumed linerity of the income distribution within these relevnt groups in which the US$1.25 nd US$2 poverty lines were locted in clculting poverty nd impoverishment. The proportion of the popultion tht would ern less thn US$1.25 or US$2 per dy fter buying medicine but not before would therefore be impoverished becuse of purchsing medicines. The medicine is deemed ffordble for the proportion of the popultion tht would remin bove the Tble 2. Description of studied medicines. Medicine Nme Ill Helth Condition Medicine Strength per Dose Totl n of Doses per Tretment Dosge Form Tretment Durtion (d) Slbutmol inhler Asthm 100 mcg 200 Inhler 30 (1 inhler) Glibenclmide Dibetes 5 mg 60 Cpsule/tblet 30 Atenolol Hypertension 50 mg 30 Cpsule/tblet 30 Amoxicillin Adult Respirtory Infection 250 mg 21 Cpsule/tblet 7 doi: /journl.pmed t002 PLoS Medicine 3 August 2010 Volume 7 Issue 8 e

4 Tble 3. Percentge of the popultion below the poverty line before procurement of the medicines nd the popultion drwn below the poverty line by expenditures on these medicines. Percent of Popultion below Poverty Lines nd LPGW Wge, before Medicine Purchse Percent of Popultion below Poverty Line fter Medicine Purchse Slbutmol Inhler Glibenclmide Atenolol Amoxicillin Country GDP/Cp (Current US$) b US$1.25 US$2 LPGW wge US$1.25 US$2 US$1.25 US$2 US$1.25 US$2 US$1.25 US$2 OB LPG OB LPG OB LPG OB LPG OB LPG OB LPG OB LPG OB LPG LIC Kyrgyzstn Mli Nigeri Pkistn Tjikistn Tnzni Ugnd Uzbekistn Yemen MIC El Slvdor 3, Indonesi 1, Jordn 2, Mongoli Peru 2, Philippines 1, Tunisi 2, The sum of both gives the proportion of the popultion for which the medicine is unffordble. No relible medicine price estimte ws possible due to lck of dt. b Source: WDI [18]. doi: /journl.pmed t003 PLoS Medicine 4 August 2010 Volume 7 Issue 8 e

5 poverty line fter hving purchsed it. We lso estimted the ctul number of ptients with one of the three chronic illnesses for which the medicine is unffordble. To mke this estimtion, we used prevlence rtes from vrious dt sources nd gin ssume tht the respective disese is evenly spred over the income distribution. Becuse HHFCE is mesured in current US$, we reclculted the US$1.25 nd US$2 poverty lines to US$ vlues for the HAI/ WHO survey yer. HAI/WHO medicine prices were expressed in US$ for the sme yer. Results Tble 3 presents the percentges of the popultion tht re pushed below the poverty line owing to the purchsing of ech of the four study medicines, both LPG nd OB products. For ech country, Tble 3 first highlights the proportion of the popultion lredy below the US$1.25 nd US$2 poverty lines without purchsing these medicines. These poverty estimtes correlte highly with the commonly used (household-survey bsed) estimtes from the United Ntions Development Progrm with Person correltion coefficients [24] equl to 0.90 for the proportion of the popultion below the US$1.25 poverty line, nd 0.86 for the proportion below the US$2 poverty line. Tble 3 lso shows the proportion of the popultion erning less thn the LPGW, which vries widely cross countries; from only 1% in Tjikistn to 96% in Tnzni. This cross-country vribility represents one of the limittions of the LPGW metric s used by the WHO/HAI methodology [9]. Compring the proportion of the popultion below the US$1.25 nd US$2 poverty lines before nd fter procurement of medicines gives insight into the impoverishing effect of medicine procurement. By dding the proportion of the popultion lredy living below the US$1.25 nd US$2 poverty lines to the group tht would fll below these poverty lines when procuring the medicines, we get the proportion of the popultion for which the four medicines re unffordble. The results in Tble 3 illustrte tht the impoverishing effect of medicines vries substntilly between OB nd LPG products. For exmple in Yemen, LIC where 7% of the popultion lives on prepyment income of less thn US$1.25 dy, OB glibenclmide purchsed in the privte sector would impoverish n dditionl 22% of the popultion versus 3% for the LPG equivlent. In Nigeri, LIC where 56% of the popultion lives below US$1.25 per dy, purchsing moxicillin from the privte sector would impoverish n dditionl 23% if the OB is bought nd 12% if buying the LPG. Rther thn showing proportions of the popultion, Tble 4 presents both the bsolute number of individuls tht would be pushed into poverty owing to the cost of buying medicines from the privte sector ( Impoverished column) nd the number of people for which medicines re unffordble ( Unffordble column). Besides bsolute figures, in Tble 5 we present the reltive chnge of the poverty estimtes for the totl popultion studied s well s for the ptient popultion. So, if 40% of the popultion is initilly bove the poverty line, while only 30% would remin bove fter purchsing medicines, this proportion is 25% (10% out of 40% re impoverished). These numbers re listed for ll four medicines, both OB nd LPG. The totl popultion of the 16 countries nlyzed mounts to over 775 million people, of which pproximtely 126 million live on less thn US$1.25 nd 209 million on less thn US$2 per dy, respectively. Tble 4 illustrtes tht cross this set of 16 developing countries, for respectively lmost one-fourth nd two-fifths of the Tble 4. Absolute impoverishment nd unffordbility estimtes of medicines procured in the privte sector for the totl nd chronic ptient popultions cross 16 countries (rounded to millions). Medicine Under US$1.25 Under US$2 OB LPG OB LPG Impoverished Unffordble Impoverished Unffordble Impoverished Unffordble Impoverished Unffordble Totl Popultion Slbutmol inhler Glibenclmide Atenolol Amoxicillin Chronic Ptient Popultion Slbutmol inhler Glibenclmide Atenolol Impoverished, the number of people tht would be pushed below the US$1.25 nd US$2 poverty lines if the totl popultion hd to buy the respective medicine. Unffordble, the totl number of people for which the respective medicine cn be considered unffordble. doi: /journl.pmed t004 PLoS Medicine 5 August 2010 Volume 7 Issue 8 e

6 Tble 5. The reltive chnge of the poverty estimtes (i.e., the impoverished popultion expressed s proportion of the popultion initilly bove the poverty line). Medicine Additionl Percentge under US$1.25 Additionl Percentge under US$2 OB LPG OB LPG Totl Popultion Slbutmol inhler Glibenclmide Atenolol Amoxicillin Chronic Ptient Popultion Slbutmol inhler Glibenclmide Atenolol doi: /journl.pmed t005 totl popultion, essentil medicines re unffordble using the US$1.25 nd US$2 poverty line. The upper hlf of Tble 4 shows the proportions of the totl popultion for which medicines would be unffordble when hving to procure them. The ctul number of people ffected by this unffordbility (in terms of experiencing the disese) depends on the prevlence of diseses s well. Therefore, the lower hlf of Tble 4 lso shows the expected bsolute number of ptients ffected by the unffordbility of medicines using the prevlence rtes listed in Tble S1. As the prevlence rtes of hypertension re substntilly higher thn those of sthm nd dibetes, the impoverishing effect, nd therefore lso the unffordbility, of tenolol is substntilly higher thn tht for the other medicines. In this pproch, given the height nd distribution of income, impoverishment is determined by both medicine prices nd prevlence rtes for the relevnt diseses. Discussion The results illustrte tht substntil proportions of the popultion would be pushed into poverty s result of medicine procurement, implying tht in mny countries ffordbility of these tretments is low. In the privte sector, LPGs were generlly substntilly more ffordble thn OB products. Thus, incresing the use of qulity-ssured generics could reduce the impoverishing effect of medicines. This use of generics, in turn, could bring bout improvements in the helth sttus of these popultions by voiding low complince to recommended dosges or durtion of tretment, resulting in problems such s sustined hypertension, elevted blood glucose levels, or the promotion of bcteril resistnce due to too short courses of ntibiotics. Our clcultion method hs the dvntge of llowing for comprisons of medicine-induced impoverishment cross time nd cross countries using widely vilble ggregte dt. The method, therefore, is useful nd generlisble for studying the ffordbility of wide rnge of goods nd helth cre services. The use of such dt lso brings some limittions, which re discussed in further detil in Niëns et l. [11]. First, dividing HHFCE by totl popultion to get n estimte of income per cpit ssumes tht ech household is the sme size. However, poor households re generlly lrger thn their richer counterprts [25]. This discrepncy cuses the verge income per cpit to be overestimted in the lower income groups, mking our ffordbility estimtes rther conservtive. Second, the ssumption of linerity of the income distribution between income groups is lso likely to led to n overestimtion of verge incomes cross the income distribution nd therefore to downwrd bis in our results. We lso ssumed liner distribution of illness over the income distribution to clculte expected numbers of ffected people. Although, in generl, disese my be more prevlent in low income groups, which would imply conservtive estimtes of unffordbility, this lso depends on the exct diseses studied. Moreover, it is cler tht considering only medicine costs, for four medicines independently, merely demonstrtes the lrger problem of medicine nd helth cre ffordbility. The tretment of chronic conditions often requires combintion of medicines nd is therefore likely to be even more unffordble thn wht is reported here [4]. For chronic sthm ptients, for exmple, pproprite mngement of their disese requires use of both slbutmol nd beclometsone inhlers for tretment nd prevention [17]. Due to the lck of vilble price informtion on beclometsone inhlers (becuse of poor vilbility), it ws not possible to include this medicine in the nlysis. As such, the true ffordbility of sthm tretment is likely to be lower thn reported in Tbles 3 nd 4. Hving sid this, the medicines studied in this pper re commonly used to tret ill helth conditions from which considerble proportions of the popultion in the developing world suffer, s is lso illustrted in Tble S1 [26]. As such, low ffordbility of these medicines is likely to signl more generl problem of low ffordbility of medicines in LIC nd MIC. Further, it should be noted tht comprbility of impoverishment rtes for cute nd chronic conditions my be limited. If people suffer from n dult respirtory infection, on verge three times per yer, nd re ble to shift resources over time, the impoverishment rtes for moxicillin should be interpreted with cution. Further reserch is needed on this issue, for exmple by clculting ffordbility for stndrdized time periods tking into ccount the relevnt incidence rtes of respirtory infections. Notwithstnding these limittions, this study provides useful insights into the ffordbility of these four medicines in the developing world. When medicine prices re known, the methods used, s they rely on esily obtinble ggregted dt, cn be used to compre ffordbility of medicines cross countries nd over time. Clerly, medicines represent only prt of the costs ssocited with the mngement of n illness. Other costs, such s for dignostics, physicin consulttions, trnsport costs to clinics, lost work time, etc., plce n dditionl burden on household finnces in developing countries. However, given the reltively lrge shre of helth cre costs for medicines in developing PLoS Medicine 6 August 2010 Volume 7 Issue 8 e

7 countries [1 4], medicine ffordbility is likely to be n importnt determinnt to ccess to tretment. This study shows high medicine costs cn push lrge groups of ptients into poverty. These results cll for ction, both by governments, civil society orgniztions, nd others, to mke ccess to essentil medicines priority, nd not only to ensure ccess to necessry medicines, but lso s component in the context of reducing poverty. Possible lines of ction include developing, implementing, nd enforcing sound ntionl nd interntionl price policies. In the short term these policies could encompss, for exmple, restrictions on supply chin mrk-ups, tx exemptions, nd regulting prices for end-users. Promoting the use of qulity-ssured, low-cost generics, for exmple, through preferentil registrtion procedures, is lso n importnt strtegy [4]. In the public sector, ensuring vilbility of essentil medicines t little or no chrge to the poor is criticl. In the longer term, estblishing helth insurnce systems with outptient medicine benefits seems crucil to void poverty due to helth shocks (nd poor helth due to poverty). Innovtive pproches, such s using privte distribution systems to supply subsidized medicines to chronic disese ptients, should lso be considered. For medicines tht re still subject to ptent restrictions, phrmceuticl compnies should be encourged to differentilly price these products, s is the cse with ntiretrovirls [27]. Countries lso hve the option of using compulsory licensing to oblige ptent holders to grnt its use to the stte or others [28], s ws recently done by Thilnd [29,30]. When resources re limited, those in gretest need, such s people suffering from chronic disese who ern less thn US$1.25 per dy, should benefit from stte nd/or donor ctions. The price References 1. World Helth Orgniztion (2000) Globl comprtive phrmceuticl expenditures with relted reference informtion. Helth Economics nd Drugs EDM Series No. 3. Genev: World Helth Orgniztion. 2. World Helth Orgniztion (2004) WHO medicines strtegy countries t the core. Avilble: medicinedocs/pdf/s5416e/s5416e.pdf Accessed 28 April vn Doorsler E, O Donnell O, Rnnn-Eliy RP, Somnthn A, Adhikri SR, et l. (2006) Effect of pyments for helth cre on poverty estimtes in 11 countries in Asi: n nlysis of household survey dt. Lncet 368: Cmeron A, Ewen M, Ross-Degnn D, Bll D, Ling R (2009) Medicine prices, vilbility, nd ffordbility in 36 developing nd middle-income countries: secondry nlysis. Lncet 373: Dror DM, Preker AS, Jkb M (2002) The role of communities in combting socil exclusion. Dror DM, Preker AS, eds. Socil reinsurnce - new pproch to sustinble community helth finncing. Wshington (D.C.); Genev: The World Bnk Group nd the Interntionl Lbour Office. 6. World Helth Orgniztion (2008) Access to medicines. Avilble: who.int/trde/glossry/story002/en/ Accessed 22 April United Ntions (1948) The universl declrtion of humn rights, rticle 25. Avilble: Accessed 22 April United Ntions (1966) Interntionl covennt on economic, socil nd culturl rights, rticle 12. Genev. Avilble: _cescr.htm. Accessed 22 April World Helth Orgniztion, Helth Action Interntionl (2008) Mesuring medicine prices, vilbility, ffordbility nd price components 2nd edition. Genev: World Helth Orgniztion. 10. Niëns LM, Brouwer WB (2009) Better mesures of ffordbility required. Lncet 373: uthor reply Niëns LM, Vn de Poel E, Cmeron A, Ewen M, Ling R, et l. (2009) Prcticl mesurement of ffordbility: n ppliction to medicines. Rotterdm: Institute of Helth Policy nd Mngement, Ersmus University, Working Pper W Hncock KE (1993) Cn py? won t py? or economic principles of Affordbility. Urbn Stud 30: Kutty NK (2005) A new mesure of housing ffordbility: estimtes nd nlyticl results. Hous Policy Debte 16: Bundorf MK, Puly MV (2006) Is helth insurnce ffordble for the uninsured? J Helth Econ 25: in terms of helth losses due to unffordble medicines is something we cnnot fford. Supporting Informtion Alterntive Lnguge Abstrct S1 Abstrct trnslted into French by Ellen Vn de Poel nd Gbriel Flores. Found t: doi: /journl.pmed s001 (0.02 MB DOC) Alterntive Lnguge Abstrct S2 Abstrct trnslted into Spnish by Lurens M. Niëns nd Isc Corro Rmos. Found t: doi: /journl.pmed s002 (0.02 MB DOC) Tble S1 The prevlence of three chronic diseses. Found t: doi: /journl.pmed s003 (0.05 MB DOC) Acknowledgments We would like to thnk Dele Abegunde for his criticl review of the mnuscript nd Eddy Vn Doorsler nd Frns Rutten for their useful ides on this topic. Author Contributions ICMJE criteri for uthorship red nd met: LMN AC EvdP ME WBFB RL. Agree with the mnuscript s results nd conclusions: LMN AC EvdP ME WBFB RL. Designed the experiments/the study: LMN AC WBFB RL. Anlyzed the dt: LMN AC ME. Collected dt/did experiments for the study: LMN. Wrote the first drft of the pper: LMN. Contributed to the writing of the pper: LMN AC EvdP ME WBFB RL. 15. Chen S, Rvllion M (2008) The developing world is poorer thn we thought, but no less successful in the fight ginst poverty. Wshington (D.C.): Development Reserch Group, The World Bnk Group. 16. The World Bnk Group. Avilble: Accessed 10 Jnury Helth Action Interntionl. Medicine prices. Avilble: org/medicineprices/. Accessed 5 Mrch The World Bnk Group. World development indictors. Avilble: publictions.worldbnk.org/wdi/. Accessed 12 Mrch O Donnell O, vn Doorsler E, Wgstff A, Lindelow M (2008) Anlyzing helth equity using household survey dt A guide to techniques nd their implementtion. Wshington (D.C.): The World Bnk Group. 20. The Economist. The economist intelligence unit. Avilble: com/. Accessed 2 April The World Bnk Group. Country groups. Avilble: D7SN0B8YU0. Accessed 16 Mrch Flores G, Krishnkumr J, O Donnell O, vn Doorsler E (2008) Coping with helth-cre costs: implictions for the mesurement of ctstrophic expenditures nd poverty. Helth Econ 17: World Helth Orgniztion (2008) WHO model formulry. Avilble: Accessed 27 August United Ntions Development Progrm (2008) Humn development report 2007/ Avilble: Accessed 19 Februry Lipton M, Rvillon M (1994) Povert nd policy. Behrmn J, Srinivsn TN, eds. Hndbook of development economics. Amsterdm: Elsevier. 26. World Helth Orgniztion (2004) Globl burden of disese updte. Avilble: updte/en/index.html. Accessed 12 Februry Wning B, Kpln W, King AC, Lwrence DA, Leufkens HG (2009) Globl strtegies to reduce the price of ntiretrovirl medicines: evidence from trnsctionl dtbses. Bull World Helth Orgn 87: World Helth Orgniztion (2006) Public helth innovtion nd intellectul property rights. report of the commission on intellectul property rights, innovtion, nd public helth. Genev: World Helth Orgniztion. 29. Seim L (2007) Thilnd: government issues compulsory licences for HIV/AIDS drugs. HIV AIDS Policy Lw Rev 12: Ford N, Wilson D, Cost Chves G, Lotrowsk M, Kijtiwtchkul K (2007) Sustining ccess to ntiretrovirl therpy in the less-developed world: lessons from brzil nd Thilnd. AIDS (London) 21: S21 S29. PLoS Medicine 7 August 2010 Volume 7 Issue 8 e

8 Editors Summry Bckground In recent yers, the interntionl community hs prioritized ccess to essentil medicines, which hs required focusing on the ccessibility, vilbility, qulity, nd ffordbility of life-sving medicines nd the development of pproprite dt nd reserch gends to mesure these components. Determining the degree of ffordbility of medicines, especilly in low- nd middleincome countries, is complex process s the term ffordbility is vgue. However, the cost of medicines is mjor public helth issue, especilly s the mjority of people in developing countries do not hve helth insurnce nd medicines freely provided through the public sector re often unvilble. Therefore, lthough countries hve legl obligtion to mke essentil medicines vilble to those who need them t n ffordble cost, poor people often hve to py for the medicines tht they need when they re ill. Consequently, where medicine prices re high, people my hve to forego tretment or they my go into debt if they decide to buy the necessry medicines. Why Ws This Study Done? The reserchers wnted to show the impct of the cost of medicines on poorer popultions by undertking n nlysis tht quntified the proportion of people who would be pushed into poverty (n income level of US$1.25 or US$2 dy) becuse their only option is to py out-of-pocket expenses for the life-sving medicines they need. The reserchers referred to this consequence s the impoverishing effect of medicine. Wht Did the Reserchers Do nd Find? The reserchers generted impoverishment rtes of four medicines in 16 low- nd middle-income countries by compring households dily per cpit income before nd fter (the hypotheticl) purchse of one of the following: slbutmol 100 mcg/dose inhler, glibenclmide 5 mg cp/tb, tenolol 50 mg cp/tb, nd moxicillin 250 mg cp/tb. This selection of drugs covers the tretment/mngement of three chronic diseses nd one cute illness. The cost of ech medicine ws tken from stndrdized surveys, which report medin ptient prices for selection of commonly used medicines in the privte sector (the vilbility of essentil medicines in the public sector is much lower so mny people will depend on the privte sector for their medicines) for both origintor brnd nd lowest priced generic products. If the prepyment income ws bove the US$1.25 (or US$2) poverty line nd the postpyment income fell below these lines, purchsing these medicines t current prices impoverishes people. According to the results of this nlysis, substntil proportion (up to 86%) of the popultion in the countries studied would be pushed into poverty s result of purchsing one of the four selected medicines. Furthermore, the lowest priced generic versions of ech medicine were generlly substntilly more ffordble thn origintor brnd products. For exmple, in the Philippines, purchsing origintor brnd tenolol would push n dditionl 22% of the popultion below US$1.25 per dy compred to 7% if the lowest priced generic equivlent ws bought insted. In effect, purchsing essentil medicines for both chronic nd cute conditions could impoverish lrge numbers of people, especilly if origintor brnd products re bought. Wht Do These Findings Men? Although the purchsing of medicines represents only prt of the costs ssocited with the mngement of n illness, it is cler tht the high cost of medicines hve ctstrophic effects on poor people. In ddition, s the tretment of chronic conditions often requires combintion of medicines, the cost of treting nd mnging chronic condition such s sthm, dibetes, nd crdiovsculr disese is likely to be even more unffordble thn wht is reported in this study. Therefore concerted ction is urgently required to improve medicine ffordbility nd prevent poor popultions from being pushed further into poverty. Such ction could include: governments, civil society orgniztions, nd others mking ccess to essentil medicines more of priority nd to consider this strtegy s n integrl prt of reducing poverty; the development, implementtion, nd enforcement of sound ntionl nd interntionl price policies; ctively promoting the use of qulity ssured, low-cost generic drugs; ensuring the vilbility of essentil medicines in the public sector t little or no chrge to poor people; estblishing helth insurnce systems with outptient medicine benefits; encourging phrmceuticl compnies to differentilly price medicines tht re still subject to ptent restrictions. Additionl Informtion. Plese ccess these Web sites vi the online version of this summry t /journl.pmed N For comprehensive resource for medicine prices, vilbility, nd ffordbility, see Helth Action Interntionl N Guidelines bout ccess to essentil medicines nd phrmceuticl policies cn be found t WHO N Trnsprency Allince provides more informtion bout medicines N Access to essentil medicines hs become key cmpign topic; for more informtion see Médecins Sns Frontières (Doctors without Borders) PLoS Medicine 8 August 2010 Volume 7 Issue 8 e