Antimicrobial resistance

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Access to essential drugs staggering inequities
- unparalleled opportunities

Jonathan D. Quick, MD, MPH Director, Essential
Drugs and Medicines Policy Health Technology and
Pharmaceuticals Cluster World Health
Organization Presented at SEAM Conference,
Washington, DC 27-29 November 2001
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Access to essential drugs staggering
inequities - unparalleled opportunities
Inequities
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Economic inequity - percent of population below
the poverty line has changed little in 2 decades
Inequities
Source WHO/HFA (1997)
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Health status inequity - infant mortality still
varies 10-fold among regions of the world
Inequities
Source WHO/HFA (1997)
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RD inequity - expenditures grow, new drugs are
launched, few specific for tropical diseases
Inequities

• Between 1975 and 1997 -
• 1,223 new compounds launched
• only 11 for tropical diseases

RD expenditure (US billions - top companies)
New chemical entities launched (number)
Sources D. Gannaway and PriceWaterhouseCoopers
(1999) RD, NCE data P. Trouiller et al (1999)
tropical research data
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Therapeutic inequity - growing resistance is
affecting prevalent infectious diseases

• Malaria
• chloroquine resistance in 81/92 countries
• Tuberculosis
• 2 - 40 primary multi-drug resistance
• Gonorrhoea
• 5 - 98 penicillin resistance in N. gonorrhoeae
• Pneumonia and bacterial meningitis
• 12 - 55 penicillin resistance in S. pneumoniae
• Diarrhoea shigellosis
• 10-90 amp, 5-95 TMP/SMZ resistance

Source DAP, EMC, GTB, CHD (1997)
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Health literacy inequity - information explosion
for some people, information poverty for others
Inequities

• Among high income countries -
• 300 million world-wide internet users by 2000
• 2/3 of users search for health information
• 43 of 700,000 US doctors or their staff browse
  the Web
• 67 of doctors patients have Internet
  information
• Among low and middle income countries -
• available information often under-utilized
• 1/2 of drugs with sufficient information for
  safe, effective use
• only 1/4 of drug packets in Asia contain inserts
• 25-45 of adult women illiterate - over 90 in
  some countries

Source D. Gannaway (1999), World Development
Report (1997), WHO/DAP (1998), WHO/EDM (1999)
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Pharmaceutical care inequity - a 100-fold
variation in pharmacists per million population
Inequities
Source WHO/HST/GSP/94.1 (1994)
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Affordability inequity - number of working hours
to pay full treatment course
Inequities
Based on average worldwide price and national per
capita income. Source WHO/EDM
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Financing inequity - the burden falls heaviest on
those least able to pay
Inequities
Drugs are the largest health expenditure for poor
households

• Inequity in health and pharmaceutical financing
• High income countries 50-90 publicly funded
• Low/middle income countries 50-90
  out-of-pocket

Source Azerbaijan - UNICEF-Bamako Technical
Report No. 35 Bangladesh 1995 - National
Accounts 1996/97 Mali (1986) - Diarra K and
Coulibaly S. Financing of recurrent health costs
in Mali. Health Policy and planning 1990,
5(2)126-138
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Access inequity - financing, delivery, and other
constraints still limit access to essential drugs
Inequities

• 1/3 of worlds population lacks regular access
• 320 million in Africa have lt50
• Problem worsens with economic pressures

Source WHO/DAP (1998)
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People are needlessly suffering and dying - drugs
unavailable, unaffordable, unsafe, or wrongly used
Inequities

• In Africa and S.E.Asia
• 1/2 of deaths among children, young adults due to
  6 diseases
• prompt diagnosis and treatment could save over3
  million lives per year

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Access to essential drugs staggering
inequities - unparalleled opportunities
Inequities
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Ensuring access to essential drugs -
framework for collective action
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Essential drugs concept nearly universal - lists
and guidelines put the concept into practice
? Selection ? Affordability ? Financing ?
Health systems
158 countries with essential drugs lists 90
countries with treatment guidelines 83 countries
with both
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Standard treatment guidelines (STGs) - save lives
when effectively implemented
? Selection ? Affordability ? Financing ?
Health systems
Source WHO/CDS/CSR/DRS/2001.9
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Getting mothers and clinicians to talk- reducing
injection use in Indonesia
? Selection ? Affordability ? Financing ?
Health systems
Source Long-term impact of small group
interventions, Santoso et al., 1996
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Advocacy, corporate responsiveness, competition
have reduced prices 95 in 3 years
? Selection ? Affordability ? Financing ?
Health systems
??
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Competition is highly effective in reducing
prices - the example of antiretrovirals
? Selection ? Affordability ? Financing ?
Health systems
Source UNAIDS, B. Samb, 2000
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Drug benefits in public health insurance - access
and risk-sharing
? Selection ? Affordability ? Financing ?
Health systems
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Global Fund to fight AIDS, Tuberculosis and
Malaria - pledges from May to August 2001
? Selection ? Affordability ? Financing ?
Health systems
1.5 billion
US millions
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Shopkeeper training - helping households get the
best value for their health spending
? Selection ? Affordability ? Financing ?
Health systems
Source Marsh et al, 2001
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Reliable health and supply systems - successful
examples exist in all regions
? Selection ? Affordability ? Financing ?
Health systems
Direct delivery system - privatized, decentralized
Primary distributor system - privatized,
centralized
Autonomous medical stores - partly private,
centralized
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India - state essential drugs programmes
developed through an NGO
? Selection ? Affordability ? Financing ?
Health systems
Himachal Pradesh
Punjab

• Components
• State drug policy
• Essential drugs lists by level of care
• Pooled procurement
• Efficient distribution
• Quality assurance
• Information--patients prescribers
• Training in rational prescribing
• Studies on drug use, pharmacoeconomics

Haryana
Delhi State
Rajasthan
Bihar
Madhya Pradesh
Gujarat
West Bengal
Maharashtra
Andhra Pradesh
Goa
13 states - total population 580 million
Tamil Nadu
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Conclusion
Staggering inequities exist - in income, health
status, RD, pharmaceutical care, and access
Unparalleled opportunities exist - to build on
local successes to expand access for those in
need
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