financing essential medicines in low- and middle-income countries: cameroon case study

WHO/EMP TBS| 02 November 20111 |1

Financing Essential Medicines in Low- and Middle-income

Countries: Cameroon Case Study

Financing Essential Medicines in Low- and Middle-income

Countries: Cameroon Case Study

Dr Dele Abegunde (MAR)

&

Mrs Helen Tata (MCP/MAR)


Inequalities (or inequities) access to medicines: growing with needs

Inequalities (or inequities) access to medicines: growing with needs

Access to pharmaceuticals essential to healthcare 25 -70% of health spending in the developing countries, 10-18% in OECD countries

Marginal cost of consumption at point of need: for most consumers in the developing countries is way greater than zero.

Less that 3% of population in low-income countries have some forms of insurance cover

Total pharmaceutical expenditure: 0.2 – 3.8% of GDP

TPE / Total Health expenditure: 25 – 36% OECD countries. Likely higher in LIMC countries?

Share of TPE from external sources increased from 12% in 2000 to 17% in 2006 in LMIC, 22% in the 49 least developed countries.


Inequality in access = poor access to medicinesInequality in access = poor access to medicines

80% global TPE spent on 18% of population: May suggest regressive global financing scenario

Medicines financing remain regressive in LMIC: Medicines are largely financed through OOP – only about 3% have access to some forms of insurance mechanism

Market failures justify public intervention:global economic recession threatening to dry up traditional funding sources


Dimensions to medicines financingDimensions to medicines financing

Providers (Supply of medicines)–National governments–Collaborating & Development partners (NGOs) –Health care systems and direct provides

Consumers (Demand for medicines)–General needs consumers–Special needs consumers

Nearly all the global financing efforts to increase access to medicines is actively focused on Supply of medicines


Government health expenditure (as source) is Increasing Government health expenditure (as source) is Increasing


Official Development Assistance (ODA) and Health ODAOfficial Development Assistance (ODA) and Health ODA

Source: OECD

Official Development Assistance (ODA) for Health, Bilateral and Multilateral flows[ in constant 2006 US$ billions]

1

2

3

4

5

6

7

8

9

10

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

"H

ealt

h"

OD

A U

S$

bil

lio

ns

10

20

30

40

50

60

70

80

90

100

To

tal

OD

A U

S$

bil

lio

ns

ODA for Health Total ODA


Source Of Funds

ESSENTIAL MEDICINES

ARVs MALARIA TB OIARVs Ped

REAGENT Blood safety(+ HIV test)

VACCINES CONDOMS CONTRACEPTIVESMEDICALSUPPLIES

GOVERNMENT

MULTILATERAL DONOR

BILATERAL DONOR

NGO/PRIVATE

GOVERNMENT

WBGLOBAL

FUND

SIDA

PEPFAR

USAID

UNICEF

OMS

ABBOTT

CSSC

COLUMBIA

PFIZER

JICA

CLINTON

UNITAID

CIDA

CDC

GAVI

CUAMM

HAVARD

NORAD

AXIOS

Tanzania: Funding by Supply TypeTanzania: Funding by Supply Type (2006-2007 Data)(2006-2007 Data)Tanzania: Funding by Supply TypeTanzania: Funding by Supply Type (2006-2007 Data)(2006-2007 Data)

$ ‘000 65,869 56,853 54,201 4,700 3,722 37,027 17,300 3,905 17,734 53,859 315,170

% 20.9% 18.0% 17.2% 1.5% 1.2% 11.7% 5.5% 1.2% 5.6% 17.1% 100%

Source: Supply management, WHO/EMP/MAR


Source: Helen Tata, WHO


$ ‘000 5,666 45,335 11,718 0.3 2,984 1,495 10,889 0 1,305 0.6 1,862 82,156

% 7% 55% 14% 0.5% 4% 2% 13% 0% 2% 1% 2% 100%

Zambia: Funding by Supply typeZambia: Funding by Supply type

Source Of Funds

WORLD

BANK

PEPFAR

DFID

USAID

UNICEF

WHO

CHAZ

CHAI

JICA

WORLDVISION

UNFPA

ZABART

ESSENTIAL MEDICINES

ARVs MALARIA TB OIARVs

Ped

REAGENT Blood safety(+ test HIV)

VACCINES CONDOMS ContraceptivesMEDICAL

Supplies

Category of

Products Color

GOVERNMENT

BILATERAL DONOR

MULTILATERAL DONOR

NGO/PRIVATE

BGATES

ITN

AXIOS

UNITAID

GLOBALFUND

CDC

GLASER

M

O

H

Source: Supply management, WHO/EMP/MAR


Players and Partners?Players and Partners?

)(),(N~QQQ oviderPrnon

_

oviderPr

_

differenceMean

_

10 2

)(),(N~QQQ Before

_

After

_

differenceMean

_

20 2


What is happening in countries?What is happening in countries?

Increased funding, more investment to improve access to medicines

Access to medicines improving in some disease areas?

Impact on health systems and unfavoured diseases areas

Pharmaceutical work force challenges

Uneven development of the procurement, supply and systems

Demand for medicines is increasing in scale and scope

Hardly any active planning budgeting for medicines in countries

Is optimal and equitable access to medicines being achieved?


ChallengesChallenges

Distorted view of total medicines financing with inputs to specific disease programs by donors

Reduced government contributions to health and medicines

Constrained technical capacity in countries

Political will

Global economic (financial) crisis

Human resources

Healthcare systems.

Weak tax systems – large informal sector


Innovative financing mechanism galoreInnovative financing mechanism galore

hypotheticated taxes, e.g. 'sin taxes' for tobacco and alcohol

national and state lotteries dedicated to health

public-private partnerships between governments and the private sector to co-fund health care.

Other mechanisms are internationally focused, such as:– the (recently proposed) International Finance Facility (IFF). This would front-load

development assistance by selling government bonds secured by future aids flows

debt for health swaps, in which external government debt is converted into domestic debt, thereby resulting in less pressure to generate foreign exchange for debt service. A debt-for-health swap also represents an opportunity for a foreign donor to increase the local currency equivalent of a donation.

the use of public-private partnerships to develop new products using capital markets.


Financing demand for medicinesFinancing demand for medicines

Mechanisms to empower consumers such that economic considerations diminishes in making the decision to use medicines rationally to restore or improve health.

– Insurance & reimbursement systems– Prepayment mechanisms– Market system manipulation and affordability


Global Picture: Medicines reimbursementGlobal Picture: Medicines reimbursement

Low-Income

Lower Middle-Income

Upper Middle- Income

High-Income

Number of countries n = 40 (%) n = 54 (%) n = 46 (%) n = 50 (%)

Number of countries with any insurance coverage 18 (45.0%) 31 (57.4%) 35 (76.1%) 47 (94.0%)

Number (%) of countries with medicines reimbursement 18 (45.0%) 19 (35.2%) 27 (58.7%) 46 (92%)

Total population 0.88e+09 3.97e+09 1.03e+09 1.10e+09

Population coverage ratio: Health insurance 13.8% 24.8% 54.18% 93.2%

Coverage for medicines reimbursement 14.1% 19.8% 47.2% 92.7%

Health insurance coverage and medicines reimbursement coverage by countries’ 2011 World Bank income classification



0 20 40 60 80 100coverage: % of population

Equatorial GuineaTrinidad & TobagoRepublic of Korea

CyprusCroatia

USASan Marino

GermanyOman

AndorraSloveniaEstonia

NetherlandsBelgiumGreece

LuxembourgSpain

AustraliaAustria

BahamasBahrain

Brunei DarussalamCanada

Czech RepublicDenmark

FinlandFrance

HungaryIcelandIreland

IsraelItaly

JapanKuwaitLatviaMalta

New ZealandNorwayPoland

PortugalQatar

Saudi ArabiaSingapore

SlovakiaSweden

SwitzerlandUAE

United Kingdom

50 countries

i. High-income countries


BelarusGabon

KazakhstanLibya Arab Jama.

MauritiusPalau

SeychellesSaint Lucia

St. Vincent & the GrenadinesSaint Kitts & Nevis

NamibiaDominica

Dominican RepublicJamaica

PeruBrazil

AlgeriaVenezuela BR

LebanonAlbaniaMexico

ArgentinaPanama

South AfricaBosnia and Herzegovina

ColombiaRepublic of Montenegro

Republic of SerbiaSuriname

Costa RicaUruguay

TurkeyBulgaria

Russian FederationAntigua & Barbuda

AzerbaijanChileCuba

LithuaniaMacedonia FYR

MalaysiaRomania

46 countries

ii. Upper middle-income countries

Figure 1: Health insurance coverage and reimbursement for medicines in countriesHigh- & Upper middle-income countries

Health Insurance coverage Reimbursement for medicines




AngolaBhutanCongo

Côte d'IvoireIraq

KiribatiMaldives

Marshall IslandsPakistan

Papua New GuineaSamoa

Sao Tome & PrincipeSyrian Arab Republic

TuvaluUkraineVanuatu

YemenCameroon

NigeriaSri Lanka

BelizeIndia

TurkmenistanHonduras

TongaParaguayMorocco

GuatemalaEcuador

SwazilandSenegal

El SalvadorCape Verde

NicaraguaBoliviaEgypt

ArmeniaIndonesia

Micronesia, Fed StaChina

Viet NamRepublic of Moldova

PhilippinesTunisiaJordan

ThailandTimor LesteUzbekistan

54 countries

i. Lower middle-income countries


AfghanistanCentral African Republic

ChadComoros

Congo Dem RepEritrea

GambiaGuinea

Guinea-BissauHaiti

LiberiaMadagascar

MalawiMauritania

MozambiqueNiger

Sierra LeoneSolomon Islands

SomaliaTajikistan

ZambiaNepalTogo

BangladeshBenin

Burkina FasoMali

UgandaTanzania Uni Rep

BurundiCambodia

KenyaRwanda

GhanaZimbabwe

Korea DPRKyrgyzstan

Lao PDREthiopia

40 countries

ii. Low-income countries

Figure 2: Health insurance coverage and reimbursement for medicines in countriesLower middle- & Low-income countries

Health Insurance coverage Reimbursement for medicines


Persisting SituationPersisting Situation

Medicines reimbursement reflects comparable coverage with health insurance coverage in countries with universal, or tax financed insurance systems.

Drug Revolving Funds are often precursors of community health insurance schemes in the developing countries and may explain the slightly higher medicines cover in low-income countries.

Community health insurance is growing in low- and middle-income countries,

– but majority of countries and populations have no access to health insurance compared to high-income countries.


CHICHI

Community finance schemes– This market is evolving in the contest of:

• Government failure to organize taxes, public finance, provision of social protection to vulnerable populations and to exercise oversight over the health sector.

• Market failure to offer effective exchange between demand and supply

– Strength• Social capital• Pre existing community institutions• Interconnectivity between local communities

– Limitations to overcome to serve the community well• Lack of insurance and reinsurance mechanisms to spread risk over larger population• Isolation from formal financing and provider networks• Have difficulties in mobilizing enough resources to cover costs of priority health services for the poor• Limited ability to encourage prevention or use of therapies effectively• Rely on management staff with limited professional training.


Community Health Insurance and Access to Medicines:

Evidence from Cameroon


Supported by GTZ and Cameroon government in 3 regions North West South West Littoral

An effective medicines supply system on cost-recovery basis

Hosted by Provincial Special Funds for Health (the FUNDs)

Strong community participation

Essential Medicines Program Essential Medicines Program


Public Medicines Supply System in Cameroon

Public Medicines Supply System in Cameroon


Community Mutual Health Organisation (Mutuelle)

Community Mutual Health Organisation (Mutuelle)

A subsidiary of the Fund.

Built on well mobilized community platform of the EMP

Not-for-Profit community-based health financing schemes

Provides a viable alternative health financing mechanism Pulls resources together from households Risk sharing Affordable health care to the rural poor


AIM of studyAIM of study

Evaluate the impact of the community health insurance schemes on supply

and distribution of essential medicines to public health care facilities in 3

regions in Cameroon.


Methodology (1)Methodology (1)

Medicines selection Antimalarial Antibiotic Maternal health Chronic ailments (diabetes and hypertension)

Detailed supply records kept at regional medical stores (RMS)

– Supply details to Health Facilities of 8 essential medicines (aminophyline, amoxicillin, co-trimoxazole, folic acid in combination with ferrous sulphate, metformin, nifedipine paracetamol and quinine)


AnalysisAnalysis

Two-by-two Analysis

mean monthly quantity of orders per facility – (Ho): zero mean difference between the comparative groups

(across the two partitions), rejected at 95% degree of confidence

student t test used to evaluate the significance of the mean difference after and before CMHO.

)(),(N~QQQ oviderPrnon

_

oviderPr

_

differenceMean

_

10 2

)(),(N~QQQ Before

_

After

_

differenceMean

_

20 2


Health Centres North West South West Littoral

Medicines

CHMO vs Non-

CHMO

Before vs After

CHMO

CHMO vs Non-

CHMO

Before vs After

CHMO

CHMO vs Non-

CHMO

Before vs After

CHMO

Aminophylline 19( 0.29) 31( 0.10) -3( 0.83) 14( 0.30) -19( 0.83) 60( 0.30)

Amoxicillin 4( 0.00) 2( 0.09) 4( 0.00) -2( 0.03) 8( 0.01) 0( 0.88)

Co-trimoxazole 588( 0.00) 65( 0.42) 141( 0.00) -25( 0.67) -132( 0.35) 78( 0.39)

Fafs 608( 0.00) 705( 0.00) - - 855( 0.54) -522( 0.59)

Metformin 331( 0.00) -86( 0.18) 200( 0.00) -119( 0.09) - -

Nifedipine 488( 0.00) 55( 0.35) 259( 0.00) -68( 0.28) -179 -479( 0.16)

Paracetamol 373( 0.00) 43( 0.16) 250( 0.00) -73( 0.31) 338( 0.33) -411( 0.06)

Quinine 85( 0.00) -38( 0.01) 45( 0.09) 123( 0.00) 82( 0.63) -176( 0.13)

Results: Mean Differences (Total Supply)Results: Mean Differences (Total Supply)


Results: North West Results: North West

05000

01000

0015

0000

2000

0025

0000

2005m1 2006m1 2007m1 2008m1 2009m1 2010m1Datemonthvalue

(a) Hospital Provider Facilities

05000

01000

0015

0000

2000

0025

0000


Non-provider Facilities

-500

00

0

5000

0

1000

00

1500

00


(b) Health Centre level

-500

00

0

5000

0

1000

00

1500

00


Mean Monthly Facility Ordering Trends from 2005 to 2010 in the North West Region


Results: South WestResults: South West

0

2000

0

4000

0

6000

0



0

2000

0

4000

0

6000

0



0

1000

0

2000

0

3000

0


(b) Health Centre level

0

1000

0

2000

0

3000

0


Mean Monthly Facility Ordering Trends from 2005 to 2010 in the South West Region


Results: Littoral RegionResults: Littoral Region

0

5000

0

1000

00

1500

00



0

5000

0

1000

00

1500

00



-400

000

-200

000

0

2000

00


(a) Health Centre level

-400

000

-200

000

0

2000

00


Mean Monthly Facility Ordering Trends from 2005 to 2010 in the Littoral Region


Summary of ResultsSummary of Results

Regularly supply sustained in all centres - including non provider centres

Increased consumption of medicines and utilization of associated services

Evidently sustainable financing of medicines

Indications or demand for quality of medicines and care


ConclusionConclusion

A well designed and positioned mutual health insurance systems can have a positive impact on access to medicines and associated health services.

A well designed and functioning medicines supply system is essential for community health insurance to function.

financing essential medicines in low- and middle-income countries: cameroon case study

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