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

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  • Laurens M Niëns
  • Alexandra Cameron
  • Ellen Van de Poel
  • Margaret Ewen
  • Werner B F Brouwer
  • Richard Laing

Abstract

Laurens Niëns and colleagues estimate the impoverishing effects of four medicines in 16 low- and middle-income countries using the impoverishment method as a metric of affordability and show that medicine purchases could impoverish large numbers of people.Background: Increasing attention is being paid to the affordability of medicines in low- and middle-income countries (LICs and MICs) where medicines are often highly priced in relation to income levels. The impoverishing effect of medicine purchases can be estimated by determining pre- and postpayment incomes, which are then compared to a poverty line. Here we estimate the impoverishing effects of four medicines in 16 LICs and MICs using the impoverishment method as a metric of affordability. Methods and Findings: Affordability was assessed in terms of the proportion of the population being pushed below US$1.25 or US$2 per day poverty levels because of the purchase of medicines. The prices of salbutamol 100 mcg/dose inhaler, glibenclamide 5 mg cap/tab, atenolol 50 mg cap/tab, and amoxicillin 250 mg cap/tab were obtained from facility-based surveys undertaken using a standard measurement methodology. The World Bank's World Development Indicators provided household expenditure data and information on income distributions. In the countries studied, purchasing these medicines would impoverish large portions of the population (up to 86%). Originator brand products were less affordable than the lowest-priced generic equivalents. In the Philippines, for example, originator brand atenolol would push an additional 22% of the population below US$1.25 per day, whereas for the lowest priced generic equivalent this demographic shift is 7%. Given related prevalence figures, substantial numbers of people are affected by the unaffordability of medicines. Conclusions: Comparing medicine prices to available income in LICs and MICs shows that medicine purchases by individuals in those countries could lead to the impoverishment of large numbers of people. Action is needed to improve medicine affordability, such as promoting the use of quality assured, low-priced generics, and establishing health insurance systems. : Please see later in the article for the Editors' Summary Background: In recent years, the international community has prioritized access to essential medicines, which has required focusing on the accessibility, availability, quality, and affordability of life-saving medicines and the development of appropriate data and research agendas to measure these components. Determining the degree of affordability of medicines, especially in low- and middle-income countries, is a complex process as the term affordability is vague. However, the cost of medicines is a major public health issue, especially as the majority of people in developing countries do not have health insurance and medicines freely provided through the public sector are often unavailable. Therefore, although countries have a legal obligation to make essential medicines available to those who need them at an affordable cost, poor people often have to pay for the medicines that they need when they are ill. Consequently, where medicine prices are high, people may have to forego treatment or they may go into debt if they decide to buy the necessary medicines. Why Was This Study Done?: The researchers wanted to show the impact of the cost of medicines on poorer populations by undertaking an analysis that quantified the proportion of people who would be pushed into poverty (an income level of US$1.25 or US$2 a day) because their only option is to pay out-of-pocket expenses for the life-saving medicines they need. The researchers referred to this consequence as the “impoverishing effect of a medicine.” What Did the Researchers Do and Find?: The researchers generated “impoverishment rates” of four medicines in 16 low- and middle-income countries by comparing households' daily per capita income before and after (the hypothetical) purchase of one of the following: a salbutamol 100 mcg/dose inhaler, glibenclamide 5 mg cap/tab, atenolol 50 mg cap/tab, and amoxicillin 250 mg cap/tab. This selection of drugs covers the treatment/management of three chronic diseases and one acute illness. The cost of each medicine was taken from standardized surveys, which report median patient prices for a selection of commonly used medicines in the private sector (the availability of essential medicines in the public sector is much lower so many people will depend on the private sector for their medicines) for both originator brand and lowest priced generic products. If the prepayment income was above the US$1.25 (or US$2) poverty line and the postpayment income fell below these lines, purchasing these medicines at current prices impoverishes people. What Do These Findings Mean?: Although the purchasing of medicines represents only part of the costs associated with the management of an illness, it is clear that the high cost of medicines have catastrophic effects on poor people. In addition, as the treatment of chronic conditions often requires a combination of medicines, the cost of treating and managing a chronic condition such as asthma, diabetes, and cardiovascular disease is likely to be even more unaffordable than what is reported in this study. Therefore concerted action is urgently required to improve medicine affordability and prevent poor populations from being pushed further into poverty. Such action could include: governments, civil society organizations, and others making access to essential medicines more of a priority and to consider this strategy as an integral part of reducing poverty; the development, implementation, and enforcement of sound national and international price policies; actively promoting the use of quality assured, low-cost generic drugs; ensuring the availability of essential medicines in the public sector at little or no charge to poor people; establishing health insurance systems with outpatient medicine benefits; encouraging pharmaceutical companies to differentially price medicines that are still subject to patent restrictions. Additional Information: Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000333.

Suggested Citation

  • Laurens M Niëns & Alexandra Cameron & Ellen Van de Poel & Margaret Ewen & Werner B F Brouwer & Richard Laing, 2010. "Quantifying the Impoverishing Effects of Purchasing Medicines: A Cross-Country Comparison of the Affordability of Medicines in the Developing World," PLOS Medicine, Public Library of Science, vol. 7(8), pages 1-8, August.
  • Handle: RePEc:plo:pmed00:1000333
    DOI: 10.1371/journal.pmed.1000333
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    Citations

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    Cited by:

    1. Tamara Hafner & David Popp, 2011. "China and India as Suppliers of Affordable Medicines to Developing Countries," NBER Working Papers 17249, National Bureau of Economic Research, Inc.
    2. Sabine Vogler, 2019. "Fair prices for medicines? Exploring competent authorities’ and public payers’ preferences on pharmaceutical policies," Empirica, Springer;Austrian Institute for Economic Research;Austrian Economic Association, vol. 46(3), pages 443-469, August.
    3. John Tayu Lee & Fozia Hamid & Sanghamitra Pati & Rifat Atun & Christopher Millett, 2015. "Impact of Noncommunicable Disease Multimorbidity on Healthcare Utilisation and Out-Of-Pocket Expenditures in Middle-Income Countries: Cross Sectional Analysis," PLOS ONE, Public Library of Science, vol. 10(7), pages 1-18, July.
    4. Kankeu Tchewonpi, Hyacinthe & Saksena, Priyanka & Xu, Ke & Evans, David B, 2013. "The financial burden from non-communicable diseases in low- and middle-income countries: a literature review," MPRA Paper 54534, University Library of Munich, Germany.
    5. Leila Zarei & Iman Karimzadeh & Najmeh Moradi & Payam Peymani & Sara Asadi & Zaheer-Ud-Din Babar, 2020. "Affordability Assessment from a Static to Dynamic Concept: A Scenario-Based Assessment of Cardiovascular Medicines," IJERPH, MDPI, vol. 17(5), pages 1-19, March.
    6. Xiao Wang & Yu Fang & Shimin Yang & Minghuan Jiang & Kangkang Yan & Lina Wu & Bing Lv & Qian Shen, 2014. "Access to Paediatric Essential Medicines: A Survey of Prices, Availability, Affordability and Price Components in Shaanxi Province, China," PLOS ONE, Public Library of Science, vol. 9(3), pages 1-7, March.
    7. Kiran Raj Pandey & David O Meltzer, 2016. "Financial Burden and Impoverishment Due to Cardiovascular Medications in Low and Middle Income Countries: An Illustration from India," PLOS ONE, Public Library of Science, vol. 11(5), pages 1-19, May.
    8. Niëns, L.M. & Brouwer, W.B.F., 2013. "Measuring the affordability of medicines: Importance and challenges," Health Policy, Elsevier, vol. 112(1), pages 45-52.

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