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)
WHO/EMP TBS| 02 November 20112 |2
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.
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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
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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
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Government health expenditure (as source) is Increasing Government health expenditure (as source) is Increasing
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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
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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
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Source: Helen Tata, WHO
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$ ‘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
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Players and Partners?Players and Partners?
)(),(N~QQQ oviderPrnon
_
oviderPr
_
differenceMean
_
10 2
)(),(N~QQQ Before
_
After
_
differenceMean
_
20 2
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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?
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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
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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.
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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
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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
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Global Picture: Medicines reimbursementGlobal Picture: Medicines reimbursement
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
0 20 40 60 80 100coverage: % of population
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
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Global Picture: Medicines reimbursementGlobal Picture: Medicines reimbursement
0 20 40 60 80 100coverage: % of population
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
0 20 40 60 80 100coverage: % of population
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
WHO/EMP TBS| 02 November 201118 |18
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.
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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.
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Community Health Insurance and Access to Medicines:
Evidence from Cameroon
WHO/EMP TBS| 02 November 201121 |21
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
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Public Medicines Supply System in Cameroon
Public Medicines Supply System in Cameroon
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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
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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.
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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)
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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
WHO/EMP TBS| 02 November 201127 |27
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)
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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
2005m1 2006m1 2007m1 2008m1 2009m1 2010m1Datemonthvalue
Non-provider Facilities
-500
00
0
5000
0
1000
00
1500
00
2005m1 2006m1 2007m1 2008m1 2009m1 2010m1Datemonthvalue
(b) Health Centre level
-500
00
0
5000
0
1000
00
1500
00
2005m1 2006m1 2007m1 2008m1 2009m1 2010m1Datemonthvalue
Mean Monthly Facility Ordering Trends from 2005 to 2010 in the North West Region
WHO/EMP TBS| 02 November 201129 |29
Results: South WestResults: South West
0
2000
0
4000
0
6000
0
2008m1 2008m7 2009m1 2009m7 2010m1 2010m7Datemonthvalue
(a) Hospital Provider Facilities
0
2000
0
4000
0
6000
0
2008m1 2008m7 2009m1 2009m7 2010m1 2010m7Datemonthvalue
Non-provider Facilities
0
1000
0
2000
0
3000
0
2008m1 2008m7 2009m1 2009m7 2010m1 2010m7Datemonthvalue
(b) Health Centre level
0
1000
0
2000
0
3000
0
2008m1 2008m7 2009m1 2009m7 2010m1 2010m7Datemonthvalue
Mean Monthly Facility Ordering Trends from 2005 to 2010 in the South West Region
WHO/EMP TBS| 02 November 201130 |30
Results: Littoral RegionResults: Littoral Region
0
5000
0
1000
00
1500
00
2005m1 2006m1 2007m1 2008m1 2009m1 2010m1Datemonthvalue
(a) Hospital Provider Facilities
0
5000
0
1000
00
1500
00
2005m1 2006m1 2007m1 2008m1 2009m1 2010m1Datemonthvalue
Non-provider Facilities
-400
000
-200
000
0
2000
00
2005m1 2006m1 2007m1 2008m1 2009m1 2010m1Datemonthvalue
(a) Health Centre level
-400
000
-200
000
0
2000
00
2005m1 2006m1 2007m1 2008m1 2009m1 2010m1Datemonthvalue
Mean Monthly Facility Ordering Trends from 2005 to 2010 in the Littoral Region
WHO/EMP TBS| 02 November 201131 |31
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
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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.
WHO/EMP TBS| 02 November 201133 |33